PREMATURE MEMBRANE 1

Background

The definition of premature rupture of membrane (PROM) is rupture of membranes

before the onset of labor. When membrane rupture occurs before 37 weeks of gestation, it
is referred to as preterm PROM. Premature rupture of membranes can result from a wide
array of pathologic mechanisms acting individually or in concert ( Ventura SJ, Martin
JA, Curtin SC, Mathews,1997)

1
 The gestational age at membrane rupture has significant implications regarding the
etiology and consequences of PROM. Management may be dictated by the presence of
overt intrauterine infection, advanced labor, or fetal compromise. When such factors are
not present, especially with preterm PROM, other interventions may have a significant
impact on maternal and infant morbidity. An accurate assessment of gestational age and
knowledge of the maternal, fetal, and neonatal risks are essential to appropriate
evaluation, counseling, and management of patients with PROM.

Etiology
Membrane rupture may occur for a variety of reasons. At term, weakening of the
membranes may result from physiologic changes combined with shearing forces created
by uterine contractions ( French JI, McGregor JA,1996).
Intrauterine infection has been shown to play an important role in preterm PROM,
especially at earlier gestational ages (McGregor JA, French JI,1997 ). Factors associated
with an increase in PROM include lower socioeconomic status, sexually transmissible
infections, prior preterm delivery especially due to PROM, vaginal bleeding, cervical
conization, and cigarette smoking during pregnancy (Harger JH, Hsing AW, Tuomala RE,
Gibbs RS, Mead PB, Eschenbach DA, et al,1989). Uterine distention (hydramnios,
twins), emergency cervical cerclage, prior antepartum antibiotic treatment, and preterm
labor also may be associated with PROM. In many cases, however, PROM may occur in
the absence of recognized risk factors.
Term Premature Rupture of Membranes
At term, PROM complicates approximately 8% of pregnancies and is generally followed
by the onset of labor and delivery. In a large randomized trial, half of women with PROM
who were managed expectantly delivered within 5 hours, and 95% delivered within 28
hours of membrane rupture (Gold RB, Goyert GL, Schwartz DB, Evans MI, Seabolt
LA,1990 ). Other studies have reported similar rates (Wagner MV, Chin VP, Peters CJ,
Drexler B, Newman LA;1989).
The most significant maternal risk of term PROM is intrauterine infection, a risk that
increases with the duration of membrane rupture (Hannah ME, Ohlsson A, Farine D,
Hewson SA, Hodnett ED, Myhr TL, et al. ,1996 ). Fetal risks associated with PROM
include umbilical cord compression and ascending infection.
Preterm Premature Rupture of Membranes
Regardless of management or clinical presentation, birth within 1 week is the most likely
outcome of any patient with PROM prior to term. A review of 13 randomized trials
reported that approximately 75% of patients with preterm PROM who were managed
expectantly delivered within 1 week (Mercer BM, Arheart KL,1995 ). The earlier in
gestation that PROM occurs, the greater the potential for pregnancy prolongation. With
expectant management, 2.8-13% of women can anticipate cessation of fluid leakage
(Mercer BM,1992 ).
Of women with preterm PROM, clinically evident intraamniotic infection occurs in 13-
60% and postpartum infection occurs in 2-13% (Vergani P, Ghidini A, Locatelli A,
Cavallone M, Ciarla I, Cappellini A, et al. , 1994). The incidence of infection increases
with decreasing gestational age at membrane rupture (Hillier SL, Martius J, Krohn M,
Kiviat N, Holmes KK, Eschenbach DA,1988 ) and increases with digital vaginal
examination (Schutte MF, Treffers PE, Kloosterman GJ, Soepatmi,1983) with

