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8/10/2019 Ketuban Pecah Dini-prom

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Premature Ruptureof Membranes

UNC School of MedicineObstetrics and Gynecology Clerkship

Case Based Seminar Series

PREMATURE RUPTURE OFMEMBRANES (PROM)


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Premature rupture of membranes (PROM)Ketuban pecah/selaput ketuban robek sebelum inpartu/Partus kala I fase laten

Preterm premature rupture of membranes (PPROM)PROM < 37-mgg

Definisi


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PROM 12% of all pregnanciesPROM 8% term pregnanciesPPROM 30% of preterm deliveries

Incidence


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Anamnesakeluar air- air ( jumlah, warna, bau)Air ketuban merembes

Pemeriksaan fisikPemeriksaan Spekulum

MinimalisiarVaginal ToucherKeluar cairan amnion dari osteum uteri eksternumMengetahui warna, bau

Mengetahui pembukaan

PROM/PPROM:


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TestNitrazine test/lakmus

Lakmus merah biruLakmus biru biru (pH > 7.1)

USG : jumlah air ketuban

Fern test(+) : gambaran spt daun(-)

PROM/PPROM: Diagnosis


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False positive Nitrazine testAlkaline urineSemen (recent coitus)Cervical mucusBlood contamination

Vaginitis (e.g. Trichomonas)

False-Negative Nitrazine testTidak ada sisa ketuban di vaginaAir ketuban merembes sedikit

PROM/PPROM: Diagnosis


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PROM/PPROM: Risk Factors

Risk Factors:Prior PROM or PPROMPrior preterm deliveryMultiple gestation

PolyhydramniosIncompetent cervixVaginal/Cervical Infection

Gonorrhea, Chlamydia, GBS, S. AureusAntepartum bleeding (threatened abortion)

SmokingPoor nutrition


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Patient counselingExpectant management vs. induction of laborGBS prophylaxis NOT recommended

AntibioticsIncomplete data

Corticosteriods NOT recommended

Management: PPROM(< 24 mgg)


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Patient counseling

Fetal complications of prolonged PPROMPulmonary hypoplasiaSkeletal malformationsFetal growth restrictionIUFD

Maternal complications of prolonged PPROMChorioamnionitishttp://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/dataShow.cfm

Management: PPROM(< 24 wk gestation previable)

Gestational Age(In Completed

Weeks)

Death BeforeNICU Discharge

Outcomes at 18 to 22 Months Corrected Age*

DeathDeath/ Profound

NeurodevelopmentalImpairment

Death/Moderate to Severe Neuro-developmental Impairment

22 Weeks 95% 95% 98% 99%23 Weeks 74% 74% 84% 91%24 Weeks 44% 44% 57% 72%25 Weeks 24% 25% 38% 54%


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Expectant managementDeliver at 34 wksUnless documented fetal lung maturity

GBS prophylaxisAntibioticsCorticosteroids

No consensus, some experts recommend

Management: PPROM(24 33 wk gestation)


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Proceed to deliveryInduction of labor

GBS prophylaxis

Management: PROM(> 34 wk gestation)


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AntibioticsProlong latency periodProphylaxis of GBS in neonatePrevention of maternal chorioamnionitis and neonatal sepsis

CorticosteroidsEnhance fetal lung maturityDecrease risk of RDS, IVH, and necrotizing enterocolitis

TocolyticsDelay delivery to allow administration of corticosteroidsControversial, randomized trials have shown no pregnancyprolongation

Management: Rationale


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AntibioticsAmpicillin 2 g IV Q6 x 48 hrsAmoxicillin 500 mg po TID x 5 daysAzithromycin 1 g po x 1

CorticosteroidsBetamethasone 12 mg IM q24 x 2Dexamethasone 6 mg IM q12 x 4

TocolyticsNifedipine 10 mg po q20min x 3, then q6 x 48 hrs

Management: Drug Regimen


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Typically performed after 32 wks

Tests for fetal lung maturity (FLM)Lecethin/Sphingomyelin ratio (not commonlyused, more for historic interest)

L/S ratio > 2 indicates pulmonary maturityPhosphatidylglycerol

> 0.5 associated with minimal respiratory distress

Flouresecence polarization (FLM-TDx II)> 55 mg/g of albumin

Lamellar body count30,000-40,000

If negative, proceed with expectantmanagement until 34 wks

Management: Amniocentesis

Courtesy of Thomas Shipp, MD.


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Maternal: Monitor for signs of infectionTemperatureMaternal heart rateFetal heart rate

Uterine tendernessContractions

Fetal: Monitor for fetal well-beingKick countsNonstress tests ( NSTs)Biophysical profile (BPP)

Management: Surveillance


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Expectant Management Risks:

MaternalIncrease in chorioamnionitisIncrease in Cesarean deliverySpontaneous labor in ~ 90% within 48 hr ROMIncreased risk of placental abruption

FetalIncrease in RDSIncrease in intraventricular hemorrhageIncrease in neonatal sepsis and subsequent cerebral palsyIncrease in perinatal mortalityIncrease in cord prolapse

Expectant Managementvs. Preterm Delivery


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Preterm Delivery Risks: use NICHD calculatorhttp://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/epbo_case.cfm

Expectant Managementvs. Preterm Delivery

Gestation(w)

Weight Sex Steroids Survival Survival w/oprofound NDimpairment

25 550 Female Yes 64% 50%24 500 Male Yes 35% 22%

23 450 Male Yes 16% 9%

22 401g Female No 2% 1%
http://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/epbo_case.cfmhttp://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/epbo_case.cfmhttp://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/epbo_case.cfmhttp://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/epbo_case.cfmhttp://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/epbo_case.cfm


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Bottom Line ConceptsPreterm premature rupture of membranes refers to rupture of fetalmembranes prior to labor in pregnancies < 37 weeks.

A history of PPROM or PROM, genital tract infection, antepartum bleeding,and smoking are risk factors for PPROM and PROM.

A clinical history suggestive of PPROM or PROM should be confirmed withvisual inspection and laboratory tests including ferning and nitrazinepaper.

Management of PPROM at < 24 wks includes a discussion with the familyreviewing the maternal risks against the fetal risks of significant morbidityand mortality during expectant management.

For women with PPROM or PROM in whom intrauterine infection,abruptio placenta, repetitive fetal heart rate decelerations, or a high risk ofcord prolapse is present, immediate delivery is recommended.

Counseling after the delivery for the recurrence risk of PROM should

occur, and modifiable risk factors addressed


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References and Resources

APGO Medical Student Educational Objectives, 9 th edition, (2009),

Educational Topic 25 (p52-53).

Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, WilliamNP Herbert, Douglas W Laube, Roger P Smith. Chapter 22 (p213-217).

Hacker & Moore: Hacker and Moore's Essentials of Obstetrics andGynecology, 5th edition (2009) , Neville F Hacker, Joseph C Gambone,Calvin J Hobe l. Chapter 12 (p150-153).

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