Premature Ruptured Membranes Mounira Habli MD Helen How MD Basics Description PROM is defined as rupture of amniotic membranes >1

1 hour before the onset of labor. Term PROM: fter !" wee#s$ %estation

PPROM: Before !" wee#s:

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PPPROM: >&' hours without deli(er).

*atenc) is the inter(al from time of rupture to onset of labor:

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*atenc) is in(ersel) proportional to + . Between &,-&. wee#s/ mean latenc) 1& da)s Between !&-!' wee#s/ mean latenc) ' da)s

%e0Related 1actors More common in mothers 213 )ears and >', )ears old 4pidemiolo%) PPROM occurs in !-5 6 of all pre%nancies. ccounts for &5-',6 of all preterm deli(eries.

ccounts for 75,6 of ad(erse lon%0term outcomes and .,6 of perinatal mortalit) Between &,-!. wee#s/ .,-",6 of patients with PPROM deli(er with in '3 hours. t !!-!. wee#s/ 3,6 deli(er within '3 hours. 1!.56 ris# of recurrence:
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1!.5 times %reater when pre(ious episode PPROM was 2&3 wee#s$ %estation

Ris# 1actors 5,6 ha(e no ris# factors. Prior PPPROM or preterm birth

Bleedin% in 1st trimester/ +8 tract infection/ blac# race/ low prepre%nanc) wei%ht/ a%e 213/ pre%nanc) 2. month pre(iousl) 9mo#in%/ fre:uent contractions/ ps)chiatric disorders 8terine anomal). ;ulliparous women at %reater ris# of PPROM if wor#in% durin% pre%nanc) with medical complications and a short cer(i< =&5 mm.

Hemo%lobin 211.1 %>d* ?OR '.!!@ *ow socioeconomic status ?OR !.1@ Bacterial (a%inosis is ;OT associated

+enetics PPROM is a multifactorial condition with interpla) of %enetic and en(ironmental factors. Pathoph)siolo%) 4tiolo%) is multifactorial. At is un#nown in >5,6. Man) mechanisms are proposed: membrane colla%en de%radation/ local inflammation/ choriodecidual infection due to increased susceptibilit) to ascendin% infection/ decreased membrane colla%en content/ localiBed membrane defects/ membrane stretch ?uterine o(erdistension@/ pro%rammed cell death ssociated Conditions mniocentesis Cer(ical cercla%e/ cer(ical insufficienc)

Chronic abruption placenta/ abnormal placentation *44P/ cer(ical coniBation 8terine o(erdistension

Dia%nosis 9i%ns and 9)mptoms Histor) Adentif) ris# factors Patients usuall) present with %ush or lea#a%e of fluids/ continuous drippin%/ wet pants/ increase in (a%inal dischar%e/ li%ht (a%inal bleedin%/ and labor pain. Ph)sical 4<am Dital si%ns: o Temperature ?>!3.,E C@: Chec# for a source of infection.
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Blood pressure and pulse ?if tach)cardiac/ rule out intrauterine infection@

bdominal e<am: ssess for uterine tenderness/ hei%ht of fundus measurement/ fetal presentation. Dul(ar e<am: Chec# for lesions. 9terile speculum e<am to confirm PPROM. Combination of F& tests ?1ernin%/ ;itraBine/ or patient histor)@ pro(ide an accurac) of G!.16.
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1ernin% testin%: Microscop) of (a%inal fluid:

Performed on the mid(a%inal or posterior forni< fluid.

1alse0positi(e results due to cer(ical mucus. llowed to dr) for a minimum of 1, minutes. 8naffected b) meconium or chan%e in PH

;itraBine paper test ?pH@:

Blue color due to al#aline pH 1alse0positi(e results from: Blood/ semen/ al#aline urine/ soap/ antiseptic solutions.

Pel(ic e<am: (oid di%ital e<am unless imminent deli(er) suspected: o Disual assessment of cer(i<
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F& di%ital e<ams resulted in shorter latenc) ?! (s. 5 da)s@ but did not worsen maternal or neonatal outcome.

