Pre-labor Rupture of Membranes (PROM) Family Medicine Specialist CME Vientiane, Lao PDR December 10 – 12, 2008

Objectives Define prelabor rupture of membranes (PROM) and discuss possible etiology Discuss diagnosis of PROM Discuss management of PROM

PROM (Pre-labour Rupture of Membranes) Rupture of membranes at term (>37 weeks gestation) Occurs 2-10% of pregnancies Latent phase (time from rupture to labor) 90% will go into labor within 24 hours

PPROM (Preterm Prelabor Rupture of Membranes) Rupture of the membranes before 37 completed weeks of gestation Occurs: 2 – 3% of all pregnancies Accounts for 1/3 of all preterm deliveries Latent Phase – Time from rupture till labor 28 – 34 weeks gestation 50% go into labor within 24 hours 80 – 90% go into labor within 1 week

Etiology Idiopathic Infections Polyhydramnios Multiple gestation (Twins) Uterine abnormality Cervical incompetence Trauma (MVA, domestic violence) Previous cervical surgery (Cone Biopsy) Other (Smoker, stress, lifestyle, nutrition, drugs)

Complications of PROM Term Preterm Fetal / neonatal Maternal Neonatal Infection Cord compression / prolapse Maternal Increased induction rate Increased cesarean section rate Preterm Neonatal Infection Cord compression / prolapse Pulmonary hypoplasia & fetal deformation (ROM <24 weeks gestation) Maternal Increased cesarean section rate Preterm labor & delivery

Diagnosis History Sterile speculum exam Amniotic fluid testing for Ferning Nitrazine (pH)

Management - any gestation Confirm diagnosis Assess maternal & fetal well-being Determine fetal position Assess cervical status with speculum exam (obtain fluid for cultures / testing) Avoid digital examination until induction Assess for conditions requiring immediate delivery Infections Conditions requiring concurrent management (eg. PIH) Indications for immediate delivery

PROM (>37 weeks) Management Avoid digital exam until induction of labor Maternal and fetal well-being good Assess and monitor expectantly up to 48 hours Perform cesarean section if contraindications to vaginal delivery Eg. Breech, Cord prolapse, placenta previa

PPROM (34 – 37 weeks) Management Limited research Consider transfer to hospital with NICU for delivery Consider induction versus expectant management Expectant care may have higher risk Chorioamnionitis Neonatal infections

PROM (<34 weeks) Management Consider transfer to hospital with NICU Consider Betamethasone treatment Consider antibiotics to delay latent phase Ampicillin / Erythromycin Assess for infection / Chorioamnionitis Treat & deliver if develops Perform ultrasound Determine fetal position, Amniotic fluid volume

Conclusion PROM at any gestation has many causes Management of PROM is aimed at reducing both maternal & neonatal infections and complications