Characteristics of PPROM in General Hospital Dr . Soetomo Surabaya Period September 2017 to September 2019

Submission: November 28th, 2020 Review: December 7th, 2020 Publish: July 25th, 2021 Background: Preterm Prelabour Rupture of Membranes (PPROM) is one of the causes of perinatal morbidity and mortality. Objective: To find out the characteristic of PPROM in Dr. Soetomo Hospital in September 2018 to September 2019. Method: A Retrospective Descriptive Study. The data came from the medical records of patients with PPROM who were included in the inclusion criteria. The exclusion criteria is all PPROM cases at Gestational age > 34 weeks. Result: The incidence of PPROM during September 2017 to September 2019 was 6.8% (175 patients), of which 152 patients included NBC cases and 23 patients with BC cases. Primipara 76 patients and Multipara 99 patients. For gestational age <26 weeks it was 17.1%, 26-30 weeks 29.7% and 3134 weeks 53.1%. In this study, PPROM was amused 23.6%, underweight 3.1%, HBsAg 7.5%, HIV 7%, anemia 10.3%, Obesity 5.2%, Pragestational Diabetes 7.4%, Gestational Diabetes. 2,6%, preeclampsia 7,9% and severe preeclampsia 2,2%. The distribution of PPROM patients who received lung maturation was 72%, while the remaining 28% did not get lung maturation. Type of delivery for PPROM cases was vaginal delivery as much as 60% while 40% for cesarean section. Indications for vaginal delivery include fetal distress 25%, abnormal NST 18%, gemeli 17%, BSC 12%, febris 10%, pulmonary edema 5% and breech presentation 5%. The outcome distribution of PPROM infants born with asphyxia at birth was 87%. Weight of babies born with PPROM> 2500 g 4%, 1000-2500 g 73% and <1000 g 23%. The condition of the babies at birth with spontaneous breathing was 36 babies, nasal O2 was 13 babies and CPAP was 70 babies. The causes of death for preterm KPP babies included RDS 9 babies, Sepsis 4 babies and severe asphyxia 19 babies. The length of NICU care for infants who died with KPP Preterm mothers was <24 hours for 15 babies, 1-3 days 13 babies, 4-7 days 3 babies,> 7 days 3 babies and 5 fetuses were IUFD. 12 patients with PPROM received amnioinfusion while 5 patients with amniopatch, Outcome of infants from conservative PPROM who were treated with amniopatch or amnioinfusion obtained 6 babies died at birth, 8 babies with CPAP breath support, 1 baby with PCV breath support, 1 baby with ventilator and 1 infant spontaneously breathed. A total of 3 babies were outpatient after treatment for a maximum of ± 25 days. Conclusion: Perinatal care is currently experiencing some rapid progress, but the case of PPROM is still one of the biggest contributors to perinatal morbidity and mortality.


