CLINICAL SCIENCE SESSION

PERUBAHAN SITOKIN DAN MATRIKS METALLOPROTEINASE PADA PASIEN

DENGAN KETUBAN PECAH DINI DAN MAKNA KLINISNYA

Oleh:
SILVYA ANINDITA
G1A219044

Pembimbing:
Dr. dr. Herlambang, Sp.OG, KFM

BAGIAN OBSTETRI DAN GINEKOLOGI

RSUD RADEN MATTAHER JAMBI
FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN
UNIVERSITAS JAMBI
2020
 LEMBAR PENGESAHAN
CLINICAL SCIENCE SESSION (CSS)
PERUBAHAN SITOKIN DAN MATRIKS METALLOPROTEINASE PADA PASIEN
DENGAN KETUBAN PECAH DINI DAN MAKNA KLINISNYA

Oleh:
SILVYA ANINDITA

BAGIAN OBSTETRI DAN GINEKOLOGI

RSUD RADEN MATTAHER JAMBI
FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN
UNIVERSITAS JAMBI
2020

Jambi, Maret 2020

Pembimbing

Dr. dr. Herlambang, Sp.OG, KFM

 KATA PENGANTAR

Puji syukur atas kehadirat Allah SWT, karena dengan rahmat-Nya penulis dapat menyelesaikan
tugas Clinical Science Session (CSS) pada Kepaniteraan Klinik Senior Bagian Obstetri dan Ginekologi
Fakultas Kedokteran dan Kesehatan Universitas Jambi yang berjudul “Perubahan sitokin dan
matriks metalloproteinase pada pasien dengan ketuban pecah dini dan makna klinisnya”.
Clinical Science Session (CSS) ini bertujuan agar penulis dapat memahami lebih dalam teori-
teori yang diberikan selama menjalani Kepaniteraan Klinik Senior Bagian Obstetri dan Ginekologi di
RSUD Raden Mattaher Jambi, dan melihat penerapannya secara langsung di lapangan. Pada
kesempatan ini penulis mengucapkan banyak terima kasih kepada Dr. dr. Herlambang, Sp.OG, KFM
sebagai pembimbing yang telah meluangkan waktunya untuk membimbing penulis.
Penulis menyadari bahwa penulisan Clinical Science Session (CSS) ini masih banyak
kekurangan, oleh karena itu penulis sangat mengharapkan kritik dan saran yang bersifat membangun
dari semua pihak yang membacanya. Semoga tugas ini dapat memberikan manfaat bagi semua pihak
yang membutuhkan.

Jambi, Maret 2020

Penulis
 Journal of Hainan Medical University 2017; 23(20): 73-76 73

Journal of Hainan Medical University

http://www.hnykdxxb.com

Changes of cytokines and matrix metalloproteinases in patients with

premature rupture of chorioamnion and its clinical significance
Hao Li, Ai-Ping Ma
Department of Obstetrics and Gynecology, Hanchuan People's Hospital, Hubei, Hanchuan 431600, China

ARTICLE INFO ABSTRACT

Article history: Objective: To investigate changes of cytokines and matrix metalloproteinases in patients
Received 11 Oct 2017
Received in revised form 15 Oct
with premature rupture of membranes (PROM) with chorioamnionitis (HCA) and its clinical
2017 Accepted 18 Oct 2017 significance. Methods: A total of 80 pregnant women with premature rupture of membranes
Available online 28 Oct 2017 were selected as PROM group and 80 normal pregnant women as control group. The PROM
group was subgrouped into HCA group (n=45) and non HCA group (n=35) according to the
Keywords: presence or absence of HCA. Matrix metalloproteinases (MMP-8, MMP-9) and cytokines (IL-8,
Premature rupture of IL-10, TNF-α) in pregnant women were compared. Results: The level of IL-8, TNF-αwere
membranes Chorioamnionitis (420.45±110.26) ng/L, (413.53±125.19) ng/L in the PROM group, which were significantly
Cytokines higher than those in the control group; the levels of IL-10 were(332.07±48.12) ng/L in the PROM
Matrix metalloproteinases
groups, which were significantly lower than the control group. The levels of IL-8 and TNF-α in
PROM combined with HCA group were significantly higher than those in non-HCA group, the
levels of IL-10 were significantly lower than those in non-HCA group. The level of MMP-8,
MMP-9 were (11.02±2.48) ng/mL, (648.42±73.35) ng/L in the PROM group, which were
significantly higher than the control group. The levels of MMP-8, MMP-9 in
PROM combined with HCA were significantly higher than those in non-HCA group with the
difference was statistically significant. Conclusion: When premature rupture of membranes
and chorioamniositis occurring, pregnant women were accompanied by the level changes of
cytokines and matrix metalloproteinases, so timely monitoring of these indicators can offer
basis for the early diagnosis the premature rupture of membranes and chorioamnionitis,
which will help to reduce morbidity and mortality of the perinatal pregnant women and
newborns with important clinical value.

a basis for clinical diagnosis and treatment of chorionic amniotic

1. Introduction
Premature rupture of membranes (PROM) refers to the prenatal
rupture of membranes in pregnant women before being in labor, is the
most common complications of perinatal period, in which gestational
rupture of membranes happens when gestational age<37 weeks is also
known as preterm premature rupture of membranes (not full) [1,2].
Premature rupture of membranes can lead to the increase of preterm
birth rate, perinatal mortality, and intrauterine infection rate, which
has serious adverse consequences for pregnant women and
fetuses[3,4]. Histological evidences suggest that PROM pregnant
women are often associated with chorioamnionitis. But
chorioamnionitis has no obvious clinical symptoms, resulting in
prenatal diagnosis difficult[5,6]. The aim of this study is to provide

