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PREMATURE RUPTURE OF MEMBRANES (PROM)
Definition:
 Premature rupture of membranes (PROM) refers to rupture of

the membranes before the onset of labor at any stage of
gestation before the onset of labor or regular uterine
contractions
 Preterm PROM (PPROM) refers to this occurrence in
pregnancies less than 37 weeks of gestation and accounts for
25 percent of cases of PROM
...

 Prolonged ROM is any ROM that persists for more than 24
hours and prior to the onset of labor
Epidemiology
 The frequencies of term, preterm, and midtrimester PROM are
8, 1 to 3, and less than 1 percent of pregnancies, respectively
 Eighty-five percent of neonatal morbidity and mortality is a
result of prematurity
...

 PPROM complicates 3% of all pregnancies
 When PPROM occurs remote from term, significant risks of
morbidity and mortality are present for both the fetus and the
mother

Risk factors
1
...
g
...
Intrauterine infection
3
...
Multiple previous pregnancies
5
...
Nutritional deficit
7
...
Familial history of premature rupture of membranes
9
...
Low body mass index
11
...
Preterm labor history
13
...
Vaginal bleeding at any time in pregnancy
15
...
Amniocentesis
Pathology & Pathophysiology
 At term, programmed cell death and activation of catabolic
enzymes, such as collagenase and mechanical forces, result in
ruptured membranes
...

 However, early PROM also appears to be linked to underlying
pathologic processes, most likely due to inflammation and/or
infection of the membranes
...


 Amnionitis is an important cause of endomyometritis and
puerperal sepsis
...

 If rupture of membranes occurs early in pregnancy at less than
26 weeks' EGA, it can cause pulmonary hypoplasia and limb
positioning defects in the newborn
...

 Others describe constant leakage of small amounts of fluid or a
sensation of wetness within the vagina or on the perineum
 Additional symptoms that may be useful include the color and
consistency of the fluid and the presence of flecks of vernix or
meconium, reduced size of the uterus, and increased
prominence of the fetus to palpation
...

 This examination is the key to differentiating PROM from
hydrorrhea gravidarum (discharge of a watery fluid from the
vagina during pregnancy), vaginitis, increased vaginal
secretions, and urinary incontinence
...

b) Nitrazine test: A sterile cotton-tipped swab should be used
to collect fluid from the posterior fornix and apply it to
nitrazine paper
...
0-7
...

c) Ferning: A drop of fluid from the posterior fornix should be
placed on a slide and allowed to air-dry
...

The absence of one of the above findings is an indication for
further testing because other factors can produce falsepositive results
...

Cervical mucus can cause ferning
...

If there is a significant vaginal pool, this pool can be collected
and sent for fetal lung maturity determination
...

Other confirmatory tests for PROM include observed loss of
fluid from the cervical os when the patient coughs or performs
a Valsalva maneuver during speculum exam and
oligohydramnios on ultrasound exam
...

 After 15-20 minutes, insertion of a vaginal speculum will reveal
blue dye in the vagina if the membranes are ruptured
Physical Examination
 Once PROM is confirmed, a careful physical examination should
be done to search for other signs of infection
...

 The sterile speculum exam is sufficient to distinguish between
early and advanced labor
...

 The most common organisms causing amnionitis are those that
ascend from the vagina (e
...
streptococci B and D and
anaerobes)
...
Fever: The temperature should be checked every 4 hours
...
Maternal leukocytosis: A daily leukocyte count and
differential should be obtained
...

3
...

4
...

5
...


Investigations
Laboratory Studies
 Initial laboratory studies should include a complete blood
count with differential
...

Ultrasonography
 Ultrasound examination also may be of value in the diagnosis
of PPROM
...

Treatment
 A digital examination of the cervix is not performed, because it

may initiate intrauterine infection (due to pathogens ascending
from the vagina) and it decreases the latency period (i
...
time
from rupture of membranes to delivery)
 Rather, examination with a clean speculum is performed to
verify rupture, estimate dilation, and collect fluid for maturity
studies and culture
 Rupture of the membranes may happen at any time during
pregnancy
...

