Diagnosis

Premature rupture of membranes

Etiology

Cause [kvy]

• Infection: chlamydia, strep B, gonococcus, ammnionitis

• Physiologic membrane weakening at the end of gestation

• Intraamniotic pressure

• Cervical insufficiency

• Trauma

• Unknown

Pathophysiology

1. Fetal membranes give mechanical protection to the fetus from microbes

   in the uterus

2. A woman with premature rupture of membranes is at risk of intra-amniotic infection, postpartum infection, endometritis, and death

3. A neonate born from premature rupture of membranes mother is at high risk of respiratory distress syndrome, sepsis, intraventricular hemorrhage and death

Risk factors [tq3]

• Previous PROM

• Short cervical length

• Smoking

• Age young and old

• STD

• Poverty

• Uterus distention (twins, polyhydramnion)

• Low BMI

• Diabetes

• Hypertension

• Hypertyreosis

• Cerclage

• Amniocentesis

Complications [kvy]

• Maternal:

  • Intrauterine infection

  • Sepsis

  • Placental abruption

  • Antenatal, intrapartum, and postpartum hemorrhage

  • Death

• Fetal:

  • Neonatal sepsis

  • Prematurity

    • Pulmonary hypoplasia

    • Respiratory distress syndrome

    • Intraventricular hemorrhage

    • Necrotizing enterocolitis

    • Retinopathy of prematurity

    • Limb contractures and skeletal deformities

    • Hypothermia

    • Glucose and electrolyte abnormalities

    • Failure to thrive

    • Death

Epidemiology

Incidence per 100.000 [b3m][gei][gmg][tpb][s6c][swh][tq3][bsr][q18]

Approach

• Speculum examination

• Nitrazine swab of vaginal fluid: pH of amniotic fluid typically is 7.1-7.3

• Microscopic examination of vaginal fluid for "ferning"

• Dye test (tampon test)

• Amniotic fluid proteins: placental alpha microglobulin-1, IGFBP-1, alpha-fetoprotein

• Ultrasound: oligohydramnios

• Urine stix

• Urine culture

• Cervical cultures

• Cytology

• Vaginal pH

• Amniocentesis:

  • Injection of indigo carmine to demonstre blue staining on a tampon or pad:

  • Lung maturity accuracy

  • Infection

Treatment

Management of PPROM: balance the risks of prolonging pregnancy with fetal risks of prematurity [s6c][jix][kvy]

1. Maternal vital signs

2. Fetal monitoring

3. Ultrasonographic documentation of gestational age, fetal weight, fetal presentation

4. Visual inspection of the cervix can accurately estimate cervical dilatation

5. Prior to 34 weeks gestation:

   • Transfer to a tertiary care center because of the risk of preterm birth

   • Corticosteroids (Betamethasone 12 mg IM, 2 doses) --> accelerate lung maturity

   • Tocolysis for transfer

   • Broad spectrum antibiotic therapy

   • Conservative management to improve fetal outcome

     • Risk of maternal infection: chorioamnionitis (13-60%), endometritis (2-13%), sepsis (< 1%), and maternal death (1-2 cases per 1000)

6. After 34 weeks gestation:

   • Immediate induction of labour, with the potential risk of prematurity requiring neonatal intensive care unit management

   • Expectant management (waiting for fetal maturity or the spontaneous onset of labour) may prolong pregnancy but increase the risk of chorioamnionitis

7. Immediate delivery of the fetus: infection/chorioamnionitis, advanced labor, maternal or fetal distress, placental abruption, fetal lung maturity

Differential diagnoses

Cervicitis, Perspiration, Urinary incontinence, Urinary tract infection, Vaginitis, Vesicovaginal fistula