Corresponding author: Ai-Ping Ma, Department of Obstetrics and Gynecology,
Hanchuan People's Hospital, Hubei, Hanchuan 431600, China.
E-mail: lihao6463@163.com
Fund Project: Natural Science Fund of Hubei Province (Number: 2015ACe141).
membrane infection by investigating the changes in cytokines and
matrix metalloproteinases in patients with premature rupture of
membranes, after premature rupture of membranes.
2. Research objects and methods
2.1. Research objects
A total of 80 pregnant women with premature rupture of membranes
from Oct. 2016 to May. 2017 in our hospital were selected as PROM
group with ages of 22-30 years, gestational age of 30.5-36.4 weeks,
and 80 normal pregnant women as control group with ages of 23-30
years, gestational age of 37.6-41.4 weeks. The PROM group was
subgrouped into HCA group (n=45) and non-HCA group (n=35)
according to the presence or absence of HCA. The gender and age of
all the subjects were not significantly
 74 Hao Li et al./ Journal of Hainan Medical University 2017; 23(20): 73-76

different (P> 0.05). This study is in accordance with the standards

of the hospital ethics committee and the process is in compliance
with the requirements. 3. Results

2.2 Diagnostic criteria 3.1 Comparison of the cytokines levels in two

groups of pregnant women
(1) PROM diagnostic criteria[7]: (1) uncontrollable liquid outflow in
vaginal; (2) after the test paper, vaginal secretions PH≥7, indicating The levels of cytokines in two groups of pregnant women are shown
rupture of membrane; (3) after microscopic examination, rhabdoid in Table 1. The levels of IL-8 and TNF-α in PROM group were
crystals can be seen from vaginal liquid smear. After being stained (420.45 ± 110.26) ng/L, (413.53 ± 125.19) ng/L, respectively, which
with 0.5 ‰ meilan, vaginal liquid smear can see light blue or not significantly higher than those in the control group (310.23
colored fetal epithelium and hair; stained with 0.1% to 0.5% nylon ± 78.51) ng/L, (360.27 ± 68.32) ng/L. And the difference was
blue stained, vaginal liquid smear can see orange fetal epithelial cells, statistically significant (P<0.05). The level of IL-10 in the PROM
These can be diagnosed with premature rupture of membranes; group was (332.07 ± 48.12) ng/L, significantly lower than that in the
(4) the fetal hair can be observed by amniotic examination; (5) control group (380.42 ± 53.35) ng/L, the difference was
amniotic sac cannot be seen by ultrasonic examination of fetal statistically significant (P<0.05).
exposed parts. (2) HCA diagnostic criteria [8]: amniotic membrane
and chorionic tissue were tested by pathology examination, at high 3.2 Comparison of maternal cytokine levels in HCA
magnification, neutrophil infiltration of 5 to 30 could be consider and non-HCA groups
as mild to moderate HCA, more than 30 as severe HCA.
The levels of cytokines in HCA group and non-HCA group of
2.3 Testing indexes pregnant women were shown in Table 2. PROM group was
divided into HCA group and non-HCA group according to the
presence or absence of chorioamnionitis. The levels of IL-8 and
A totally of 5 mL of elbow venous blood of each pregnant woman
TNF-α in HCA group were (580.23 ± 108.51) ng/L, (485.33 ±
was collected. Blood serum was collected by centrifugation, placed at
125.19) ng/L, respectively, which was significantly higher than
EP tube and stored at -20 ℃ for further use. The levels of IL-8, IL-10,
that of non-HCA group (P<0.05). The level of IL-10 in HCA
MMP-8 and MMP-9 were measured by enzyme-linked immunosorbent
group was (278.51 ± 42.53) ng/L, which was significantly lower
assay (kit was improved by Beijing Bai'ulebo Technology Co., Ltd.).
than that in non-HCA group (P <0.05).
The level of TNF-α was detected by radioimmunoassay (kit was
purchased from Ruier Biotechnology Co., Ltd.). All the operating
process strictly follow the instructions.
3.3 Comparison of matrix metalloproteinase levels
of pregnant women in both groups
2.4 Statistical analysis
The levels of matrix metalloproteinases in two groups were
shown in Table 3. The levels of MMP-8 and MMP-9 in PROM
The data were analyzed by SPSS 17.0 software. The levels of
group were (11.02 ± 2.48) ng/mL, (648.42 ± 73.35) ng/L,
cytokines and matrix metalloproteinases in the study were
respectively, significantly higher than those in control group (7.36
consistent with the normal distribution, and described as Mean ±
± 1.42) ng/mL, (298.07 ± 38.42) ng/L, the difference was
SD. t test was conducted for all the data. Values of P<0.05 were
statistically significant (P<0.05).
considered to be statistically significant.
Table 1.
Comparison of the cytokines levels in two groups of pregnant women (ng/L).
n α

Groups IL-8 IL-10 TNF-

PROM 80 420.45±110.26 332.07±48.12 413.53±125.19
Control group 80 310.23±78.51 380.42±53.35 360.27±68.32
t 7.283 6.019 3.340
P 0.000 0.000 0.001

Table 2.
Comparison of maternal cytokine levels in HCA and non-HCA groups (ng/L).
Groups n IL-8 IL-10 TNF-α
HCA 45 580.23±108.51 278.51±42.53 485.33±125.19
Non-HCA 35 356.45±71.26 349.17±58.22 391.27±78.32
t 10.551 6.273 3.889
P 0.000 0.000 0.000
 Hao Li et al./ Journal of Hainan Medical University 2017; 23(20): 73-76
75
Table 3.
Comparison of matrix metalloproteinase levels of pregnant women in both groups.
Groups n MMP-8 (ng/mL) MMP-9 (ng/L)
PROM 80 11.02±2.48 648.42±73.35
Control group 80 7.36±1.42 298.07±38.42
t 11.455 37.844
P 0.000 0.000

