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PREMATURE
of
Membranes
RUPTURE OF
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
MEMBRANES
(PROM)
Definisi
Premature rupture of membranes (PROM)
Ketuban pecah/selaput ketuban robek sebelum
inpartu/ Partus kala I fase laten
Incidence
PROM 12% of all pregnancies
PROM 8% term pregnancies
PPROM 30% of preterm deliveries
PROM/PPROM:
Anamnesa
keluar air-air (jumlah, warna, bau)
Air ketuban merembes
Pemeriksaan fisik
Pemeriksaan Spekulum
MinimalisiarVaginal Toucher
Keluar cairan amnion dari osteum uteri eksternum
Mengetahui warna, bau
Mengetahui pembukaan
PROM/PPROM: Diagnosis
Test
Nitrazine test/lakmus
Lakmus merah biru
Lakmus biru biru (pH >
7.1)
PROM/PPROM: Diagnosis
False positive Nitrazine test
Alkaline urine
Semen (recent coitus)
Cervical mucus
Blood contamination
Vaginitis (e.g. Trichomonas)
Management: PPROM
(< 24 mgg)
Patient counseling
Expectant management vs. induction of labor
GBS prophylaxis NOT recommended
Antibiotics
Incomplete data
Management: PPROM
(< 24 wk gestation previable)
Patient counseling
Outcomes at 18 to 22 Months Corrected Age*
Gestational
Age
(In
Completed
Weeks)
22
23
24
25
Death Before
NICU Discharge
Death
Death/ Profound
Neurodevelopmental
Impairment
Weeks
95%
95%
Weeks
74%
74%
Weeks
44%
44%
Weeks
24%
25%
Fetal complications
of prolonged
Death/Moderate to Severe
Neurodevelopmental Impairment
98%
84%
57%
38%
PPROM
Pulmonary hypoplasia
Skeletal malformations
Fetal growth restriction
IUFD
99%
91%
72%
54%
Management: PPROM
(24 33 wk gestation)
Expectant management
Deliver at 34 wks
Unless documented fetal lung maturity
GBS prophylaxis
Antibiotics
Corticosteroids
No consensus, some experts recommend
Management: PROM
(> 34 wk gestation)
Proceed to delivery
Induction of labor
GBS prophylaxis
Management: Rationale
Antibiotics
Prolong latency period
Prophylaxis of GBS in neonate
Prevention of maternal chorioamnionitis and neonatal
sepsis
Corticosteroids
Enhance fetal lung maturity
Decrease risk of RDS, IVH, and necrotizing enterocolitis
Tocolytics
Delay delivery to allow administration of corticosteroids
Controversial, randomized trials have shown no
pregnancy prolongation
Corticosteroids
Betamethasone 12 mg IM q24 x 2
Dexamethasone 6 mg IM q12 x 4
Tocolytics
Nifedipine 10 mg po q20min x 3, then q6 x 48 hrs
Management: Amniocentesis
Typically performed after 32 wks
Tests for fetal lung maturity (FLM)
Lecethin/Sphingomyelin ratio (not
commonly used, more for historic
interest)
L/S ratio > 2 indicates pulmonary maturity
Phosphatidylglycerol
> 0.5 associated with minimal respiratory
distress
Management: Surveillance
Maternal: Monitor for signs of infection
Temperature
Maternal heart rate
Fetal heart rate
Uterine tenderness
Contractions
Management: Surveillance
Immediate Delivery
Intrauterine infection
Abruptio placenta
Repetitive fetal heart rate decelerations
Cord prolapse
Expectant Management
vs. Preterm Delivery
Expectant Management Risks:
Maternal
Increase in chorioamnionitis
Increase in Cesarean delivery
Spontaneous labor in ~ 90% within 48 hr ROM
Increased risk of placental abruption
Fetal
Increase in RDS
Increase in intraventricular hemorrhage
Increase in neonatal sepsis and subsequent cerebral
palsy
Increase in perinatal mortality
Increase in cord prolapse
Expectant Management
vs. Preterm Delivery
Preterm Delivery Risks: use NICHD calculator
http://
www.nichd.nih.gov/about/org/cdbpm/pp/prog_
epbo/epbo_case.cfm
Gestation Weight
(w)
Sex
Steroids
Survival
Survival
w/o
profound
ND
impairme
nt
25
550
Female
Yes
64%
50%
24
500
Male
Yes
35%
22%
23
450
Male
Yes
16%
9%
22
401g
Female
No
2%
1%
References and
Resources
APGO Medical Student Educational Objectives, 9th edition,
(2009), Educational Topic 25 (p52-53).