2
appropriate management risk ofmaternal sequelae are uncommon. Fetal malpresentation
is increased with preterm PROM. Abruptio placentae affects 4-12% of pregnancies with
preterm PROM (Ananth CV, Savitz DA, Williams MA,1996).
The most significant risks to the fetus after preterm PROM are complications of
prematurity. At all gestational ages prior to term, respiratory distress has been reported to
be the most common complication (Fanaroff AA, Wright LL, Stevenson DK, Shankaran
S, Donovan EF, Ehrenkranz RA, et al,1995)other serious forms of morbidity, including
necrotizing enterocolitis and intraventricular hemorrhage, also are associated with pre-
maturity but are less common nearer to term. The presence of maternal infection poses
the additional risk of neonatal infection. Infection, cord accident, and other factors
contribute to the 1-2% risk of antenatal fetal demise after preterm PROM (Mercer BM,
Arheart KL,1995).
Midtrimester Premature Rupture of Membranes
Premature rupture of membranes occurring before and around the time of neonatal
viability often is referred to as midtrimester PROM. Premature rupture of membranes at
16-26 weeks of gestation complicates almost 1% of pregnancies ( . Schucker JL, Mercer
BM,1999).
e the 1970s, delivery in the second trimester was generally associated with neonatal death
resulting from complications of prematurity. Primarily because of advances in neonatal
intensive care over the past two decades, neonates are surviving at increasingly younger
gestational ages. Currently, overall infant survival after delivery at 24-26 weeks of
gestation is reported to be between 50% and 75% (Kilpatrick SJ, Schlueter MA, Piecuch
R, Leonard CH, Rogido M, Sola A.,1997).survival rates in pregnancies complicated by
PROM are comparable but decreased in the presence of infection or deformations.
A small number of patients with midtrimester PROM will have an extended latency
period. In a review of 12 studies evaluating patients with midtrimester PROM, the mean
latency period ranged from 10.6 to 21.5 days ( Schucker JL, Mercer BM,1997).Although
delivery occurred within 1 week of membrane rupture in 57% of patients, in 22% of
patients pregnancy continued for 1 month. Most studies of midtrimester PROM have
been retrospective and include only those patients amenable to expectant management.
Patients usually are excluded from analysis in the presence of labor, infection, prolapsed
membranes, and fetal demise, thus potentially exaggerating the latency period to delivery
and deceptively decreasing the apparent maternal and infant morbidity.
Reported maternal complications of midtrimester PROM include intraamniotic infection,
endometritis, abruptio placentae, retained placentae, and postpartum hemorrhage.
Maternal sepsis is a rare but serious complication reported to affect approximately 1% of
cases (Schucker JL, Mercer BM,1997).
The incidence of stillbirth subsequent to PROM at 16-25 weeks of gestation ranges from
3.8% to 21.7% (Bengtson JM, VanMarter LJ, Barss VA, Greene MF, Tuomala RE,
Epstein MF,1989).compared with 0-2% with PROM at 30-36 weeks of gestation (Cox
SM, Leveno KJ,1995).
This increased rate of death may be explained by increased susceptibility of the umbilical
cord to compression or of the fetus to hypoxia and intrauterine infection. Alternatively,
this finding may reflect the lack of intervention for fetal compromise prior to neonatal
viability. The fetal survival rate subsequent to PROM at less than 24 weeks of gestation

3
has been reported to be about 30%, compared with a 57% survival rate with rupture at
24-26 weeks of gestation (Schucker JL, Mercer BM,1997).

Several trials have described outcomes of survivors after PROM at 16-26 weeks of
gestation (Morales WJ, Talley T.,1993).Although up to 69% of these neonates were
reported as having normal neurologic development, these results may be biased by a lack
of follow-up. Generalized developmental delay, delayed motor development, and other
less frequent complications, including cerebral palsy, chronic lung disease, blindness,
hydrocephalus, and mental retardation, also were reported to occur.

A variety of conditions that are associated with fetal lung compression or

oligohydramnios or both can result in pulmonary hypoplasia. Reported risks of
pulmonary hypoplasia after PROM at 16-26 weeks of gestation vary from less than 1% to
27% (Moretti M, Sibai BM.,1988).
Pulmonary hypoplasia rarely occurs with membrane rupture subsequent to 26 weeks of
gestation, presumably because alveolar growth adequate to support postnatal
development already has occurred (.van Eyck J, van der Mooren K, Wladimiroff
JW,1990).
Prolonged oligohydramnios also is associated with in utero deformation including
abnormal facies (ie, low-set ears and epicanthal folds) and limb positioning
abnormalities.
When leakage of amniotic fluid occurs after amniocentesis, the outcome is better than
after spontaneous preterm PROM. In one study of 603 women who had second-trimester
amniocentesis for prenatal diagnosis of genetic disorders, seven women (1.2%)
experienced PROM, and leakage stopped in all with conservative management ( Gold
RB, Goyert GL, Schwartz DB, Evans MI, Seabolt LA,1989).