 There are a variety of options for management of PROM
depending upon the gestational age at occurrence and the
patient's clinical condition
...

 The neonatal risks of expectant management of PROM include
infection, placental abruption, fetal distress, fetal restriction
deformities and pulmonary hypoplasia, and fetal/neonatal
death
...

 Expectant management entails nonintervention while waiting
for the patient to go into labor spontaneously, whereas active
management entails induction of labor with an agent such as
pitocin

 Nonintervention is an acceptable initial course of treatment,
but if the patient does not go into labor within 6-12 hours after
PROM, labor should be induced to minimize the risk of
infection
...

 Immediate induction of labor is associated with lower rates of
maternal infection and neonatal morbidity
...

 The benefits are highest in women with favorable cervices and
those who are GBS-positive
Preterm Pregnancy without Amnionitis
 Prematurity is the principal risk to the fetus, while infection
morbidity and its complications are the primary maternal risks
 Women with PPROM who have a viable fetus should be
hospitalized from the time of diagnosis until delivery
 Expeditious delivery is indicated for abruptio placentae,
intrauterine infection, or evidence of fetal compromise, such as
repetitive FHR decelerations or an unstable fetal presentation
that poses a risk of cord prolapse
 Pregnancies 32 weeks of gestation with documented fetal lung
maturity will achieve better maternal and neonatal outcomes
with immediate delivery than with expectant management

 Group B streptococcal (GBS) status should be determined and
intrapartum antibiotic prophylaxis should be administered, as
appropriate
 Pregnant women whose culture status is unknown (culture not
performed or result not available) and who also have delivery
at <37 weeks of gestation, amniotic membrane rupture for 18
hours, or an intrapartum temperature 100
...

 Hospitalization: Patients are typically kept at modified bedrest
and frequently assessed for evidence of infection or labor
...

 Many clinicians administer tocolytics to women with
contractions for a period of 48 hours to allow administration of
antenatal corticosteroids and antibiotics if there is no infection
or other contraindication
 Fetal lung maturity: Antenatal corticosteroid administration is
recommended for pregnancies complicated by PPROM at less
than 32 weeks of gestation, as long as there is no clinical
evidence of chorioamnionitis
 Corticosteroid: 12 mg of betamethasone IM given twice in a 24hour interval or dexamethasone 6 mg q12h given for 4 doses
 Expectant management of PPROM in pregnancies of
approximately 32 weeks of gestation or more is associated with
higher risk of maternal chorioamnionitis without demonstrable
maternal or neonatal benefit

PPROM <32 weeks of gestation
 In general, preterm delivery is the greatest risk to the fetus
with PPROM at less than 32 weeks of gestation
...
g
...

 Monitoring for maternal or fetal infection and signs of fetal
compromise should be initiated and consists of routine vital
signs (temperature, maternal and fetal heart rates, subjective
assessment of fetal activity) and may include serial nonstress
testing or biophysical profile scoring, assessment of peripheral
white blood cell count, and amniocentesis
...

 Amoxicillin-clavulanate should be avoided in women at risk of
preterm delivery because of the increased risk of neonatal
necrotizing enterocolitis
 My preference is ampicillin 2 g IV every 6 hours for 48 hours,
followed by amoxicillin (500 mg orally three times daily or 875
mg orally twice daily) for an additional five days
...

 When the pregnancy reaches 32 weeks, I aspirate amniotic
fluid from the vaginal vault to test for fetal lung maturity
...


 However, if I cannot aspirate fluid or testing suggests immature
lungs, then I continue to manage the patient expectantly until
34 weeks at which time I proceed with induction without
resampling the fluid
...

 Such women hospitalized at centers capable of providing
intensive neonatal care are best managed by prompt induction
of labor
 However, if fetal lung maturity cannot be confirmed, then I
administer a course of corticosteroids, begin GBS prophylaxis,
and deliver at 34 weeks
PPROM after 34 weeks
 Patients admitted with PPROM at 34 weeks gestation are
begun on GBS prophylaxis and delivered
...


 Broad-spectrum antibiotics should be started to treat the
amnionitis
...




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