Premature Rupture of Membranes

Aka: Premature Rupture of Membranes, Preterm Premature Rupture of Membranes, Rupture of Membranes, PROM, PPROM

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II. Definitions

  1. Premature Rupture of Membranes (PROM)
    1. Rupture of Membranes >1 prior to labor onset
  2. Preterm Premature Rupture of Membranes (PPROM)
    1. PROM that occurs prior to 37 weeks gestation

III. Epidemiology

  1. Incidence
    1. Premature Rupture of Membranes (PROM): 8%
    2. Preterm Premature Rupture of Membranes (PPROM): 2%

IV. Symptoms

  1. Gushing of fluid from vagina
  2. Fluid leakage increases with movement change

V. Signs

  1. See evaluation below

VI. Differential diagnosis

  1. Urinary Incontinence
  2. Vaginal Discharge
  3. Water from recent bathing

VII. Complications

  1. Premature Birth (PPROM)
  2. Chorioamnionitis
  3. Cord compression
  4. Respiratory distress syndrome
  5. Abruptio Placentae
  6. Malpresentation

VIII. Course prior to delivery

  1. Term: Labor starts within 24 hours in 95% of cases
  2. Weeks 28 to 34
    1. Labor starts within 24 hours in 50% of cases
    2. Labor starts within 1 week in 80% of cases
  3. Weeks 24 to 26
    1. Labor starts within 1 week in >50%
    2. Labor delayed 4 weeks in 22%
  4. References
    1. Schucker (1996) Semin Perinatol 20:389-400 [PubMed]

IX. Risk Factors

  1. History of PROM in prior pregnancy
  2. Prior Cervical Cone Biopsy
  3. Amniocentesis or Cerclage
  4. Uterine distention
    1. Polyhydramnios
    2. Multiple Gestation pregnancy
  5. Tobacco Abuse
  6. Cervical or vaginal infections
    1. Group B Streptococcus
    2. Bacterial Vaginosis
    3. Mycoplasma
    4. Ureaplasma
    5. NeisseriaGonorrhea
    6. Chlamydia
  7. Intercourse (unproven)

X. Evaluation

  1. Methods to confirm Rupture of Membranes
    1. AmniSure ROM Test (PAMG-1 Protein Marker Test) or
    2. Vaginal Pooling
    3. Vaginal Fluid Ferning
    4. Vaginal Fluid pH (Nitrazine)
  2. Other bedside evaluation
    1. Visualize Cervix with speculum to estimate dilation
    2. Chlamydia PCR and Gonorrhea PCR
    3. Group B Streptococcus Culture from vagina and Rectum
    4. Fetal Monitoring for well-being
  3. Advanced diagnostics to consider
    1. Ultrasound
      1. Ultrasound Exam of Uterine Cervical Length
      2. May help confirm PROM (e.g. oligohydramnios)
      3. Determines Fetal Position and placental location
      4. Estimates fetal weight
    2. Amniocentesis
      1. Evaluate Fetal Lung Maturity
      2. Method to confirm ROM in uncertain cases
        1. Uses Indigo carmine dye 1 ml in 9 ml sterile NS
        2. Instilled into Uterus via Amniocentesis
        3. Vaginal tampon turns blue within 30 min in ROM

XI. Precautions: Avoid digital cervical exam in PPROM

  1. Digital exam raises infection risk, other morbidities
    1. Alexander (2000) Am J Obstet Gynecol 183:1003-7 [PubMed]
  2. Digital exam reduces time to labor by 9 days
    1. Lewis (1992) Obstet Gynecol 80:630-4 [PubMed]
  3. Speculum visualization offers similar dilation estimate
    1. Munson (1985) Am J Obstet Gynecol 153:562-3 [PubMed]

XII. Precautions: Indications for imminent delivery

  1. Fetal Compromise
  2. Chorioamnionitis
  3. Placental Abruption

XIII. Management: Term Premature Rupture of Membranes (PROM)

  1. Indications
    1. Fetus 36 weeks gestation or
    2. Weight >2500 grams or
    3. Fetal Lung Maturity adequate by Amniocentesis
  2. Protocol
    1. Expectant management
    2. Consider Oxytocin Induction of Labor
      1. Spontaneous labor onset within 48 hours in 90%
      2. Oxytocin decreases PROM infection rates
      3. Oxytocin does not increase ceserean rates in PROM
    3. Consider Cervical Ripening if unfavorable Cervix
      1. Decreases risk of Chorioamnionitis in PROM
      2. Does not increase ceserean rate in PROM
    4. Indications for GBS Prophylaxis
      1. Prolonged ruptured membranes anticipated >18 hours
      2. Fever >38 degrees Celsius

XIV. Management: Preterm Premature Rupture Membranes (PPROM)

  1. Indications
    1. Fetus <32-34 weeks gestation or
    2. Weight <2500 grams or
    3. Indequate Fetal Lung Maturity
  2. Protocol: General
    1. See Preterm Labor Management
    2. Tocolysis
      1. Delay labor unless overt infection, Fetal Distress
    3. Maternal Corticosteroids for 2 days (single course)
      1. Betamethasone 12 mg IM 2 doses 24 hours apart or
      2. Dexamethasone 6 mg IM 4 doses 12 hours apart
    4. Maternal Antibiotic prophylaxis
      1. See GBS Prophylaxis
      2. Antibiotic protocol improves neonatal outcomes
        1. Initial 48 hours start with IV agents
          1. Ampicillin 2 grams IV q6 hours and
          2. Erythromycin 250 mg IV q6 hours
        2. After 48 hours, switch to oral agents for 5 days
          1. Amoxicillin 250 mg PO q8 hours and
          2. Erythromycin Base 333 mg PO q8 hours
        3. Reference
          1. Mercer (1997) JAMA 278:989-95 [PubMed]
    5. Consider transfer to tertiary care center
    6. Avoid digital cervical exam
    7. Observation
      1. Signs of Chorioamnionitis
      2. Fetal well-being
  3. Protocol: Gestational age specific
    1. Gestational age 34 weeks or older
      1. Consider transport to facility with NICU
      2. Antibiotics (see regimen above)
      3. Labor Induction
    2. Gastational age 32-33 weeks
      1. Transport to facility with NICU
      2. Antibiotics (see regimen above)
      3. Amniocentesis for Fetal Lung Maturity
        1. Fetal lungs mature: Labor Induction
        2. Fetal lungs not mature
          1. Maternal Corticosteroids as above
          2. Delay delivery 48 hours (preferably >34 weeks)
    3. Gestational age 24-31 weeks
      1. Transport to facility with NICU
      2. Antibiotics (see regimen above)
      3. Daily or continuous Fetal Monitoring
        1. Higher risk of cord compression
    4. Gestational age <24 weeks (pre-viability)
      1. Consultation with neonatology

XV. References

  1. Morrison (2000) ALSO, p. 1-7
  2. Ehrenberg (2001) Clin Perinatol 28(4):807-18 [PubMed]
  3. Lee (2001) Clin Perinatol 28(4):721-34 [PubMed]
  4. Medina (2006) Am Fam Physician 73(4):659-64 [PubMed]
  5. Rundell (2017) Am Fam Physician 95(6): 366-72 [PubMed]

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