References

1. Ventura SJ, Martin JA, Curtin SC, Mathews TJ. Report of final natality
statistics, 1995. Monthly vital statistics report; vol 45, no. 11, supp.
Hyattsville, Maryland: National Center for Health Statistics, 1997
2. French JI, McGregor JA. The pathobiology of premature rupture of
membranes. Semin Perinatol 1996;20:344-368

4
3. McGregor JA, French JI. Evidence-based prevention of preterm birth and
rupture of membranes: infection and inflammation. J SOGC 1997;19:835-
852
4. Harger JH, Hsing AW, Tuomala RE, Gibbs RS, Mead PB, Eschenbach DA,
et al. Risk factors for preterm premature rupture of fetal membranes: a
multicenter case-control study. Am J Obstet Gynecol 1990;163:130-13
5. Gold RB, Goyert GL, Schwartz DB, Evans MI, Seabolt LA. Conservative
management of second trimester post-amniocentesis fluid leakage. Obstet
Gynecol 1989;74:745-747
6. Hannah ME, Ohlsson A, Farine D, Hewson SA, Hodnett ED, Myhr TL, et
al. Induction of labor compared with expectant management for prelabor
rupture of the membranes at term. N Engl J Med 1996;334:1005-1010
7. Wagner MV, Chin VP, Peters CJ, Drexler B, Newman LA. A comparison of
early and delayed induction of labor with spontaneous rupture of
membranes at term. Obstet Gynecol 1989;74:93-97
8. Mercer BM, Arheart KL. Antimicrobial therapy in expectant management of
preterm premature rupture of the membranes. Lancet 1995;346:1271-1279
9. Mercer BM. Management of premature rupture of membranes before 26
weeks' gestation. Obstet Gynecol Clin North Am 1992;19:339-351
10. Vergani P, Ghidini A, Locatelli A, Cavallone M, Ciarla I, Cappellini A, et al.
Risk factors for pulmonary hypoplasia in second-trimester premature
rupture of membranes. Am J Obstet Gynecol 1994;170:1359-1364
11. Hillier SL, Martius J, Krohn M, Kiviat N, Holmes KK, Eschenbach DA. A
case-control study of chorioamnionic infection and histologic
chorioamnionitis in prematurity. N Engl J Med 1988;319:972-978
12. Morales WJ. The effect of chorioamnionitis on the developmental outcome
of preterm infants at one year. Obstet Gynecol 1987;70:183-186
13. Schutte MF, Treffers PE, Kloosterman GJ, Soepatmi S. Management of
premature rupture of membranes: the risk of vaginal examination to the
infant. Am J Obstet Gynecol 1983;146:395-400
14. Ananth CV, Savitz DA, Williams MA. Placental abruption and its
association with hypertension and prolonged rupture of membranes: a
methodologic review and meta-analysis. Obstet Gynecol 1996;88:309-31
15. Fanaroff AA, Wright LL, Stevenson DK, Shankaran S, Donovan EF,
Ehrenkranz RA, et al. Very-low-birth-weight outcomes of the National
Institute of Child Health and Human Development Neonatal Research
Network, May 1991 through December 1992. Am J Obstet Gynecol 1995;
173:1423-1431
16. Schucker JL, Mercer BM. Midtrimester premature rupture of the
membranes. Semin Perinatol 1996;20:38
17. Kilpatrick SJ, Schlueter MA, Piecuch R, Leonard CH, Rogido M, Sola A.
Outcome of infants born at 24-26 weeks' gestation: I. Survival and cost.
Obstet Gynecol 1997;90:803-808
18. Moretti M, Sibai BM. Maternal and perinatal outcome of expectant
management of premature rupture of the membranes in midtrimester. Am J
Obstet Gynecol 1988;159:390-396

5
19. Bengtson JM, VanMarter LJ, Barss VA, Greene MF, Tuomala RE, Epstein
MF. Pregnancy outcome after premature rupture of the membranes at or
before 26 weeks' gestation. Obstet Gynecol 1989;73:921-926
20. Cox SM, Leveno KJ. Intentional delivery versus expec- tant management
with preterm ruptured membranes at 30-34 weeks' gestation. Obstet Gynecol
1995;86:875-879
21. Mercer BM, Crocker LG, Boe NM, Sibai BM. Induction versus expectant
management in premature rupture of the membranes with mature amniotic
fluid at 32 to 36 weeks: a randomized trial. Am J Obstet Gynecol
1993;169:775-782
22. Morales WJ, Talley T. Premature rupture of membranes at <25 weeks: a
management dilemma. Am J Obstet Gynecol 1993;168:503-507
23. van Eyck J, van der Mooren K, Wladimiroff JW. Ductus arteriosus flow
velocity modulation by fetal breathing movements as a measure of fetal lung
development. Am J Obstet Gynecol 1990;163:558-566

6
7