MANAGEMENT OUTCOME OF PREMATURE RUPTURE OF MEMBRANES IN A TERTIARY HEALTH FACILITY IN SOUTH WESTERN NIGERIA

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B.K Suleiman^1,2, O.O Bello^2,3*, A.M Tijani¹ and T.A.O Oluwasola^2,3

1. Department of Obstetrics and Gynaecology, Ladoke Akintola University of Technology Teaching Hospital, Ogbomoso, Nigeria.
2. Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria. 
3. Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria.

Abstract

Background: Pre-labour Rupture of Membranes (PROM) contributes immensely to the potential risk of maternal morbidity and mortality. Objective: To explore the incidence and management outcome of PROM at Ladoke Akintola University of Technology Teaching Hospital (LTH), Ogbomoso, Nigeria 

Methods: A retrospective study of 61 cases of PROM managed at LTH, Ogbomoso over a 3-year period. Information on the socio-demographics and obstetrics characteristics, management instituted, and outcomes were obtained using a structured proforma. Data were analysed using SPSS version 20. Level of statistical significance was set at <0.05 and 95% confidence interval. 

Results: The incidence of PROM was 4.1% with a perinatal mortality rate of 0.18 per 1000 deliveries. Twenty (33%) were pre-term while 41 (67%) were term PROM with 10% of the perinatal death occurring among those with preterm PROM. The mean age of the women was 36.9 (SD=2.1) years and median parity of 1(range 1-5) children. There was a significant association between the women’s gestational age at which PROM occurred with the latency period (p< 0.001). Fetal birth weight, APGAR score and Neonatal Intensive Care Unit (NICU) admission were all significantly associated with the gestational age at which PROM occurred (p<0.05). There was a significant difference between the intervention instituted and mode of delivery (p=0.009). 

Conclusion: The incidence of PROM at term was high and conservative/ expectant management was effective. The latency period and fetal outcomes such as birth weight, apgar score and NICU admission were determined by the gestational age at which PROM occurred.

Keywords: PROM, Incidence, Preterm, Term

Introduction

Pre-labour or premature rupture of membranes is the rupture of membranes before the onset of labour after the age of viability and could be term or preterm depending on the gestational age it occurred.^1,2 PROM poses one of the most important therapeutic predicaments in current obstetric practice, complicating approximately 5% to 10% of term pregnancies and between 2.3% and 30% of preterm deliveries.^3,4,5 It is associated with a perinatal morbidity and mortality with a rate in excess of 20%, and the outcomes are primarily dependent on the gestational age at delivery. However, other factors that affect fetomaternal outcomes include previous history of PROM, presence of bacteria vaginosis, poor nutrition and poor socioeconomic status.^6,7 On the other hand, the adverse effects and outcome of PROM can be minimized by making prompt diagnosis, commencing antibiotic therapy, stimulating labour and delivery.^2,6,8,9

Rupture of membranes results from a variety of factors that lead to accelerated membrane weakening which could be caused by an increase in local cytokines, imbalance in the interaction between matrix metalloproteinases and their tissue inhibitors, increased collagenase and protease activities, as well as other factors that can cause increased intrauterine pressure.¹⁰ The major risk factors often identified are previous history of PROM, previous genital infection especially bacterial vaginosis, cervical incompetence, uterine over distension, poor nutrition and poor socio-economic status. ^6,11,12

Diagnosis is generally confirmed by either direct visualization of amniotic fluid egressing from the cervical os during a sterile speculum examination, demonstration of a vaginal pH >6.0, or ferning on microscopic examination.¹³ Management is highly variable depending on gestational age and the clinical setting¹⁴ and in some cases the management of PROM at term could be controversial. The major problem regarding management of these patients is timely and accurate diagnosis and whether to allow them wait for spontaneous commencement of labour or to stimulate their labour. Patients’ wishes and desires have also been documented as pertinent in decision making.^11,15

In developing countries extra uterine survival of fetuses at gestational ages less than 28 weeks is quite slim which informed the decision to manage PROM occurring before 34 weeks gestation conservatively, usually with antibiotics, steroids therapy for lung maturity, strict bed rest and continuous fetal monitoring and surveillance. These measures have occasionally proved to improve neonatal outcomes. ^6,16,17 Notwithstanding, the management of PROM at term remains controversial with some researchers supporting the stimulation of labour against, expectant management so as to decrease the risk of chorioamnionitis without increasing the caesarean delivery rate.^6,16,18

It has been documented that intra-amniotic infection occurs in 13%–60% of women with PROM aside the incidences of pre-term birth and birth asphyxia which have been documented as being common contributors to maternal and fetal mortality in developing countries.⁴ Nigeria is included among the few countries responsible for more than 50% of the maternal and neonatal deaths globally.¹⁹ It is against this background that this study aimed to compare the feto-maternal outcomes following management of women with term and preterm PROM.