Tests 1etal monitorin%: ;9T to assess fetal well bein% 8terine tocod)namometr) for uterine contractions. *abs

CBC with differential/ plateletsH fibrino%en if bleedin% 8 / culture/ sensiti(ities/ to<icolo%) screen Cer(ical culture for ;eisseria %onorrhea/ Chlam)dia trachomatis Chec# for bacterial (a%inosis and trichomonas b) either (a%inal swab or D; probe. +B9 cultures from lower 1>! of (a%ina and perineum Biochemical testin% has been used/ but none is (er) useful clinicall) in dia%nosis of PPROM:
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1 contains >5,/,,, n%>m* 11; 4<tracellular %l)coprotein that attaches the fetal membranes and uterine decidua ;ormall) absent between && and !" wee#s. Af no cer(ical e<am or se<ual intercourse in the last &' hours/ do the test between &'-!' wee#s.

Ihen histor)/ 1ernin% test/ and ;itraBine are e:ui(ocal then 11; has a role. 9ensiti(it) G'6/ specificit) G"6/ PPD G"6/ ;PD G'6

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1P Diamino0o<)dase

Ama%in% 89 testin%: o To assess for + / fetal presentation/ estimated fetal wei%ht/ 1A/ rule out ob(ious fetal anomalies/ placenta location

mniocentesis under 89 %uidance:

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D)e test ?indi%o carmine test@ is the %old standard for dia%nosis. Andi%o carmine d)e is instilled (ia amniocentesisH if (a%inal tampon turns blue/ PROM is confirmed Af intrauterine infection suspected Af fetal lun% maturit) is clinicall) indicated 9end for IBC/ +ram stain/ culture/ %lucose A*0. is the best mar#er for intrauterine infection.

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Treatment +eneral Measures Pre(enti(e treatment to pre(ent preterm deli(er) Transport mother to appropriate facilit) for fetal care.

Corticosteroids to reduce ris# of RD9/ ADH ntibiotic for +B9 proph)la<is and to increase latenc) period

Pre%nanc)09pecific Assues 8pon arri(al to tria%e: Confirm dia%nosis ssess fetal status and presentation ?;9T/ 89@

Bed rest/ AD h)dration/ fluid bolus if deh)drated Ta#e cultures before startin% antibiotics

B) Trimester fter the dia%nosis of PPROM is confirmed/ deli(er re%ardless of + if e(idence of clinical intrauterine infection/ fetal death/ nonreassurin% fetal status/ or ad(anced labor. Otherwise mana%ement is based on + :

Af 2&' wee#s:

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Counsel patient about ris#s of PPROM at 2&' wee#s ?see below@ Consider termination Monitor and bed rest with serial 89 if patient elects conser(ati(e mana%ement. Af persistent oli%oh)dramnios ? 1A 25 cm@ a%ain discuss options of termination of pre%nanc) or conser(ati(e mana%ement:

An conser(ati(e mana%ement/ consider antibiotics for " da)s. Dischar%e patient home with infection precautions and readmit at (iabilit) ?&' wee#s@.

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Between &'-!1 .>" wee#s: o Af recurrent labor/ consider amniocentesis to rule out infection.
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Otherwise/ modified bed rest Corticosteroids ?de<amethasone . m% AM :1&h for total of ' doses or betamethasone 1& m% AM :&'h for & doses@:

Tocol)sis for '3 hours

ntibiotics per ;AH protocol:

AD ampicillin ?&0% dose :.h@ and er)throm)cin ?&5,-m% dose :.h@ for '3 hours followed b) oral amo<icillin ?&5,-m% dose :3h@ and er)throm)cin tablets ?!!!-m% dose :3h@ for 5 da)s Composite morbidities ?RD9/ earl) sepsis/ se(ere ADH/ se(ere ;4C@ decreased b) 5!-''6 Decrease in amnionitis and prolon%ation of the latenc) period b) >1 wee#

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9erial e(aluation for intrauterine infection/ labor/ abruption placenta 9erial e(aluation for fetal well0bein%: ;9T at least twice a wee#/ fetal %rowth e(aluation :&-! wee#s Deli(er) upon e(idence of chorioamnionitis ?clinicall) or b) amniocentesis@/ nonreassurin% fetal status/ or at !&-!' wee#s Repeat tocol)sis is not recommended be)ond &3 wee#s.

Between !&-!' wee#s:

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Chec# for fetal lun% maturit):

Af lun% maturit) results from 1 ?transabdominall) or trans(a%inall)@ are positi(e ?lecithin>sphin%om)elin >&., or lamellar bod) count F!, J@/ deli(er Af lun% maturit) results are ne%ati(e/ consider conser(ati(e mana%ement until steroids and antibiotic are %i(en.

