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Updated: May 15 2021

Premature Rupture of Membranes (PROM)

  • 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
  • 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
  • Prognosis
    • Generally good if occurring > 32 weeks of gestation
    • 90% of patients enter spontaneous labor within 24 hours if ROM occurs at term
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