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Soffin Arfian

SMF ObsGyn

RSPKU Muhammadiyah Surakarta/ FK UMS

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Definition :

Rupture Of The Chorioamniotic membranes

Prior to the onset of Labor

Interval Between PROM to onset of Labor Latency Period Varying from 1-12 Hours.

Most define PROM simply as ROM prior to the

Onset of Contraction

Pediatricians are Concerned with Duration ofROM especially In TERM Gestation

Prolonged PROM ROM for 24 Hours

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INCIDENCE

Varies Between 3 18,5% ( Gunn et al 1970 )

Approximately 8-10 % Patients at Term

Present with ROM prior to the Onset of laborPRETERM PROM is 25% of All cases of PROM

responsible 30% of allpremature delivery.

Greater in Lower socioeconomic population

and those with higher rates of STD

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Normal Fetal Membranes Extremely Strong

in early pregnancy

At TERMs Combination of Stretchingof

the membranes with uterine Growth,Frequent strain caused by Ut Contraction &

Fetal Movement Contribute Weakening

Significant Biochemical changes occur near

term such as Substantial decrease in thecollagen content.at TERM PROM maybe

a physiologic variantthan a Phatologic event

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Studies in Premature PROM Do not show

in membrane strenght EXCEPT NEAR THE

SITE of RUPTURE( Artal et al 1976 )

Suggest en EXOGENOUS Source of Weakening Local Infection Ascending from Vagina

Responsible.

Hystologic Chorioamnionitis is much more

prevalent with PRETERM than with TERMPROM ( Naeye , 1979 )

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Studies evaluating amniotic fluid and Fetal

Cord blood Ig many Patients w Preterm

PROM are infected prior ROM ( Cederqvist et

al 1979 ) Bacteria attach Fetal membrane Elaborate

substances such as Protease Cause

Membrane weakeningWhy not All? Its not

clear.Host Factor EnvirontmentcoFactor must be involved

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Other Etiology :

Polyhydramnios, Incompetent cervix,

Following procedures such as Cervical

Cerclage or Amniocentesis Epidemiologic Factor : Smoking, Multiple

gestation, Abruptio Placenta, Previous

Preterm PROM

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MATERNAL & FETAL or NEONATAL INFECTION

PREMATURE LABOR

HYPOXIA & ASPHYXIA Secondary to Umbilical

Cord Compression INCREASED RISK of C SECTION

FETAL DEFORMATION

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ROM Onset of Labor follows shortly

Duration of Latency Period Varies w/

Gestational Age. At Term within 24 Hours in

90% Cases. Between 28-34 wk, 50% in laborwithin 24 Hours and 80-90% within 1 week (

Mead,1980 ; Garite etal, 1981), Prior to 26

wk, 50% begin labor within 1 week ( Taylor &

Garrite , 1984 )

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Labor at Term Desireable sequel to PROM

When does not Begin shortly NEED for

CONCERN.

Preterm PROM Subsequent Delivery &Prematurity ComplicationMost Common

Causes of Perinatal Morbidity & Mortality

Generally there is Moderate Shortening of

the 1stStage but no effect on 2ndstage

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Both Mother & Fetus are at Increased Risk fo

Infection.

Maternal Infection : Chorioamnionitis

Fetal Infection : Septicaemia, Pneumonia orUTI, Local Infection Such as Omphalitis or

Conjunctivitis.

Generally, Maternal Chorioamnionitis

Preceeds Fetal Infection But Serious FetalSepsis May occur before chorioamnionitis is

clinically evident.Preclinical infection

Intraamniotic Infection

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Incidence chorioamnionitis0,5-1% InProlonged PROM 3-15%

Chorioamnionitis More Common in PretermPROM 15-25% ( Garite & Freeman, 1982)

IMPACT of PROM and Chorioamnionitis onFetal infection Varies Incidence ofNeonatal sepsis at Term 1 : 500 babies w/Prolonged PROM.

