SUPERVISOR dr. Zanibar Aldy, Sp. OG MENTOR dr.

Yufi Permana Sherly Cancerita 070100057 Harmit Kaur 070100249 Navin Kanvinder S. 070100250

DEFENITION
Rupture of the amniotic membranes without the onset of uterine contractions.

Preterm PROM < 37 weeks gestation Term PROM > 37 weeks gestation

Rupture of membranes is generally followed by onset of labor within 24 hours. 90% of patients at term and 50% of preterm patients will begin labor within 24 hours rupture of membranes.

Infection
Idiopathic Polihidr amnion

Cigarette smoking

PROM Risk Factors/Etiology

Cervical incompe tence

Multiple pregnan cy Trauma

Uterine abnorma lity

Parry, S.,Trauss, J. Premature Rupture of The Fetal Membranes; Mechanism of Diseases. N Engl J Med. Feb 2006.

DIAGNOSIS

History Taking discharge or leaking per vagina (subtle or substansial) urinary incontinence or urinary frequency

Physical Examination Vital signs Abdominal examination Sterile Spekulum examination Fetal heart rate Uterine contractions

Laboratory Litmus paper testing or Nitrazine test the difference in pH of vaginal secretions (4.5 to 5.5) and amniotic fluid (7.0 to 7.5), it was rightly assumed that the pH of vaginal secretions would rise when contaminated by escaping amniotic fluid
Fern test,

dried sample of amniuotic fluid show characteristic fern-shaped crystalline pattern on microscopic examination
Valsava test,

 USG,

to assesss amniotic fluoid volume

Glucose and fructose measurement,
Placental alpha microglobulin 1, Non Invasive Absorbent Pad,

TREATMENT

 The consept in managing patient with PPROM is an

expectative management include appropriate monitoring of fetal heart rate and uterine contractions, sign of chorioamnitis.
Patients with PPROM should be cared for expectantly

until they have completed 34-37 weeks of gestation. The aim is to prevent delivery as long as we can while trying to accelerate fetal lung maturity with corticosteroid as desirable in preterm patients, unless fetal pulmonary maturity is documented.

 Particular attention should be paid to evaluation and

management of possible infection. Antibiotic prophylaxis is recommended to prevent infection as well to to prolong latency if there are no contraindications. Some studies include the usage of tocolytic as an agent to delay delivery by diminishing uterine contraction.

Active management in term PROM is termination of pregnancy, as we proceed to delivery, usually by induction of labor and also include antibiotic prophylaxis

 Antibiotic: Erythromycin or penicillin

Corticosteroid:
A single course of corticosteroids is recommended for

pregnant women 24-34 weeks' gestation who are at risk of preterm delivery within 7 days. A single course of antenatal corticosteroids is recommended for women with PROM before 32 weeks' gestation to reduce the risks of respiratory distress syndrome, perinatal mortality, and other morbidities.

 Tocolytic

The use of tocolysis for 48 hours to administer steroids and allow acceleration of fetal lung
Cervical Sealant

to repair a defect in the amniotic membrane and allow for reaccumulation of amniotic fluid
Amnioinfusion

Complication
Pulmonary Hipoplasia

PH is a decrease in the number of lung cells, airways, and alveoli, mainly due in PPROM to alterations of normal amniotic fluid pressure and egress of lung fluid during the canalicular stage of lung development (ending at nearly 25 weeks)
Fetal deformities

Prevention
Specific inhibitors of matrix metalloproteinases such

as tetracycline antibiotics, synthetic matrixmetalloproteinase inhibitors such as batimastat (which selectively chelates the zinc atom at the active site of the enzymes), and the native inhibitors TIMP-1 and TIMP-2
Vitamin C is involved in the synthesis and degradation

of collagen and is important for maintenance of the chorioamniotic membranes. Daily supplementation with 100 mg vitamin C after 20 wk of gestation effectively lessens the incidence of PROM.

 PERSONAL BACKROUND Name

: Mrs. P Age : 37 tahun Occupation : Ibu rumah tangga Religion : Islam Race : Batak Address : Medan, Belawan Admittance date : 11 September 2012 Time : 0918 WIT Parity : G1P0000

HISTORY TAKING
Chief Complain

: water discharge from pubic Further Investigation : This has been experienced by the patient since 10 September, 2012 at 2300 WIT with 3 times changing of undergarment. The water discharge is clear and odourless. History of abdominal discomfort was not found. History of bloody show was not found. History of whitish discharge was found, ordourless, and itchyness . History of trauma/ knocking against the door during pregnancy was found.

