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1. Premature rupture of membranes
UE MED 518
Presented by
Dr. E. NKWABONG
Pr. MBU R
Obstetricians - Gynaecologists
FMBS - Yaoundé

2. Scheme
1) Introduction
2) Definition of PRM
3) Aetiologies
4) Pathologies
5) Clinical signs
6) Differential diagnosis
7) Paraclinical
8) Complications
9) Treatment
10) Conclusion

3. Objectives :
At the end of the lecture, the student should be
capable of:
1. Defining PRM.
2. Give 4 risk factors for PRM
3. Cite 2 clinical signs of PRM
4. Give 2 differential diagnosis of PRM
5. Give 4 paralinical investigations for
confirmation of PRM
6. Enumerate 3 complications of PRM

4. 1) Introduction
• Target: Medical student, M2 level.
• Presentation:
* PRM is a frequent complaint in Obstetrics (6% of
all pregnancies). It is associated with increased
perinatal morbidity and mortality.
*Hence, prompt diagnosis and management
should be conducted.
.

5. 2) Definition
• Premature rupture of membranes (PRM) is
rupture of membranes (more than 1 hour)
before unset of labour.
It can occur preterm (preterm rupture of
membranes) or at term (prelabor rupture of
membranes.
• If 24 h elapse between rupture of membranes
and unset of labour, it is called prolonged
rupture of membranes.

6. 3) Aetiologies
3.1) Maternal causes:
• Cervicitis, vaginitis, STD
• Incompetent cervix.
• Urinary tract infection
• Malformed uterus (U. didelphys, U septus,…)

7. Maternal causes (continue)
• Undernutrition (abnormal collagen)
• Grand multiparity.
• Past history of PRM (abnormal congenital
collagen resistance).

8. 3.2) Fœtal causes
• Polyhydramnios
• Abnormal presentation (breech, transverse,…
• Multiple pregnancies
• Chorioamnionitis.
• Placenta praevia.
3.3) Traumatic causes

9. 4) Pathology
PRM is the most frequent cause of
premature labour, cord prolapse, intra
amniotic infection.
That is why there is a high perinatal
mortality associated with PRM, especially
when it occurs before term.

10. 5) Clinical signs
• Vaginal flow of liquid (continuous or not).
• Speculum examination: look for fluid coming
from the cervical canal.
• If there is any, do Valsalva maneuvre (increase
of intra abdominal pressure)

11. 6) Differential diagnosis
• Urinary incontinence
• Fissuration of membranes.
• Rupture of an amniochorial pouch
• Vaginitis with increased vaginal secretion.
• Normal or premature labour (labor pain not
really felt).

12. 7) Paraclinical investigation
7.1) For diagnosis:
• Nitrazine test (brown to blue if PRM).
• Fern test (1 drop of liquid on a slide, let it dry
at air, observe under microscope).
• Look for Lecithin/Sphingomyelin,
phosphatidylglycerol in liquid collected from
the pouch of Douglas.

13. Paraclinical (continue)
7.2) For treatment:
• Cervical swab (PCV)
• FBC, blood parasites
• Urine culture
• Ultrasound scan (amniotic fluid, gestational age,
fœtal weight)
• …

14. 8) Complications:
• Cord prolapse
• Abruptio placentae
• Chorioamnionitis (fever of 38 ° or more after
PRM, leucocytosis > 16000, uterine tenderness,
maternal and foetal tachycardia).
• Maternal complications are: endometritis,
salpingitis, …

15. Complications (continue)
• Premature labour and delivery (neonatal
mortality is increased: 4 times, Respiratory
distress syndrom: 3 times, neonatal sepsis, intra
ventricular bleeding.
• Prophylactic antibiotic seems to reduce these
complications.

16. 9) Treatment:
• The aims are to reduce the risk of infection
(chorioamnionitis) and to accelerate lungs maturity if
necessary before delivery.
• However, in case of chorioamnionitis, the fœtus must
be delivered as soon as possible.

17. Treatment (continue)
• The 2 major risks are prematurity and fœtal
infection.
• The treatment will depend on the gestational age
and the fœtal weight.
• Before delivery, a neonatal unit and a
neonatalogist should be contacted

18. 9.1) Before 28 weeks:
• Use parenteral antibiotic for 2 days, then orally
(ceftriaxone or erythromycin.
• NB: amoxicillin-clavulanic acid leads to an increased
incidence of necrotizing enterocolitis).
• Before 25 weeks, there is risk of fetal lungs
hypoplasia, neurological damage and limb
compression deformities if PRM with oligoamnios

19. Treatment Before 28 weeks (continuation)
• Antibioprophylaxis reduces in newborns
respiratory distress syndrome, necrotizing
enterocolitis, and composite adverse outcomes.
•
• The latency period is increased.
• Prolonged use of ATB increases the risk for
selection of resistant bacteria.

20. 9.2) Between 28 and 32 weeks:
*ATB,
*Corticotherapy (betamethasone: 12 mg IM to be
repeated after 12 to 24 hours or dexamethasone: 6
mg intramuscularly every 12 hours for four doses).
*NB: A single course of betamethasone is associated
with a significantly reduced incidence of
periventricular leukomalacia.

21. Treatment Between 28 and 32 weeks (continuation)
*No tocolysis or only for 24 to 48 h to allow lungs
maturation. Association of tocolysis and
corticotherapy increases the risk of maternal
pulmonary oedema .

22. Treatment (continuation)
9.3) Between 32 and 34 weeks: ATB,
Corticosteroids (debated), if L/S is more than
1.8, then induced labour or perform C/S
9.4) After 34 weeks or fœtal weight > 2000 g:
ATB, prepare for delivery.

23. 9.5) Prevention of chorioamnionitis:
• No digital vaginal examination (only 1 is necessary
when we are ready to deliver the fœtus: Bishop
score, Pelvis evaluation,…). It shortens latency
period.
• Change pad every 4 hours (2 for others)
• No sexual intercourse

24. 9.6) Precocious diagnosis of chorioamnionitis:
• Temperature every 6 hours (2 for others).
• Appreciate the colour & odor of amniotic fluid.
• FBC, CRP.
• Look for tenderness of uterine fundus

25. 9.7) For fetal well-being:
• FHR every 2 hours (or 15 min if she is in
labour)

26. 10) Conclusion:
• When premature rupture of membranes is
suspected, it must be confirmed or ruled out.
• When it is diagnosed, the treatment must be
correct.
• Don’t hesitate to have the point of view of a
neonatalogist if you want to deliver a premature
baby.
• For neonatal better care, a neonatal unit should
be available.

27. • Références:
* Current Obstetrics & Gynaecologic diagnosis & treatment
2007
* Williams Obstetrics 2007
* Dewhurst’s textbook of Obstetrics & Gynaecology for
postgraduates
• Modalités de l’évaluation: QCM, QROC, questions
Rédactionnelles
• Conseils: Consulter la bibliographie, être assidu(e) pendant
les stages cliniques,
• Contact: Dr Nkwabong, service de gynécologie, CHU
Yaoundé, Tel. 99663843/ 77450104

28. Thanks for your kind
attention