Table 4.
Comparison of matrix metalloproteinase levels in HCA group and non-HCA group.
Groups n MMP-8 (ng/mL) MMP-9 (ng/L)
HCA 45 12.51±2.63 723.12±83.53
Non-HCA 35 9.54±1.97 538.27±58.62
t 5.572 11.127
P 0.000 0.000

in the chemokine family, which is secreted by macrophages and

3.4 Comparison of matrix metalloproteinase levels
in HCA group and non-HCA group
The levels of matrix metalloproteinases in HCA group and non-
HCA group were shown in Table 4. PROM group was divided into
HCA group and non-HCA group according to the presence or
absence of chorioamnionitis.
The levels of MMP-8 and MMP-9 in HCA group were (12.51 ±
epithelial cells, and react by binding to specific receptors [16]. The
study found that IL-8 also plays an important role in the entire
reproductive process of mammals [17]. In addition, IL-8 is associated
with certain reproductive pathologies such as endometriosis,
unexplained spontaneous abortion, etc[18]. IL-10 is a multi-cell source,
multifunctional cytokines, mainly secreted by mononuclear
macrophages, T helper cells and neutrophils, etc, mainly regulates cell
growth and differentiation, and participates in inflammatory response

2.63) ng/mL and (723.12 ± 83.53) ng/L, respectively, which was
significantly higher than that of non-HCA group (9.54 ± 1.97)
ng/mL, (538.27 ± 58.62) Ng/L, respectively, the difference was
statistically significant (P<0.05).
4. Discussion
Premature rupture of membranes is a more common obstetric
disease, and it is also one of the most common factors cause premature
birth, but the pathogeny is still not clear [9]. Related studies have shown
that infection is an important factor in the process of premature rupture
of membranes. In addition, changes in the structure of the membrane
itself, cervical insufficiency, intrauterine pressure abnormalities and
other factors also can cause premature rupture of membranes [10,11]. As
a common complication of premature rupture of membranes, HCA can
lead to fetal pulmonary infection, sepsis and enterocolitis [12,13].
Therefore, in the process of preterm premature rupture of membranes
treatment in pregnant women, predicting HCA and prevention it as
soon as possible can effectively reduce the incidence of related
complications.
TNF-α is an inflammatory factor secreted by monocyte-
macrophages, which plays an important role in the process of
inflammatory reaction by regulating the expression of other cytokines,
resulting in local inflammatory response amplification [14]. Under
normal circumstances, the low level of TNF-α helps to promote cell
proliferation, differentiation, improve the body anti-infection and
immune function. If the TNF-αcontent is high, it may seriously
damage the body[15]. IL-8 is a class of cytokines
and immune response, which is currently recognized as inflammation
and immunosuppressive factors[19]. The study found that IL-10 is
mainly inhibit monocyte-macrophage synthesis and release of
inflammatory mediators, so as to decrease the secretion of TNF-α,
IL-1β, IL-6, IL-8, G-CSF, GM-CSF and other cytokines which play
the role of inflammation. In addition, it can achieve anti-inflammatory
effects by enhancing the release of antiinflammatory factors such as
IL-1 receptor antagonists and soluble TNF-α receptors[20]. This study
showed that IL-8 and TNF-α levels in PROM group were
significantly higher than those in control group, especially in pregnant
women with HCA, and the difference was significant. The level of IL-
10 in PROM group was significantly lower than that in control group,
and the difference was significant in HCA pregnant women. The
results were consistent with those of Wang et al [21,22]. The results
showed that TNF-α and IL-8 were positively correlated with the
incidence of PROM and HCA in perinatal period, and IL-10 was
negatively correlated with perinatal PROM and HCA. Hence, the
cytokines mentioned above can be used as important indicators of the
occurrence of PROM and HCA.
Matrix metalloproteinases are proteolytic enzymes that containing
metal ions such as Ca 2+, Zn2+ in their structures. They usually use
extracellular matrix (ECM) as a hydrolytic substrate [23]. MMPs mainly
synthesized by the human decidua, smooth chorionic cells and
amniotic epithelial cells. The levels of MMP-8, MMP-9 and other
proteases will significantly increase in pregnant women with rupture
of membranes, childbirth and intrauterine infection [24]. The study
found that MMPs on the one hand can cause fetal membrane local
weak by degradation type Ⅰ, Ⅱ collagen (which could the
maintenance of fetal membrane elasticity and tension) of ECM, so
 76 Hao Li et al./ Journal of Hainan Medical University 2017; 23(20): 73-76
as to easily lead to premature rupture of membranes in the physical
effect; on the other hand, activated MMPs act on cervical fibroblasts,
degrade collagen in the extracellular matrix, relax the connective tissue
in the cervical matrix, leading to cervical expansion and mature in
advance, causing premature birth[25]. The results of this study showed
that the levels of MMP-8 and MMP-9 in PROM group were
significantly higher than those in control group. In addition, PROM
group in the merger of HCA pregnant women increased more
significantly. These results suggest that MMP-8 and MMP-9 have a
