Updated: 5/15/2021

Premature Rupture of Membranes (PROM)

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Questions
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Evidence
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Snapshot
  • A 30-year-old G2P1 woman at 33 weeks of gestation presents to the emergency department saying that her "water broke." She reports that the fluid is a pale yellow color and denies the presence of mucus or blood. External fetal monitoring reveals a reactive fetal heart tracing and no uterine contractions. Speculum exam reveals a closed cervical os with a pool of fluid in the vaginal vault. A swab of her vaginal secretions is obtained and fixed to a glass slide; the view under the microscope is seen in the image. Bedside sonogram shows oligohydramnios and a fetus with cephalic presentation.
Introduction
  • Overview
    • premature rupture of membranes (PROM) occurs when a patient at ≥ 37 weeks of gestation presents with rupture of membranes (ROM) prior to the start of uterine contractions
      • preterm premature rupture of membranes (PPROM) describes PROM that occurs < 37 weeks of gestation
  • Epidemiology
    • incidence
      • ~10% of all pregnancies
    • risk factors
      • urinary tract infection
      • antepartum bleeding
      • low body mass index
      • cigarette smoking
      • cerclage
      • amniocentesis
  • Pathophysiology
    • ruptured membranes at term result from programmed cell death, activation of collagenase, and mechanical forces
      • premature rupture of membranes occurs due to premature activation of these pathways
        • may be linked to underlying inflammation and/or infection of the membranes
  • Prognosis
    • generally good if occurring > 32 weeks of gestation
    • 90% of patients enter spontaneous labor within 24 hours if ROM occurs at term
Presentation
  • Symptoms
    • leakage of fluid from the vagina in the absence of contractions
    • vaginal discharge
    • vaginal bleeding
    • pelvic pressure
  • Physical exam
    • avoid digital vaginal examination
    • observation of pooling of fluid in the vaginal fornix on speculum examination
      • most accurate observation for the diagnosis of ROM
Studies
  • Vaginal fluid
    • Fern test
      • vaginal fluid is swabbed and placed on a glass slide
        • ferning of the dried fluid under microscopic examination indicates the presence of amniotic fluid
    • Nitrazine paper test
      • tests the pH of the vaginal fluid
        • paper turns blue when pH is > 6 
          • vaginal fluid is acidic with a pH ~4, while amniotic fluid has a pH ~7
Tested Differential
  • Urinary incontinence 
    • key distinguishing factor
      • leakage of urine
  • Increased cervical discharge from infection
    • key distinguishing factor
      • negative fern and nitrazine paper test
Treatment
  • Medical
    • observation, antibiotic administration, and antenatal corticosteroid administration 
      • indications
        • if there is no evidence of chorioamnionitis or fetal compromise in patients at 22-34 weeks of gestation
      • technique
        • antibiotics
          • administer antibiotic regimen to reduce the risk of chorioamnionitis and neonatal sepsis
            • erythromycin or amoxicillin-clavulanic acid are commonly used
        • corticosteroids
          • given to promote lung development
          • if the lecithin/sphingomyelin ratio is < 2.0, can administer betamethasone up to < 36 weeks of gestation 
    • induce delivery
      • indications
        • if > 34 weeks of gestation, unless the gestational age of the fetus is uncertain and fetal maturity cannot be confirmed
Complications
  • Chorioamnionitis
    • incidence
      • from < 10% during the first 24 hours of PROM to as high as 40% after 24 hours
    • treatment
      • adminstration of intrapartum antibiotics and antipyretics 
  • Fetal/neonatal death
    • incidence
      • 1% of all patients with PROM
        • 0.001% of patients with PROM at term

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Questions (2)

(M2.OB.17.4867) A 29-year-old G2P0010 at 33 weeks and 2 days gestation presents to the labor floor after experiencing a gush of clear fluid while at dinner one hour ago. She denies vaginal bleeding, contractions, or changes in fetal movement. Aside from anxiety about her leakage of fluid, she feels well. Her prenatal course has been complicated by gestational diabetes, for which she is managed with insulin therapy. The patient has a past medical history of mild intermittent asthma, for which she uses albuterol every few weeks. She also had a hysteroscopic myomectomy two years ago, and her obstetric history is notable for one induced abortion by medication. On exam, the patient’s temperature is 98.5°F (36.9°C), pulse is 80/min, blood pressure is 121/82 mmHg, and respirations are 13/min. Cardiopulmonary exams are unremarkable, and her abdomen is gravid without tenderness. Pelvic exam reveals a cervix that is 0.5 centimeters dilated, four centimeters long, and -3 station. There is a pool of clear fluid in the vaginal vault, and a swab turns nitrazine paper blue and appears as Figure A under the microscope. Which of the following is the best next step in management?

QID: 109652
FIGURES:
1

Administration of betamethasone

89%

(8/9)

2

Administration of magnesium sulfate for neuroprotection

0%

(0/9)

3

Administration of misoprostol

0%

(0/9)

4

Discharge home with close follow-up

11%

(1/9)

5

Cesarean section

0%

(0/9)

M 7 E

Select Answer to see Preferred Response

(M2.OB.17.4868) A woman presents to the emergency department due to abdominal pain that began 1 hour ago. She is in the 35th week of her pregnancy when the pain came on during dinner. She also noted a clear rush of fluid that came from her vagina. The patient has a past medical history of depression which is treated with cognitive behavioral therapy. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note a healthy young woman who complains of painful abdominal contractions that occur every few minutes. Laboratory studies are ordered as seen below.

Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 6,500/mm^3 with normal differential
Platelet count: 197,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
Lecithin/Sphingomyelin: 1.5
AST: 12 U/L
ALT: 10 U/L

Which of the following is the best next step in management?

QID: 109671
1

Betamethasone

62%

(5/8)

2

Terbutaline

0%

(0/8)

3

Oxytocin

0%

(0/8)

4

RhoGAM

0%

(0/8)

5

Expectant management

38%

(3/8)

M 7 E

Select Answer to see Preferred Response

Evidence (1)
EXPERT COMMENTS (13)
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