Premature rupture of membranes (PROM) Neelam Bose & Latif Miah

What is PROM? Premature rupture of membranes (PROM) – Rupture of the membranes prior to the onset of labour, in a patient who is beyond 37 weeks gestation. Risk Factors Smoking Previous PROM/ P-PROM UTI Symptoms ‘Popping’ sensation or painless gush of fluid. Diagnosis + