Introduction

Premature rupture of membranes (PROM) remains a subject of great clinical relevance and intense interest and is day to day problem for each and every obstetrician. Despite exhaustive research, most aspects of PROM remain enigmatic. The mechanism of PROM is unknown, no standards for diagnosis exist and most facets of management are controversial. PROM is a major cause for prematurity which leads to increased perinatal morbidity and mortality. As prevention of PROM is difficult due to obscurity of etiology, one has to concentrate more on management of PROM to reduce its complications. Ultimate goal of obstetrics is a pregnancy that results in healthy infant and minimally traumatized mother. This study was aimed to understand incidence, etiopathogenesis, subsequent course of pregnancy, neonatal morbidity and mortality, maternal morbidity and mortality in case of PROM and its effective management and prevention strategy.

Materials And Methods

This was a prospective study carried out from August 2009 to August 2010 at Guru Gobindsingh Hospital, M.P.Shah Medical College, Jamnagar, Gujarat, India.

All patients were admitted and selected on the following criteria.

EXCLUSION CRITERIAS:

All patients were admitted and detail history was taken. Thorough clinical examination and necessary laboratory investigations were done. Per-speculum examination was done to confirm diagnosis. Presence or absences of membranes were noted. Pre-induction Bishop's score was noted in all cases. After written consent induction of labor was done with Foley’s catheter. After expulsion of catheter, if satisfactory cervical dilatation and effacement did not occur PGE₂gel application was done. All patients were assessed after 6 hours and 12 hours of gel instillation and corresponding Bishop's score were noted. Observation was made regarding the mode of delivery. The babies were observed just after birth, Apgar score was recorded at 1 and 5 minutes. Baby was examined for maturity and any congenital anomaly and followed up till discharge. All the puerperium patients were observed for any adverse outcomes.

Observations And Results

The observation tables of 384 cases of PROM admitted in G.G Hospital, M.P.Shah Medical College, Jamnagar, Gujarat, India.

Figure 1

TABLE – I: INCIDENCE OF PROM

Figure 2

TABLE – II : AGEWISE DISTRIBUTION OF PATIENTS (N-384)

Figure 3

TABLE – III: GRAVIDITY (N-384)

Figure 4

TABLE – IV: GESTATIONAL AGE (N-384)

Figure 5

TABLE – V: ASSOCIATED CONDITIONS

Figure 6

TABLE – VI: MATERNAL MORBIDITY

Figure 7

TABLE – VII: NEONATAL OUTCOME

Figure 8

TABLE – VIII: NEONATAL MORBIDITY

Figure 9

TABLE – IX: NEONATAL MORTALITY

Discussion

The incidence of PROM was 5.2% (Table I). 237 (61.7%) patients came from rural area and 147 (38.3%) were from urban area. The PROM was frequent among patients belonging to low socioeconomic class. Residential area definitely makes difference in incidence of PROM. In rural area because of unhygienic conditions, there are more chances of infection, which is an independent risk factor for PROM^{(1, 2, 3, 4)}. Lower socio-economic condition also predispose to malnutrition. The maximum incidence of PROM (77.6%) was between age group off 21-30 years, being highest in 21-25 year group (Table II). It was evident that no age was immune for PROM. The apparent higher incidence of PROM in age group 21-25 years was due to fact that our patients complete their child bearing in 3 ^rd decade. The incidence of PROM was 60.7% in primigravda while it was 39.3% in multigravida patients (Table III).340 (88.5%) cases were associated with term PROM while incidence of preterm PROM was 11.5% (Table IV). In the present study 18.17% cases were associated with some other disorders of pregnancy like anemia, PET and Rh negative pregnancy. In anemia, the chances of infections are more thus there are more chances of PROM. The conditions which cause irritation of uterus may lead to preterm labor or PROM. In present series due to diarrhea and fever 17 (4.42%) cases developed PROM (Table V). All patients were managed aggressively. Out of 384 patients 355 (92.5%) patients were delivered within 20 hours. Only 29 (7.5%) patients were delivered between 21-48 hours. No patient in this study was delivered after 48 hours. Normal vaginal delivery was the commonest mode of delivery (338 cases, 88. %), while instrumental delivery rate was only 0.5 %( 2 cases) and caesarean section rate was 11.5% (44 cases). The common indications of LSCS were fetal distress in 1 ^st stage of labor (50.0%)⁽⁵⁾ and failure to progress in 1 ^st stage of labor (31.8%). Maternal morbidity was 3.12% in form of post partum fever and abdominal distension (Table VI). From these patients, 11 (91.7%) patients had PROM delivery interval of more than 20 hrs. All these patients were treated with broad spectrum antibiotics for 7 days. Maternal morbidity increased with increased PROM delivery interval. 98 (51.6%) babies were 2.5 kg or less, and 186 (48.4%) neonates were more than 2.5 kg (Table VII). So, it was evident that PROM was associated with prematurity and low birth weight. 15 neonates (3.90%) had low Apgar score at 1 and 5 minutes (Table VII). Out of these 15 neonates having low Apgar score, 11 expired in neonatal period. There were no ante partum or intrapartum fetal deaths. Out of 384 newborns, 11 (2.9%) neonates expired in neonatal period. Perinatal mortality was 2.86%. 13 (3.38%) neonates had developed morbidity (Table VIII). Out of them 2 (0.52%) babies died. From these 13 neonates 9 newborns had low birth weight and had gestational age of less than 37 weeks. So, neonatal morbidity increases significantly in prematurity and low birth weight. Neonatal mortality was 2.86%. 7 neonates expired from RDS and 4 neonates expired from birth asphyxia. Out of them 6 babies were preterm having birth weight of less than 2 kgs and expired due to prematurity and RDS. 4 babies expired from perinatal asphyxia and 1 baby from RDS. (Table IX).

Summary And Conclusions

As the etiology of PROM remains obscure, prevention is difficult and so one has to concentrate more on its management. The ultimate goal of obstetrics is a pregnancy that results in healthy infant and minimally traumatized mother. The art of good obstetric care involves balance of avoiding caesarean section with its attendant complications. Women who are given aggressive management have less chances of chorioamnionitis, neonatal infection and morbidity and thus less hospital stay. There is increased maternal morbidity with PROM, but with availability of broad-spectrum antibiotics, it has decreased. Maternal morbidity is directly related to PROM delivery interval. It would appear that the optimal condition for perinatal survival in a pregnancy complicated by PROM would be a birth weight greater than 2000 grams and a latent period less than 24 hrs in absence of any infection. Therefore the delivery should be within a reasonable period of time. PROM is one of the major associated factors in prematurity and thus leading to high perinatal mortality. Neonatal morbidity is also increased by PROM due to prematurity. Looking after a premature infant puts immense burden on the economic and health care resources of the country. Therefore risk scoring strategies involving the demographic variables along with previous history of preterm deliveries should be developed to identify high risk cases and treating them prior to rupture of membranes. PROM is much more detrimental to baby rather than to mother the fact that has altered the management of PROM in modern obstetrics. A proposed plan of “Aggressive management” irrespective of term of gestation is final answer to decrease maternal and neonatal morbidity and mortality⁽⁶⁾.