Preterm
Prelabour Rupture of Membranes (PPROM) is a rupture of the amniotic membrane at <37 weeks of gestation (Shailja, 2020). The incidence of PPROM occurs in 3-8% of pregnancies (Okeke, 2014) and in about 20% of the causes of preterm labor. This can lead to significant perinatal morbidity. PPROM with gestational age less than 34 weeks can be considered to have a conservative therapy.
Indication for PPROM's termination is at <34 weeks of gestational age. However, if there is an emergency in the fetus, chorioamnionitis, preterm in labor or when the gestational age can exceed >34 weeks. (Medina, 2006). There are 3 divided risk factor due to the etiology of the PPROM which are maternal risk factor (such as History of Previous PPROM, Anemia, BMI <20 kg/m2 nutritional deficiencies, low socioeconomic status, too young to get pregnant or U> 35 years, smoke, collagen vascular disorders (ex.SLE)), infant risk factor (such as multiple pregnancy anomalies (malformations, aneuploidies)) and uteroplacental risk factor (for example anomalies in the uterus (uterine septum), placental abruption, history of cervical conization, infection (ex: chorioamnionitis) (Cunningham, 2014).                Mohan et al, which states that most cases are in the 20-30th age of mothers. (Mohan et al., 2017) The number of PPROM patients with gestational age <34 weeks from September 2017 to September 2019 were 175 patients, where NBC cases were 86.9% and BC cases were 13.1%. These results are consistent with the research conducted by Khade et al in India where Non Booked Cases were bigger than Booked Cases. This is due to inadequate Antenatal care which results in a lack of identification of risk factors in early pregnancy. In the PPROM cases from September 2017 to September 2019, there were more patients with multiparous (99 patients) than mothers with primiparous (76 patients). The study conducted by Khade et al showed the same result, mostly multiparous (52%) were higher than primiparous (48%). The incidence of PPROM was found in many multiparous mothers because frequent pregnancies can affect embryogenesis so that the formed amniotic membrane will be thinner and prone to rupture, and amniotic infection is easier to occur due to damage to the cervical structure in previous deliveries. Distribution of PPROM patients with Gemeli pregnancy for the period of September 2017 to September 2019, there were 17 patients, which if calculated as a whole with the number of preterm deliveries, 23.6% of preterm deliveries were obtained. Whereas in the case of PPROM with underweight mothers, there was only 1 patient during a 2 year period. There were 6 patients with HBsAg and 4 patients with HIV. The results showed that a total of 7% of HIV patients with preterm KPP. This is consistent with a study conducted by Chidebere et al in KwaZulu-Natal, South Africa, which found that the incidence of preterm KPP was not high in patients with HIV (Chidebere, 2017).

Purpose General Purpose
PPROM before 26 weeks can delay lung development and can cause pulmonary hypoplasia (Van Teeffelen, 2014). Pulmonary hypoplasia is a term to describe an altered pulmonary development characterised by a reduction in the number of pulmonary alveoli or in bronchial branching. In fetal lung development a critical interval, the canalicular phase, exists between 16 and 28 weeks gestation. Gestational age at rupture of membranes has been shown to be inversely related to the risk of pulmonary hypoplasia. (Porat et al., 2012). In this study, the distribution of PPROM patients who received lung maturation for preventing pulmonary hypoplasia was 72%, while the remaining 28% did not get lung maturation.
Type of delivery for PPROM cases was vaginal delivery as much as 60% while 40% for cesarean section. Indications for vaginal delivery include fetal distress 25%, abnormal NST 18%, gemeli 17%, BSC 12%, febris 10%, pulmonary edema 5% and breech presentation 5%. The outcome distribution of PPROM infants born with asphyxia at birth was 87%. Weight of babies born with PPROM> 2500 g 4%, 1000-2500 g 73% and <1000 g 23%. The condition of the babies at birth with spontaneous breathing was 36 babies, nasal O2 was 13 babies and CPAP was 70 babies. The causes of death for preterm KPP babies included RDS 9 babies, Sepsis 4 babies and severe asphyxia 19 babies.
The length of NICU care for infants who died with KPP Preterm mothers was <24 hours for 15 babies, 1-3 days 13 babies, 4-7 days 3 babies,> 7 days 3 babies and 5 fetuses were IUFD. Amnioinfusion might improve fetal outcome by preventing pulmonary hypoplasia (Hofmeyr, 2014), by preventing neurological complications, increasing time to delivery interval, and improving fetal biophysical profile through prevention of umbilical cord compression. It also might prevent fetal deformity (Porat et al., 2012). 12 patients with PPROM in this study received amnioinfusion while 5 patients with amniopatch, The outcome of infants from this conservative PPROM who were treated with amniopatch or amnioinfusion obtained 6 babies died at birth, 8 babies with CPAP breath support, 1 baby with PCV breath support, 1 baby with ventilator and 1 infant spontaneously breathed. A total of 3 babies were outpatient after treatment for a maximum of ± 25 days.

Conclusion
Premature infant puts immense burden on the economy and health care resources of the country. Therefore, management of PPROM requires accurate diagnosis and evaluation of the risk factors and benefits of continued pregnancy or expeditious delivery.