 History of fever during pregnancy was not

found. Fecal and urine excreation under normal range. History of previous illness : (-)
History of drug consumption

: (-)

HISTORY OF DELIVERY Current pregnancy HISTORY OF MENSES Last menstrual period : - -/Desember/2011 Estimated delivery date : - - /September/2012 Menses Cycle : Duration 28 days, Regular, length of cycle 3-4 days, frequency of changing sanitary napkin 2-3 times a day, Dysmenorhea (-)

PEMERIKSAAN FISIK STATUS PRESENT

General Condition : Good Anemic Icterus Contiousness : Compos Mentis Cyanosis Dyspnoe Edema Respiratory rate Pulse Temperature : 20 x/menit : 86 x/menit Signs of Dehydration : Not found : Not found : Not found : Not found : Not found : Not found

Blood Pressure

: 110/70 mmHg

Physical Deformity
: 36,7C

: Not found

STATUS OBSTETRIKUS
Inspection Palpation Leopold I : asymmetrical enlargement of abdomen

: 3 fingers below xypoideus proc.(32cm)

Leopold II

: right

Leopold III Leopold IV

:head : 4/5

Contraction a. Frequency per 10 minute b. Duration(seconds

: not found : :

Estimated fetal body weight a. From palpation b. From Johnson Formula

::3100 g

INTERNAL EXAMINATION VT- Closed cervix, eff 60%, amnion sac (-), SRM 10 hours, head at Hodge 1, minor fontanella ?? Promontorium : not felt Linea innominata : felt 2/3 Pubic arch : >900 Ischiadica Spine : blunt Os sacrum : concave Os Coccygeus : concave Result : adequate hip. Gloves : bloody mucous (-), Amnion fluid (-)

INSPEKULO Liquid accumulation at the posterior fornix , liquid was cleaned. Result : Liquid flowing from OUE. Erosion (-), flour albus (+), lividae (-), Nitrazin test (+) valsava test (+)

USG TAS
Single Fetus, Head Presentation, Alive Child

FM (+), FHR (+) 148x/minute regular

BPD 92 mm FL 75 mm

AC 348 mm
AFI 5,3 Result : IUP (37-38) weeks+ Head Presentation +

Alive

LABORATORIUM
Hb Ht Leucocyte Thrombocyte Blood Glucose Level SGOT SGPT :10,69 g/dL : 32,7 % : 17,300/mm3 : 313.000/mm3 : 58 mg/dL : 14 :8

Conclusion
Pregency age Fetal position Hip High Risk Pregnancy Antepartum bleeding Inpartu Fetal Condition Signs of possible uterus rupture Membrane rupture Pre-eklampsia Contraction Complication

: 37-38 weeks : Head Presentation : Normal : Found : Not Found : Not Found : Alive : Not Found : Found : Not Found : Found : Found

 CURRENT DIAGNOSIS
Term Premature Rupture of Membrane + Primi Gravida + Intra Uterine Pregnancy (37-

38 weeks) + head presentation + Alive Fetal

PROGNOSIS

Good

DELIVERY PLANNING Induction with oxytocine Monitoring of vital sign, contraction, fetal heart rate, progress of labour. Caesarean section if there is no progress of labour.

Follow up on 11 september 2012 , 10.00 WIT

Chief complain : abdominal discomfort due to labour Present Status Sensorium :compos mentis Anemia :BP :120/80 mmHg cyanosis :HR :88 x/I icteric :RR :24 x/I dyspnoe :T :36,70C oedem :Movement :+ His : 2 x 30/10 FHR :172 x/i Planning : due to the increased fetal heart rate an

emergenc y C-SEC was planned on indication of fetal tachycardia.

 C-SECTION REPORT On the 11 9- 2012 C-Sec o/i Fetal Tachycardi A female child was born with BW: 3100 gr; BL: 48cm; Apgar score

7/8; anus (+)

Patient was placed on the surgery table with infuse and cateter placed. Aceptic procedure was done using providone iodine and alcohol 70% on the abdominal wall and later was covered with steril cloth except the operating site Under spinal anastesia , incision was from the cutis, subcutis until the fascia is seen. Fascia is cut from left to right with anatomical pinset set underneath. The uterus is seen with heck blast placed. . Plika vesikouterina is cut concave until the subendometrium the endometrium is cut blunt and widend according to the direction of surgical cut. Placenta is seen and is cut. By pulling out the head of fetus, a baby girl with BW : 3100 gr; BL: 49cm; Apgar score 7/8; and anus is born. The umbilical cord is clamped at two sides and cut in between. . By constant pressure to the uterus the plasenta is born. Both end of the uterus is clamped and later the cavum is cleaned from left over blood. Hecting of the uterus is done by overhecting. No bleeding is found. The peritoneum is sewed continuously and later the muscle wall is sewed. Subcutis is sewed using simple method and the fascia is sewed cuticuler. Operation wound is closed with steril gauze and iodine. Post op: patient is stabile.