certain predictive value for the development of premature rupture of
membranes and chorioamnionitis.
In summary, when premature rupture of membranes and
chorionic amniotic inflammation occur, the levels of cytokines and
matrix metalloproteinases in pregnant women are likely to change.
Therefore, timely monitoring of these indicators can help reduce
the incidence and mortality of perinatal pregnant women and
newborns, and provide the basis for the early diagnosis of
premature rupture of membranes and chorioamnionitis, which has
an important clinical value.
References
[1] Armstrong-Wells J, Donnelly M, Post MD. Inflammatory predictors of
neurologic disability after preterm premature rupture of membranes.
Am J Obstetr Gynecol 2015; 212(2): 212-221.
[2] Dars S, Malik S, Samreen I. Maternal morbidity and perinatal outcome in
preterm premature rupture of membranes before 37 weeks gestation.
Pak J Med Sci Online 2014; 30(3): 626-629.
[3] Qiongjie Z, Weiyuan Z, Huan X. Risk factors for preterm premature
rupture of membranes in Chinese women from urban cities. Int J
Gynaecol Obstetr 2014; 127(3): 254-258.
[4] Menon R, Boldogh I, Hawkins HK. Histological evidence of oxidative
stress and premature senescence in preterm premature rupture of the
human fetal membranes recapitulated in vitro. Am J Pathol 2014;
184(6): 1740-1751.
[5] Zhao HY, Zhang Q, Wu YZ. Advances in predictive index of premature
rupture of membranes with chorioamnion. Mil Med J Southeast
China 2014; 29(4): 397-400.
[6] Guo L, Fan GS. Expression of MMP-2 and TIMP-2 in patients with
PROM combined chorioamnionitis. J Hainan Med Univ 2014; 20(2):
169-171.
[7] Xu XH. Diagnosis and standard nursing of premature rupture of
membranes. China Foreign Med Treatment 2011; 30(3): 149-149.
[8] Zhao ZY. Progress in study on diagnosis of chorioamnionitis. J Int
Obstetr Gynecol 2011; 38(3): 207-210.
[9] Zhang JH, Xie Y, Yang LZ. Clinical analysis of spontaneous preterm birth
and premature rupture of membrane. Chin J Family Plan
Gynecotokol 2013; 5(2): 51-54.
[10]Xia H, Li X, Li X. The clinical management and outcome of term
premature rupture of membrane in East China: results from a
retrospective multicenter study. Int J Clin Exp Med 2015; 8(4): 6212-
6217.
[11]Peng JL, Luo LQ, Cui-Ping LU. The diagnostic and treatment value of
procalcitonin in patients with premature rupture of membrane. Chin J
Family Planning Gynecotokol 2016; 8(3): 28-31.
[12]Zhang H, Wang LU, Wang J. Premature rupture of the fetal membrane
combined with subclinical chorioamnionitis negatively affects
pregnancy outcomes by a mechanism associated with reduced levels of
matrix metalloproteinase-2. Exp Ther Med 2015; 10(2): 561-565.
[13]Thornburg LL, Queenan R, Brandtgriffith B. Procalcitonin for
prediction of chorioamnionitis in preterm premature rupture of
membranes. J Maternal-fetal Neonatal Med 2015; 29(13): 1-6.
[14]Jin Y, Shen CX, Liu XN. Levels of IL-6, MMP-8, TNF- ααin serum
and amniotic fluid of preterm women with premature rupture of
membrane and their correlation with intrauterine infection. Chin J
Healthy Birth Child Care 2013; 19(3): 169-172.
[15]Liu XC, Chen YH, Zhang GY. Significance of the combination
detection of IL-6, IL-8, and TNF-α to PROM early intrauterine
infection. J Hainan Med Univ 2015; 21(12): 1655-1657.
[16]Song JH, Shan HO. The relationship between the content and
chorioamnionitis and neonatal prognosis in women with premature
rupture of membranes of IL-8 and TNF-α. Heilongjiang Med
Pharm 2015; 38(6): 146-147.
[17]Jia X. Value of amniotic fluid IL-8 and Annexin A2 in prediction of
preterm delivery in preterm labor and preterm premature rupture of
membranes. J Reprod Med 2014; 59(3-4): 154-160.
[18]Zhang J. Study on the relationship between IL-6 and IL-8 and
premature rupture of membranes and neonatal prognosis. Mater Child
Health Care China 2015; 30(9): 1390-1392.
[19]Zhu TH, Wang F, Kang L. The expression of matrix
metalloproteinases, tumor necrosis factor-alpha, interleukin-10 in
maternal plasma and their relationship with preterm delivery. Chin J
Clin Obstetr Gynecol 2012; 13(3): 183-186.
[20]Zu-Feng YE. Levels and significance of IL-10,TIMP-1,TNF-αin
serum and amniotic fluid of preterm women with premature rupture of
membranes. China J Modern Med 2013; 23(11): 98-100.
[21]Wang F, Zhu ZY. Analysis of serum and amniotic fluid TNF-α, IL-6
and IL-8 in pregnant women with premature rupture of membranes. J
Radioimmunol 2013; 26(3): 344-345.
[22]IL-10 in the treatment of premature rupture of membranes with
chorioamnionitis. Guangdong Med J 2014; 35(17): 2717-2720.
[23]Wang SM, Chen L. Study of matrix metalloproteinases and premature
rupture of membranes. China Med Herald 2013; 10(20): 22-23.
[24]Xiao JC, Dai W, Min-Juan XU. The predictive value of MMP-8 on
diagnosing preterm birth with premature rupture of membranes.
Modern Prevent Med 2013; 40(19): 3582-3593
[25]Ling WU, Chen XJ. The levels and significance of MMP-9 in serum
and amniotic fluid of preterm women with premature rupture of
membranes. China Pract Med 2010; 5(22): 34-35.
 PERUBAHAN SITOKIN DAN MATRIKS METALLOPROTEINASE PADA PASIEN
DENGAN KETUBAN PECAH DINI DAN MAKNA KLINISNYA
Hao Li, Ai-Ping Ma
Departemen Obstetri dan Ginekologi, Hanchuan Rakyat ' Hospital, Hubei, Hanchuan 431.600, Cina
Jurnal Universitas Kedokteran Hainan

