8/10/2019 Ketuban Pecah Dini-prom
1/21
Premature Ruptureof Membranes
UNC School of MedicineObstetrics and Gynecology Clerkship
Case Based Seminar Series
PREMATURE RUPTURE OFMEMBRANES (PROM)
8/10/2019 Ketuban Pecah Dini-prom
2/21
8/10/2019 Ketuban Pecah Dini-prom
3/21
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
8/10/2019 Ketuban Pecah Dini-prom
4/21
PROM 12% of all pregnanciesPROM 8% term pregnanciesPPROM 30% of preterm deliveries
Incidence
8/10/2019 Ketuban Pecah Dini-prom
5/21
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:
8/10/2019 Ketuban Pecah Dini-prom
6/21
TestNitrazine test/lakmus
Lakmus merah biruLakmus biru biru (pH > 7.1)
USG : jumlah air ketuban
Fern test(+) : gambaran spt daun(-)
PROM/PPROM: Diagnosis
8/10/2019 Ketuban Pecah Dini-prom
7/21
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
8/10/2019 Ketuban Pecah Dini-prom
8/21
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
8/10/2019 Ketuban Pecah Dini-prom
9/21
Patient counselingExpectant management vs. induction of laborGBS prophylaxis NOT recommended
AntibioticsIncomplete data
Corticosteriods NOT recommended
Management: PPROM(< 24 mgg)
8/10/2019 Ketuban Pecah Dini-prom
10/21
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%
8/10/2019 Ketuban Pecah Dini-prom
11/21
Expectant managementDeliver at 34 wksUnless documented fetal lung maturity
GBS prophylaxisAntibioticsCorticosteroids
No consensus, some experts recommend
Management: PPROM(24 33 wk gestation)
8/10/2019 Ketuban Pecah Dini-prom
12/21
Proceed to deliveryInduction of labor
GBS prophylaxis
Management: PROM(> 34 wk gestation)
8/10/2019 Ketuban Pecah Dini-prom
13/21
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
8/10/2019 Ketuban Pecah Dini-prom
14/21
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
8/10/2019 Ketuban Pecah Dini-prom
15/21
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.
8/10/2019 Ketuban Pecah Dini-prom
16/21
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
8/10/2019 Ketuban Pecah Dini-prom
17/21
8/10/2019 Ketuban Pecah Dini-prom
18/21
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
8/10/2019 Ketuban Pecah Dini-prom
19/21
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.cfm8/10/2019 Ketuban Pecah Dini-prom
20/21
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
8/10/2019 Ketuban Pecah Dini-prom
21/21
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).