 Therapy :
IVFD RL + Oksitocine 10-10-5-5 20gtt/i Viccilin SX injection 1,5gr/8hour

Transamin injection 1 amp/8 hour (24hour)

Farmadol drip 1 fls/ 12 hour

Recommendation :
Monitor vital sign, uterus contraction and signs of bleeding

Check CBC 2 hours post C-Section

Mobilization by stage

NEONATUS

Birth : Single Date of Birth : 11 September 2012 ,time: 1130 Birth Condition : Alive APGAR score : 7/8 Breating Assistance : Not Found Gender : Female Body Weight (g) : 2750 gram Body length (cm) : 48 cm Congenital Disorder : Not Found Trauma : Not Found Consult : Consult to paediatrics department for immediate care of the baby.

Diagnosis : Post C-Sec o/i fetal tachycardy + Confinement Day 0

POST C-SEC MONITORING (STAGE IV)

Jam (WIB) TD (mmHg) HR 15.30 110/70 80 16.00 120/60 64 16.30 110/70 68 17.00 110/70 68 17.30 110/70 68

(kali/menit)
RR (kali/menit) 28 24 24 24 24

Kontraksi
Uterus TFU (cm)

Kuat

Kuat

lemah

Kuat

Kuat

2 jari bawah pusat

2 jari bawah pusat

2 jari bawah pusat

2 jari bawah pusat

2 jari bawah pusat

Perdarahan (cc)

 LABORATORIUM RESULTS 2 HOURS POST

C-SEC Date 11 September 2012 Hb : 9,8 g/dL Ht : 34,6% Leucocyte : 14.300/mm3 Thrombocyte : 264.000/mm3

12 september2012

13september2012

Chief Complain Painful surgical wound Sens: Compos Mentis BP : 110/70mmHg HR :74x/menit RR : 22x/menit Temp: 36,8 C Anemic :cyanosis: Ikterik : Dypsnoe: Oedema: Abdomen: soepel, peristaltic + normal Hight of fundus: 2 fingers below navel, strong contraction Bleeding through Vagina: Lochia: + Rubra Feacal (-) Urine (+) N, Flatus (+) Breast Milk (-)

Painful surgical wound Sens: Compos Mentis BP : 110/70mmHg HR :74x/menit RR : 22x/menit Temp: 36,8 C Anemic :cyanosis: Ikterik : Dypsnoe: Oedema: Abdomen: soepel, peristaltic + normal Hight of fundus: 2 fingers below navel Bleeding through Vagina: Lochia: + Rubra Feacal (+) Urine (+) N, Flatus (+) Breast Milk (+)

Present Status

Localized Status

Diagnosis

Post C-Sec o/i fetal tachycardy + Post C-Sec o/i fetal tachycardy + Confinement Day 1 Confinement Day 1

Therapy

Ivfd RL + oksitocine 5 iu Ivfd RL + oksitocine 5 iu Viccillin injection sx 1,5 gr/ 8 hours Viccillin injection sx 1,5 gr/ 8 hours Farmadol drip 100 mg/ 12 hours Farmadol drip 100 mg/ 12 hours

Planning

Mobilization

14 september2012
-

Chief Complain
Present Status

Localized Status

Sens: Compos Mentis BP : 110/70mmHg HR :74x/menit RR : 22x/menit Temp: 37,9 C Anemic :cyanosis: Ikterik : Dypsnoe: Oedem: Abdomen: soepel, peristaltic + normal Hight of fundus: 2 fingers below navel Bleeding through Vagina: Lochia: + Rubra Feacal (+) Urine (+) N, Flatus (+)

Diagnosis Therapy

Post C-Sec o/i fetal tachycardy + Confinement Day 3 Amoxicillin tablet 3x500mg Asam Mefenamat tablet 3x500mg

Teori

Kasus

Premature rupture of membranes (PROM) is a rupture of the membranes before the onset of labor. KPD full-term pregnancy occurred about 10-15% and 2-4% of preterm

This patient is aterm.