Abstrak
Tujuan: Untuk menyelidiki perubahan sitokin dan matriks metalloproteinase pada pasien dengan
Premature Rupture of Membrane (PROM) dengan korioamnionitis (HCA) dan gambaran
klinisnya. Metode: Sebanyak 80 wanita hamil dengan ketuban pecah dini dipilih sebagai kelompok
PROM dan 80 wanita hamil normal sebagai kelompok kontrol. Kelompok PROM dikelompokkan
menjadi subkelompok HCA (n = 45) dan kelompok non-HCA (n = 35) berdasarkan ada atau tidak
adanya HCA. Matriks metaloproteinase (MMP-8, MMP-9) dan sitokin (IL-8, IL-10, TNF-α) pada
wanita hamil dibandingkan. Hasil: Kadar IL-8, TNF-α pada kelompok PROM adalah (420.45 ±
110.26) ng/L, (413.53 ± 125.19) ng/L, yang secara signifikan lebih tinggi dibandingkan kelompok
kontrol; Kadar IL-10 pada kelompok PROM adalah (332,07 ± 48,12) ng/L, yang secara signifikan lebih
rendah dibandingkan kelompok kontrol. Kadar IL-8 dan TNF-α pada kelompok PROM dengan HCA
secara signifikan lebih tinggi dibandingkan kelompok non-HCA, kadar IL-10 secara signifikan lebih
rendah dibandingkan kelompok non-HCA. Kadar MMP-8, MMP-9 pada kelompok PROM adalah
(11,02 ± 2,48) ng/mL, (648,42 ± 73,35) ng/L, yang secara signifikan lebih tinggi dibandingkan
kelompok kontrol. Kadar MMP-8, MMP-9 pada PROM dengan HCA secara signifikan lebih tinggi
dibandingkan kelompok non-HCA dengan perbedaannya bermakna secara statistik. Kesimpulan: Saat
ketuban pecah dini dan chorioamniositis terjadi, wanita hamil disertai dengan perubahan kadar sitokin
dan matriks metalloproteinase, Sehingga pengecekan berkala indikator ini dapat menjadi dasar
penegakkan diagnosis dini dari ketuban pecah dini dan chorioamnionitis, dimana dapat membantu
menurunkan angka morbiditas dan mortilitas pada ibu hamil dan bayi baru lahir dengan penilaian klinis
yang bermakna.

1. Pendahuluan
Premature Rupture of Membrane (PROM) atau Ketuban Pecah Dini (KPD) mengacu pada pecahnya
selaput ketuban dini pada wanita hamil sebelum melahirkan, yang merupakan komplikasi paling umum
pada periode perinatal, di mana pecahnya ketuban terjadi saat usia kehamilan <37 minggu juga dikenal
sebagai ketuban pecah sebelum waktu (KPSW) [1,2] . Ketuban pecah dini dapat menyebabkan
peningkatan angka kelahiran prematur, kematian perinatal, dan infeksi intrauterin, yang memiliki
konsekuensi buruk yang serius bagi wanita hamil dan janin [3,4] . Bukti histologis menunjukkan bahwa
KPD sering dikaitkan dengan korioamnionitis. Namun korioamnionitis tidak memiliki gejala klinis
yang jelas, mengakibatkan penegakkan diagnosis prenatal sulit [5,6] . Tujuan dari penelitian ini adalah
untuk menyediakan dasar untuk diagnosis klinis dan pengobatan infeksi membran korionik amniotik
dengan menginvestigasi perubahan sitokin dan matrix metalloproteinases pada pasien dengan KPD,
setelah ketuban pecah dini.

2. Objek penelitian dan metode

2.1. Objek penelitian
Sebanyak 80 wanita hamil dengan ketuban pecah dini dari Oktober 2016 hingga Mei. 2017 di rumah
sakit kami dipilih sebagai kelompok KPD dengan usia 22-30 tahun, usia kehamilan 30,5-36,4 minggu,
dan 80 wanita hamil normal sebagai kelompok kontrol dengan usia 23-30 tahun, usia kehamilan 37,6-
41,4 minggu. Grup KPD dikelompokkan ke dalam subkelompok HCA (n = 45) dan kelompok non-
HCA (n = 35) sesuai dengan ada atau tidak adanya HCA. Jenis kelamin dan usia semua subjek secara
signifikan tidak terlalu berbeda (P>0,05). Penelitian ini sesuai dengan standar komite etik rumah sakit
dan prosesnya telah sesuai dengan persyaratan yang ada.

2.2 Kriteria Diagnostik

(1) Kriteria diagnostik KPD [7] : (1) aliran cairan yang tidak terkendali di vagina; (2) setelah tes kertas,
sekresi vagina PH≥7, menunjukkan pecahnya membran; (3) setelah pemeriksaan mikroskopis, kristal
rhabdoid dapat dilihat dari cairan vagina. Setelah diwarnai dengan 0,5 ‰ meilan, pada apusan cairan
vagina dapat terlihat sel epitel dan rambut fetus yang berwarna biru muda atau tidak
berwarna; diwarnai dengan nilon warna biru 0,1% sampai 0,5%, apusan cairan vagina dapat terlihat sel
epitel janin berwarna oranye, Hal ini dapat didiagnosis dengan ketuban pecah dini; (4) rambut janin
dapat diamati dengan pemeriksaan amniotik; (5) kantung ketuban tidak bisa dilihat dengan
pemeriksaan USG bagian janin yang terbuka. (2) Kriteria diagnostik HCA [8] : pemeriksaan patologi
membran amniotik dan jaringan korionik, secara garis besar, infiltrasi neutrofil 5-30 dapat dianggap
sebagai HCA ringan hingga sedang, lebih dari 30 sebagai HCA berat.

