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Premature rupture of membranes (PROM) refers to a patient who is beyond 37 weeks' gestation

and has presented with rupture of membranes (ROM) prior to the onset of labor. Preterm
premature rupture of membranes (PPROM) is ROM prior to 37 weeks' gestation. Spontaneous
premature rupture of the membranes (SPROM) is ROM after or with the onset of labor.
Prolonged ROM is any ROM that persists for more than 24 hours and prior to the onset of labor.

At term, programmed cell death and activation of catabolic enzymes, such as collagenase and
mechanical forces, result in ruptured membranes. Preterm PROM occurs probably due to the
same mechanisms and premature activation of these pathways. However, early PROM also
appears to be linked to underlying pathologic processes, most likely due to inflammation and/or
infection of the membranes. Clinical factors associated with preterm PROM include low
socioeconomic status, low body mass index, tobacco use, preterm labor history, urinary tract
infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis.[1]

Eighty-five percent of neonatal morbidity and mortality is a result of prematurity. PPROM is


associated with 30-40% of preterm deliveries and is the leading identifiable cause of preterm
delivery. PPROM complicates 3% of all pregnancies and occurs in approximately 150,000
pregnancies yearly in the United States. When PPROM occurs remote from term, significant
risks of morbidity and mortality are present for both the fetus and the mother. Thus, the
physician caring for the pregnant woman whose pregnancy has been complicated with PPROM
plays an important role in management and needs to be familiar with potential complications and
possible interventions to minimize risks and maximize the probability of the desired outcome.
This article focuses on information the physician needs to achieve these goals.[2, 1, 3]

Premature preterm rupture of membranes (PPROM) occurring from 24-37 weeks' gestation is far
more difficult to manage than premature rupture of membranes (PROM) at term. Several issues
need to be considered in formulating a plan of management. Prematurity is the principal risk to
the fetus, while infection morbidity and its complications are the primary maternal risks. All
plans for management of PPROM remote from term should include the family and the medical
team caring for the pregnancy, including the neonatal and maternal medical team. Remote from
term, PPROM should only be cared for in facilities where a NICU is available and capable of
caring for the neonate. Because most PPROM pregnancies deliver within a week of ROM,
transfer of the pregnant mother to a qualified facility is urgent and should be facilitated
immediately upon diagnoses.

The vast majority of women proceed to active labor and deliver soon after PPROM. With
appropriate therapy and conservative management, approximately 50% of all remaining
pregnancies deliver each subsequent week after PPROM. Thus, very few women remain
pregnant more than 3-4 weeks after PPROM. This is important information to give the woman
considering expectant management remote from viability.[1]

Spontaneous sealing of the membranes does occur occasionally (< 10% of all cases), mostly after
PPROM that has occurred subsequent to amniocentesis; however, this is the exception rather
than the rule.
Several areas of controversies exist regarding the best medical approach or management of
PROM remote from term. Expectant management and immediate delivery are potential options
in these patients, and each has its own advantages and disadvantages. With appropriate care, the
maternal risks of expectant management are generally accepted to be minimal and a clear
neonatal advantage exists by reducing risks of prematurity.

Controversies exist as to interventions such as steroids for acceleration of lung maturity,


antibiotics, and tocolytics.

Mekanisme Ketuban Pecah Dini

Ketuban pecah dalam persalinan secara umum disebabkan oleh kontraksi uterus dan peregangan
berulang. Selaput ketuban pecah karena pada daerah tertentu terjadi perubahan biokimia yang
menyebabkan selaput ketuban inferior rapuh, bukan karena seluruh selaput ketuban rapuh.2

Terdapat keseimbangan antara sintesis dan degradasi ekstraselular matriks. Perubahan struktur,
jumlah sel, dan katabolisme kolagen menyebabkan aktivitas kolagen berubah dan menyebabkan
selaput ketuban pecah. Faktor risiko untuk terjadinya KPD adalah:2

berkurangnya asam askorbik sebagai komponen kolagen;


o kekurangan tembaga dan asam askorbik yang berakibat penumbuhan strukmr
normal karena antara lain merokok.2

Degradasi kolagen dimediasi oleh matriks metaloproteinase (MMP) yang dihambatan


oleh inhibitor jaringan spesifik dan inhibitor protease.1-3

Mendekati waktu persalinan, keseimbangan antara MMP dan TIMP-1 mengarah pada
degradasi proteolitik dari matriks ekstraselular dan membran janin. Aktivitas degrasi
proteolitik ini meningkat menjelang persalinan. Pada penyakit periodontitis di mana
terdapat peningkatan MMP, cenderung terjadi Ketuban Pecah Dini.1

Selaput ketuban sangat kuat pada kehamilan muda. Pada trimester ketiga selaput ketuban
mudah pecah. Melemahnya kekuatan selaput ketuban ada hubungannya dengan
pembesaran uterus, kontraksi rahim, dan gerakan janin. Pada trimester terakhir, terjadi
perubahan biokimia pada selaput ketuban. Pecahnya ketuban pada kehamilan aterm
merupakan hal fisiologis. Ketuban Pecah Dini pada kehamilan prematur disebabkan oleh
adanya faktor-faktor eksternal, misalnya infeksi yang menjalar dari vagina. Ketuban
Pecah Dini prematur sering terjadi pada polihidramnion, inkompeten serviks, solusio
plasenta.1-3

etiologi

a. Serviks inkompeten ( leher rahim yang lemah ) b. Melemahnya selaput ketuban c.


Melemahnya kekuatan regang selaput ketuban d. Air ketuban yang banyak
(polihidraamnion) e. Hamil kembar (gamelli) Infeksi : saluran kencing dan vagina Faktor
lain yang mempengaruhi terjadinya ketuban pecah dini : a. Faktor golongan darah b.
Faktor multi graviditas c. Defisiensi gizi dari tembaga atau asam askorbat (vitamin c) d.
Faktor disproporsi antar kepala dan tulang panggul