Major Neonatal infection occur 5% of AllCases of Preterm PROM The Preterm Babyis much more likely to Die of InfectiousComplication

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In Most CasesPerinatal mortality

Cosequent to PRETERM PROM arises from

Complication of Prematurity : RDS,

Intraventicular Hemorrhage, NEC

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Umbilical Cord Compression even w/o

ProlapseSecondary Due to

Oligohydramnios ( Rutherford et al 1987 )

May Occur Before or During Labor

In Preterm Patients in Labor following PROM

High incidence of Fetal distress Mostly

from Cord Compression, in 8,5% of patients

with PROM compared w/ only 1,5% of thosein premature labor w/ intact Membrane (

Moberg et al, 1984 )

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Initial Evaluation Must Result in a Basic Data

Base that includes :

1. CONFIRMING DIAGNOSIS

2. DETERMINING GESTATIONAL AGE3. EVALUATION FOR THE PRESENCE OF

MATERNAL AND / OR FETAL INFECTION

4. ESTABLISHING THE ONSET OF LABOR

5. RULLING OUT FETAL DISTRESS

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Diagnosis is established by ASEPTIC

SPECULUM Vaginal ExaminationAvoid

Introducing Infection

Avoid Digital Intracervical examination whenNot In labor and Immediate Induction is

not Planned

Nitrazine test ( paper strip )

UltrasoundOligohydramnios

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Menstrual Dating

Prenatal Examination

UltrasoundBecareful to measure the

Biparietal Diameter & AbdomenCircumference due to Compression may

cause alteration

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Sign of Infection : Fever, Leukocytosis,

Maternal & Fetal Tachycardia, Uterine

Tenderness, Mal Odorous Vaginal Discharge

Diagnosis of Chorioamnionitis to be based onclinical sign include Fever ( 100,4F /38C )

and absence of any other explanation for

elevated Temperature.

Laboratory test WBC count and CRPindicates impending infection

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Preliminary speculum Examination to be

used to determine Cervical Dilatation is

present or not.

Digital examination generally avoided untilone is Certain of Labor.

CardioTocoGraphy Applied to determine

the presence & Frequency of contraction

Allow early diagnosis of Labor

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Continous Fetal Heart Monitoring / CTG

should be included in initial evaluation of All

Patient if the fetus is of a Viable Gestational

Age. ( the G A is Depend on Neonatologist

Team )

Besides Variable Deceleration, Late

deceleration may reveal a Coexistent

Abruptio or Uteroplacental pathology, andLoss of FHR Reactivity and /or Fetal

tachycardia may suggest Fetal Sepsis

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TERM PROM

-. At 36 wk and beyond The Goal is

Delivery

-. Most of patients in labor within 24 Hoursfollowing PROM

-. Many Clinicians have agressively managed

term patients by Inducing labor shortly after

PROM in an effort to shorten the intervalbetween Rupture and delivery

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Over the Past Decade Studies Evaluating

the question of Immediate Induction VS

Delayed Induction/expectant Management

Conflicted Result

However Chorioamnionitis & Postpartum

Fever were less likely in the Immediate

Induction Group Concluded that

Immediate induction of labor more positivethan Expectant Management

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Prostaglandine for preinduction cervical

ripening has a benefit.

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Major Risk related to Complication of

PrematurityManagement is Aimed at

Prolonging Gestation who is not in labor, not

infected, and not experiencing Fetal Distress

Many Clinicians have varying view regarding

tocolysis and CorticosteroidsLung

MaturityProlonged Tocolytic therapy has

not been supported in clinical trials

Continue w/ Oral tocolytic Effort to

prolonging Gestation

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Broad Spectrum Antibiotics with Good

amniotic fluid penetration in Conjunction

with Cortocosteroids

Amnioinfusion

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PROM that occur in very early pregnancy

Low Probability (25-40%) achieved a viable

Gestational Age and that deliver a surviving

Infant.

In the process of waiting Thre are Real

maternal risk ( Infection-Sepsis-Death cause

of sepsis, Abruption )serious neurologic

Morbidity on Fetus, Fetal deformationsyndrome ( Growth Retardation, Compression

Deformities, Pulmonary Hypoplasia )

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ManagementExpectant Management or

TerminationCRUCIAL w/ High Maternal

risk & Poor Prognosis for Good Fetal Outcome

Patient must Be Involved for Decision

process.

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