2.3 Indeks Uji

Sebanyak 5 mL darah vena mediana cubiti dari setiap wanita hamil telah dikumpulkan. Serum darah
dikumpulkan dengan sentrifugasi, ditempatkan di tabung EP dan disimpan pada -20 ℃ untuk
penggunaan lebih lanjut. Kadar IL-8, IL-10, MMP-8 dan MMP-9 diukur dengan imunosorben yang
berikatan dengan enzim (kit ditingkatkan oleh Beijing Bai'ulebo Technology Co, Ltd). Kadar TNF-α
dideteksi oleh radioimmunoassay (kit dibeli dari Ruier Biotechnology Co, Ltd.). Semua proses
penelitian mengikuti instruksi dengan ketat.

2.4 Analisis statistik

Data dianalisis dengan perangkat lunak SPSS 17.0. Kadar sitokin dan matriks metalloproteinase dalam
penelitian ini konsisten dengan distribusi normal, dan digambarkan sebagai Mean ± SD. Uji T adalah
dilakukan untuk semua data. Nilai P <0,05 dianggap signifikan secara statistik.
3. Hasil
3.1 Perbandingan kadar sitokin pada dua kelompok wanita hamil
Kadar sitokin pada dua kelompok wanita hamil terdapat pada Tabel 1. Kadar IL-8 dan TNF-α pada
kelompok KPD adalah (420,45 ± 110,26) ng/L, (413,53 ± 125,19) ng/L, yang secara signifikan lebih
tinggi dibandingkan kelompok kontrol (310,23 ± 78,51) ng/L, (360,27 ± 68,32) ng/L. Dan
perbedaannya signifikan secara statistik (P <0,05). Kadar IL-10 pada kelompok KPD adalah (332,07 ±
48,12) ng/L, secara signifikan lebih rendah dibandingkan kelompok kontrol (380,42 ± 53,35) ng/L,
perbedaannya signifikan secara statistik (P <0,05).

Tabel 1. Pebandingan kadar sitokin pada kedua kelompok Ibu hamil (ng/L)

Kelompok n IL-8 IL-10 TNF-α

KPD 80 420.45 ± 110.26 332.07 ± 48.12 413.53 ± 125.19

Kontrol 80 310.23 ± 78.51 380.42 ± 53.35 360.27 ± 68.32
t 7.283 6.019 3.340
P 0.000 0.000 0.001

3.2 Perbandingan kadar sitokin kelompok ibu HCA dan non-HCA

Kadar sitokin pada kelompok wanita hamil dengan HCA dan non-HCA terdapat pada Tabel 2.
Kelompok KPD dibagi kedalam subkelompok HCA dan non-HCA sesuai dengan ada atau tidaknya
korioamnionitis. Kadar IL-8 dan TNF-α pada kelompok HCA adalah (580,23 ± 108,51) ng/L, (485,33
± 125,19) ng/L, yang secara signifikan lebih tinggi dibandingkan kelompok non-HCA (P<0,05). Kadar
IL-10 pada kelompok HCA adalah (278,51 ± 42,53) ng/L, yang secara signifikan lebih rendah
dibandingkan kelompok non-HCA (P <0,05).

Tabel 2. Perbandingan kadar sitokin kelompok HCA dan non-HCA(ng/L)

Kelompok n IL-8 IL-10 TNF-α

HCA 45 580.23 ± 108.51 278.51 ± 42.53 485.33 ± 125.19

Non-HCA 35 356.45 ± 71.26 349.17 ± 58.22 391.27 ± 78.32
T 10.551 6.273 3.889
P 0.000 0.000 0.000

3.3 Perbandingan kadar matriks metalloproteinase wanita hamil pada kedua kelompok
Kadar matriks metaloproteinase pada dua kelompok terdapat pada Tabel 3. Kadar MMP-8 dan MMP-9
pada kelompok KPD adalah (11,02 ± 2,48) ng/mL, (648,42 ± 73,35) ng/L, yang secara signifikan lebih
tinggi dibandingkan kelompok kontrol (7,36 ± 1,42) ng/mL, (298,07 ± 38,42) ng/L, perbedaannya
signifikan secara statistik (P <0,05).
Tabel 3. Perbandingan kadar MMP pada kedua kelompok Ibu hamil

Kelompok n MMP-8 (ng/mL) MMP-9 (ng/mL)

KPD 80 11.02 ± 2.48 648.42 ± 73.35

Kontrol 80 7.36 ± 1.42 298.07 ± 38.42
T 11.455 37.844
P 0.000 0.000

3.4 Perbandingan kadar matrix metalloproteinase pada kelompok HCA dan non-HCA
Kadar matriks metaloproteinase pada kelompok HCA dan non-HCA terdapat pada Tabel 4. Kelompok
KPD dibagi menjadi subkelompok HCA dan non-HCA sesuai dengan ada atau tidaknya
korioamnionitis. Kadar MMP-8 dan MMP-9 pada kelompok HCA adalah (12,51 ± 2,63) ng/mL dan
(723,12 ± 83,53) ng / L, yang secara signifikan lebih tinggi dibandingkan kelompok non-HCA (9,54 ±
1,97) ng/mL, (538,27 ± 58,62) Ng/L, perbedaannya signifikan secara statistik (P <0,05).