ANALISA KASUS

Etiology

The existence of uterine hypermotility that happened a long time before the rupture of membranes. Diseases such as cystitis, cervicitis, and vaginitis there together with hipermotilias uterus. amniotic membrane is too thin (fetal abnormalities). Infection (chorioamnionitis or amnionitis). Other factors that predispose was: polyhydramnios, smoking, incompetent cervix. Artificial premature rupture of membranes (amniotomy), where amniotic solved too early.

In this patient was found history of whitish discharge including itchiness , trauma was also found.

Teori DIAGNOSIS: History: a history of water discharge, cloudy white, clear, yellow-green or brown a little or a lot through the vagina, wet feeling in the perineum. Of history can also be found to the reduced size of the uterus. CLINICAL EXAMINATION: With a direct discharge from the genitals. With inspekulo, see amniotic fluid flowing out from the cervical canal. DIAGNOSIS SUPPORT: Litmus test: red Litmus turns blue when there is amniotic fluid, this is due to the alkaline pH amnion (pH 7.1 to 7.4).

Kasus Patient came with chief complaint of water discharge.

From inspekulo fluid was found in the posterior fornix and was cleaned. Conclusion: fluid flowing from OUI.valsava test (+).nitrazin (+) , blood (-), lividae (+), flour albus (+)

Teori

Kasus

LABORATORY EXAMINATION Examination of leukocytes> 15,000 / UL if there is an infection .

11 September 2012 Hb :10,5 g/dL Ht : 32,6.1 % Leukocyte : 17.300/mm3 Thrombocyte : 313.000/mm3 POST SC 11 September 2012 Hb :9,8g/dL Ht : 34,6% Leukocyte : 14.300/mm3 Thrombocyte : 265.000/mm3

MANAGEMENT Based on gestational age Viable For Life (gestational age> 37 weeks, weight> 2500 g) in the absence of chorioamnionitis Good observation for 6 - 12 hours after rupture of membranes, waiting for signs of the onset of spontaneous inpartu. Perform induction of parturition when there has been no sign of inpartu to prevent the risk of infection

Vital signs and pregnancy advances was monitored. After 2hours and 30 minutes the patients started having contraction of giving labour with fetal movement (+), His 2x30/10, fetal heart rate 172x/I, opening of cervix 2 cm, eff 100%, membrane was not found, amnion fluid color greenish. With consideration to fetal tachycardia, the patient was opted for an emergency C section. ER Viccillin injection 1,5gram/8jam POST C-SEC Amoxicillin tablet 3X500mg

Antibiotics showed effective results in prolonging the latency period until delivery and may reduce the number of infections in patients with KPD. Ampicillin 2 g IV every 6 hours + Erythromycin 250 mg every 6 hours. After 48 hours, if labor is retained, it can be replaced with Amoxicillin 250 mg orally per 8 hour

CONCLUSION
A women aged 35 years old came to the Emergency Department of Pringadi Hospital on the 11 august at 09.00 WIB with the chief complaint of watery discharge from her pubic. This has been experienced from the day

before at about 2000 WIB. Abdominal discomfort due to labour was not felt. History of trauma and whitish discharge was found. Whitish discharge was odorless and itchy. History of trauma/ knocking against the door during pregnancy was found.This is her first pregnancy. Last menstrual period : ?/12/2011, Estimated delivery date: ?/9/2012. Signs of labour was not found.

 From inspection there were no abnormalities. From obstetrics finding, the abdomen was asymmetrically enlarged and during palpation Leopold 1 : 31cm, Leopold II : on the left, Leopold III : the head and Leopold IV : the head is as low as 4/5, fetal heart rate 140 x/minute, HIS wasnt found. From inspekulo fluid was found in the

posterior fornix and was cleaned. Conclusion: fluid flowing from OUI. Valsava test (+), nitrazin test (+) , blood (-), lividae (+), flour albus (+). From USG findings : IUP (37-38)week + head presentation+life baby.

Patient was diagnosed with preterm rupture of membrane + primigravida+ IUP (37-38 week) + head presentation+ life baby and was planned for termination of pregnancy with oxytocin induction. Vital signs was monitored and pregnancy advances was monitored. After 2 hours and 30 minutes the patients started having labour contraction with fetal movement (+), His 2x30/10, fetal heart rate 172x/I, opening of cervix 2 cm,eff 80%, membrane was not found, amnion fluid colour green.

With consideration to fetal tachycardia the patient was opted for an emergency C section. A baby girl was born with BW: 2750 g, BL :48 cm, A/S : 7/8, anus (+). The patient was stabil post operation and was monitored for three days and then discharged.

PROBLEMS
1. Is the management of this patient correct ? 2. What is a generals practitioners responsibility if presented with such case?