Premature rupture of membranes resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords:

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

Common risk factors in the development of PROM include :

• Maternal risk factors:
  • Sepsis
  • Previous history of PROM, recurrence risk is 16%–32% as compared with 4% in women with a prior uncomplicated term delivery.
  • Chronic steroid therapy
  • Abnormal bleeding during the second trimester or late in the pregnancy.
  • Low body mass index (BMI < 19.8 kg/m2)
  • Smoking and drug abuse
  • Low socioeconomic status
  • Deficiency of copper or vitamin C, along with connective tissue disorders such as Ehlers-Danlos syndrome, Systemic Lupus Erythematosus are also linked to increased risk of PROM.
  • Direct abdominal trauma
  • Preterm labor
  • Anemia

• Uteroplacental Factors:
  • Uterine anomalies (such as uterine septum)
  • Placental abruption
  • Advanced cervical dilation (cervical insufficiency)
  • Prior cervical conization
  • Cervical shortening in the 2nd trimester (< 2.5 cm)
  • Uterine overdistention (Polyhydramnios, Multiple pregnancy)
  • Intra-amniotic infection (Chorioamnionitis)
  • Multiple bimanual vaginal examinations (but not sterile speculum or transvaginal ultrasound examinations)

• Fetal factors include :
  • Multiple pregnancy ( preterm PROM complicates 7%–10% of twin pregnancies)
  • Prematurity
  • Infection
  • Cord prolapse
  • Malpresentation.

Diagnosis

Shown below is an algorithm summarizing the diagnosis of

Pregnant woman comes with Premature rupture of membranes

Take complete history

Record the vitals: ❑ Blood pressure ❑ Temperature ❑ Respiratory rate ❑ Heart rate

Take obstetric history : ❑ Date of last menstrual period? ❑ Estimated date of delivery. ❑ Confirm the gestational age, gravidity and parity. ❑ Check if this is a single or multiple gestation.

Ask about previous obstetric history if she was previously pregnant : ❑ Ask about previous pregnancies including miscarriages and terminations. ❑ Length of gestation. ❑ Ask about mode of delivery. ❑ Ask if there was similar complaints during previous pregnancy? ❑ Was there any complications throughout the pregnancy or during delivery such as shoulder dystocia, postpartum haemorrhage ?

Ask the following questions about menstrual history : ❑ Age of menarche ❑ Last menstrual period ❑ Is the menstrual flow normal? How many pads she has to use in a day? ❑ Is there any foul smell or colour change? ❑ How many days does the menstruation stay? ❑ Contraceptive history for example oral contraceptives, intrauterine device

Do Speculum examination : ❑ Visualization of amniotic fluid (AF) leaking through the cervix ❑ Vaginal pooling ❑ Fern test of dried vaginal fluid seen under microscope ❑ pH testing : Normal: 3.8 to 4.5 Amniotic Fluid: 7.1 to 7.3 False positives: Blood or semen, alkaline antiseptics False negatives: Minimal remaining amniotic fluid following rupture

If above are not conclusive, do the following tests : ❑ Ultrasound for AFV may be helpful but not diagnostic . ❑ Fetal fibronectin is sensitive with high negative predictive value but positive result is not diagnostic ❑ Amniotic protein tests have high sensitivity for PROM but false-positive rates are high.

History suggestive of PROM<be>(leakage of fluid from the vagina)

Physical examination findings confirm PROM •Pooling of fluid •Positive nitrazine and Ferning tests

Sterile speculum examination assess dilation and ultrasound if indicated

PROM ruled-out

PROM confirmed

Check gestational age •Arrange transportation to tertiary care if possible •Arrange prompt consult with obstetrician •Fetal non-stress test and ECG to assess well being

Induce delivery with oxytocin if at-term gestation

Plan delivery if any signs of infection, placental insufficiency, fetal distress, or active labor

24-31 weeks •Antibiotics+steroids •Delivery if lung maturity is satisfactory

32-33 weeks •Antibiotics+steroids •Delivery at 34 weeks or amniocentesis if abortion is suspected

34-36 weeks •Group B strep prophylaxis •Delivery

Treatment

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Do's

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Don'ts

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References

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