Deli(er) at !' wee#s

Antrapartum mana%ement:
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Anduction of labor Mode of deli(er) is 9DD/ caesarian if obstetricall) indicated. Broad0spectrum antibiotics for intrauterine infection ?ampicillin and %entamicinH add clindam)cin if caesarian deli(er)@ ntibiotic for +B9 proph)la<is

lert 8ni(ersal +B9 proph)la<is is recommended ?see topic on Preterm *abor@. Ris#s for Mother Maternal sepsis/ DAC from placenta abruption/ postpartum hemorrha%e re:uirin% blood transfusion/ h)sterectom). Ris#s for 1etus Prematurit) Anfection:
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Ris# of neonatal sepsis is in(ersel) related to + . Ancreased 1,0fold with PPROM:

Chorioamnionitis in ,.55-"16 of pre%nancies with PPROM/ dependin% on population Ris# of intrauterine infection 7!.6 at 2&. wee#s$ %estation. !1-!! wee#s: '0fold increased ris# of intrauterine infection

Pulmonar) h)poplasia if 2&' wee#s:

Depends on + at time of PPROMH most critical period of lun% de(elopment is before && wee#s but ma) continue up to &5 wee#s.

Restricti(e deformations:

Ancludin% spadeli#e hands and fle<ion contractions of elbows/ #nees/ and feet

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1etal a#inesia mniotic bands

9pecial Therap) Complementar) and lternati(e Therapies mnioinfusion: ;o ade:uate controlled trial to support neonatal benefits 9u%%ested benefits:
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Decreased maternal and neonatal morbidit) Decreased fetal distress

Ris#s:
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Cord prolapse 8terine o(erdistension/ fetal brad)cardia bruption/ infection/ PT*

Medication ?Dru%s@ 9ee Preterm *abor. 1ollowup Disposition Assues for Referral ll patients should be referred and comana%ed b) a M1M specialist. Pro%nosis Based on + and associated medical conditions Complications 9hort term: 1eedin% and %rowth difficulties/ infection/ apnea/ neurode(elopmental difficulties/ retinopath)/ transient d)stonia *on% term: Cerebral pals)/ sensor) deficits/ special needs/ incomplete catch0 up %rowth/ school difficulties/ beha(ioral problems/ chronic lun% disease Patient Monitorin% Mother Dital si%ns for e(idence of infection Contraction monitorin% 1etus ;9T Biblio%raph) +abbe 9+/ et al. Obstetrics: ;ormal and bnormal Pre%nancies. An: Aam K/ ed. Preterm birth/ 'th ed. Philadelphia: Churchill0*i(in%stoneH &,,&H"55-3&". Aams KD/ et al. Maternal01etal Medicine: Principles and Practice An: Preterm *abor and Deli(er)/ 5th ed. &,,'H.&!-..!. Miscellaneous Outpatient mana%ement is not recommended. bbre(iations L 1M mniotic fluid L 1AM mniotic fluid inde< L 1PMN01etoprotein L DACMDisseminated intra(ascular coa%ulopath)

L 11;M1etal fibronectin L + M+estational a%e L +B9M+roup B streptococcus L A*0.MAnterleu#in . L ADHMAntra(entricular hemorrha%e L *44PM*oop electrosur%ical e<cision procedure L M1MMMaternal0fetal medicine L ;4CM;ecrotiBin% enterocolitis L ;AHM;ational Anstitutes of Health L ;PDM;e%ati(e predicti(e (alue L ;9TM;onstress test L PPDMPositi(e predicti(e (alue L PROMMPremature rupture of membranes L PPROMMPreterm premature rupture of membranes L PPPROMMProlon%ed preterm premature rupture of membranes L PT*MPreterm labor L RD9MRespirator) distress s)ndrome L 9DDM9pontaneous (a%inal deli(er) Codes ACDG0CM L .''.,!/ .''.&1 Preterm labor L .53.1/ .53.& PPROM Patient Teachin% L Pro(ide written information about preterm0infant de(elopment. L 9upport %roup web sites. (ailable at www.share)ourstor).or% L Help parents to de(elop confidence in carin% for their preterm infants.