Tabel 4. Perbandingan kadar MMP pada kelompok HCA dan non-HCA

Kelompok n MMP-8 (ng/mL) MMP-9 (ng/mL)

HCA 45 12.51±2.63 723.12±83.53

Non-HCA 35 9.54±1.97 538.27±58.62
T 5.572 11.127
P 0.000 0.000

4. Diskusi
Ketuban pecah dini adalah penyakit obstetri yang lebih umum, dan juga merupakan salah satu faktor
penyebab paling umum kelahiran prematur, tetapi patogenesisnya masih belum jelas [9] . Penelitian
terkait telah menunjukkan bahwa infeksi merupakan faktor penting dalam proses terjadinya ketuban
pecah dini. Selain itu, perubahan pada struktur membran itu sendiri, insufisiensi serviks, kelainan
tekanan intrauterin dan faktor lain juga dapat menyebabkan ketuban pecah dini [10,11] . Sebagai
komplikasi umum ketuban pecah dini, HCA dapat menyebabkan infeksi paru pada janin, sepsis, dan
enterokolitis [12,13] . Oleh karena itu, pada proses pengobatan ketuban pecah dini pada wanita hamil,
deteksi dini dan pencegahan HCA secara efektif dapat mengurangi timbulnya komplikasi.

TNF-α adalah faktor inflamasi yang disekresikan oleh makrofag monosit, yang berperan penting dalam
proses reaksi inflamasi dengan mengatur ekspresi sitokin lainnya, yang menyebabkan respons inflamasi
lokal [14] . Pada keadaan normal, kadar TNF-α yang rendah membantu proliferasi dan diferensiasi sel,
meningkatkan anti-infeksi dan fungsi kekebalan tubuh. Jika kadar TNF-α tinggi, dapat merusak
tubuh[15] . IL-8 adalah golongan sitokin dalam famili chemokine, yang disekresikan oleh makrofag
dan sel epitel, dan bereaksi dengan mengikat reseptor spesifik [16]. Penelitian menemukan bahwa IL-8
juga berperan penting dalam proses reproduksi[17]. Selain itu, IL-8 dikaitkan dengan patologi
reproduksi seperti endometriosis, abortus spontan idiopatik, dll [18] . IL-10 merupakan multi-sel,
sitokin multifungsi, sebagian besar disekresikan oleh makrofag mononuklear, sel T helper, neutrofil,
dll, terutama mengatur pertumbuhan dan diferensiasi sel, dan berperan dalam respon inflamasi dan
respon imun, yang saat ini dikenal sebagai faktor inflamasi dan faktor imunosupresif [19]. Penelitian
menemukan bahwa IL-10 menghambat sintesis monosit-makrofag dan melepas mediator inflamasi,
sehingga mengurangi sekresi TNF-α, IL-1β, IL-6, IL-8, G-CSF, GM-CSF, dan sitokin lainnya yang
berperan dalam proses inflamasi. Selain itu, IL-10 juga dapat merangsang efek inflamasi dengan
meningkatkan pelepasan faktor-faktor antiinflamasi seperti reseptor antagonis IL-1 dan reseptor soluble
TNF-α [20] . Penelitian ini menunjukkan bahwa kadar IL-8 dan TNF-α pada kelompok KPD secara
signifikan lebih tinggi dibandingkan kelompok kontrol, terutama pada wanita hamil dengan
HCA. Kadar IL-10 pada kelompok KPD secara signifikan lebih rendah dibandingkan kelompok
kontrol, terutama pada kelompok wanita hamil dengan HCA. Hasil penelitian ini sejalan dengan
penelitian Wang et al [21,22] . Hasil penelitian menunjukkan bahwa TNF-α dan IL-8 berkorelasi positif
dengan insiden KPD dan HCA pada periode perinatal, dan IL-10 berkorelasi negatif dengan KPD dan
HCA. Oleh karena itu, sitokin yang disebutkan di atas dapat digunakan sebagai indikator penting dari
terjadinya KPD dan HCA.

Matriks metaloproteinase adalah enzim proteolitik yang mengandung ion logam seperti Ca 2+, Zn2+
dalam strukturnya, yang biasanya menggunakan matriks ekstraseluler (ECM) sebagai substrat
hidrolitik [23] . MMP terutama disintesis oleh sel desidua , sel korion halus dan sel epitel
amnion. Kadar MMP-8, MMP-9 dan protease lain akan meningkat secara signifikan pada wanita hamil
dengan KPD, saat persalinan dan infeksi intrauterin [24]. Penelitian menemukan bahwa MMP di satu
sisi dapat menyebabkan kelemahan selaput ketuban secara lokal dengan degradasi kolagen ECM tipe I,
II (yang menjaga tekanan dan elastisitas selaput ketuban), sehingga efek fisik dengan mudah
menyebabkan ketuban pecah dini; di sisi lain, MMP berperan pada fibroblas serviks, mendegradasi
kolagen pada matrix intraseluler, merelaksasi jaringan ikat di matriks servical yang menyebabkan
pelebaran dan pematangan serviks sehingga menyebabkan kelahiran prematur. Hasil dari penelitian ini
menunjukkan bahwa kadar dari MMP-8 dan MMP-9 pada kelompok KPD secara signifikan lebih
tinggi dibandingkan kelompok kontrol. Selain itu, kelompok KPD dengan HCA pada wanita hamil
memiliki kadar MMP yang jauh lebih tinggi. Hasil ini menunjukkan bahwa MMP-8 dan MMP-9
memiliki nilai prediktif tertentu untuk penegakkan diagnosis KPD dan HCA.

Kesimpulannya, ketika KPD dan inflamasi korionik amniotik terjadi, kadar sitokin dan MMP pada
wanita hamil cenderung berubah. Oleh karena itu, pemantauan berkala indikator ini dapat membantu
mengurangi insidensi dan angka kematian ibu dan bayi baru lahir serta memberikan dasar untuk
diagnosis dini dari KPD dan HCA yang sangat penting secara klinis.
DAFTAR PUSTAKA
1. Armstrong-Wells J, Donnelly M, Post MD. Inflammatory predictors of neurologic disability after
preterm premature rupture of membranes. Am J Obstetr Gynecol 2015; 212(2): 212-221.
2. Dars S, Malik S, Samreen I. Maternal morbidity and perinatal outcome in preterm premature
rupture of membranes before 37 weeks gestation. Pak J Med Sci Online 2014; 30(3): 626-629.
3. Qiongjie Z, Weiyuan Z, Huan X. Risk factors for preterm premature rupture of membranes in
Chinese women from urban cities. Int J Gynaecol Obstetr 2014; 127(3): 254-258.
4. Menon R, Boldogh I, Hawkins HK. Histological evidence of oxidative stress and premature
senescence in preterm premature rupture of the human fetal membranes recapitulated in vitro. Am
J Pathol 2014; 184(6): 1740-1751.
5. Zhao HY, Zhang Q, Wu YZ. Advances in predictive index of premature rupture of membranes
with chorioamnion. Mil Med J Southeast China 2014; 29(4): 397-400.
6. Guo L, Fan GS. Expression of MMP-2 and TIMP-2 in patients with PROM combined
chorioamnionitis. J Hainan Med Univ 2014; 20(2): 169-171.
7. Xu XH. Diagnosis and standard nursing of premature rupture of membranes. China Foreign Med
Treatment 2011; 30(3): 149-149.
8. Zhao ZY. Progress in study on diagnosis of chorioamnionitis. J Int Obstetr Gynecol 2011; 38(3):
207-210.
9. Zhang JH, Xie Y, Yang LZ. Clinical analysis of spontaneous preterm birth and premature rupture
of membrane. Chin J Family Plan Gynecotokol 2013; 5(2): 51-54.
10. Xia H, Li X, Li X. The clinical management and outcome of term premature rupture of membrane
in East China: results from a retrospective multicenter study. Int J Clin Exp Med 2015; 8(4): 6212-
6217.
11. Peng JL, Luo LQ, Cui-Ping LU. The diagnostic and treatment value of procalcitonin in patients
with premature rupture of membrane. Chin J Family Planning Gynecotokol 2016; 8(3): 28-31.
12. Zhang H, Wang LU, Wang J. Premature rupture of the fetal membrane combined with subclinical
chorioamnionitis negatively affects pregnancy outcomes by a mechanism associated with reduced
levels of matrix metalloproteinase-2. Exp Ther Med 2015; 10(2): 561-565.
13. Thornburg LL, Queenan R, Brandtgriffith B. Procalcitonin for prediction of chorioamnionitis in
preterm premature rupture of membranes. J Maternal-fetal Neonatal Med 2015; 29(13): 1-6.
14. Jin Y, Shen CX, Liu XN. Levels of IL-6, MMP-8, TNF-ααin serum and amniotic fluid of preterm
women with premature rupture of membrane and their correlation with intrauterine infection. Chin
J Healthy Birth Child Care 2013; 19(3): 169-172.
15. Liu XC, Chen YH, Zhang GY. Significance of the combination detection of IL-6, IL-8, and TNF-α
to PROM early intrauterine infection. J Hainan Med Univ 2015; 21(12): 1655-1657.
16. Song JH, Shan HO. The relationship between the content and chorioamnionitis and neonatal
prognosis in women with premature rupture of membranes of IL-8 and TNF-α. Heilongjiang Med
Pharm 2015; 38(6): 146-147.
17. Jia X. Value of amniotic fluid IL-8 and Annexin A2 in prediction of preterm delivery in preterm
labor and preterm premature rupture of membranes. J Reprod Med 2014; 59(3-4): 154-160.
18. Zhang J. Study on the relationship between IL-6 and IL-8 and premature rupture of membranes
and neonatal prognosis. Mater Child Health Care China 2015; 30(9): 1390-1392.
19. Zhu TH, Wang F, Kang L. The expression of matrix metalloproteinases, tumor necrosis factor-
alpha, interleukin-10 in maternal plasma and their relationship with preterm delivery. Chin J Clin
Obstetr Gynecol 2012; 13(3): 183-186.
20. Zu-Feng YE. Levels and significance of IL-10,TIMP-1,TNF-αin serum and amniotic fluid of
preterm women with premature rupture of membranes. China J Modern Med 2013; 23(11): 98-
100.
21. Wang F, Zhu ZY. Analysis of serum and amniotic fluid TNF-α, IL-6 and IL-8 in pregnant women
with premature rupture of membranes. J Radioimmunol 2013; 26(3): 344-345.
22. IL-10 in the treatment of premature rupture of membranes with chorioamnionitis. Guangdong Med
J 2014; 35(17): 2717-2720.
23. Wang SM, Chen L. Study of matrix metalloproteinases and premature rupture of membranes.
China Med Herald 2013; 10(20): 22-23.
24. Xiao JC, Dai W, Min-Juan XU. The predictive value of MMP-8 on diagnosing preterm birth with
premature rupture of membranes. Modern Prevent Med 2013; 40(19): 3582-3593
25. Ling WU, Chen XJ. The levels and significance of MMP-9 in serum and amniotic fluid of preterm
women with premature rupture of membranes. China Pract Med 2010; 5(22): 34-35.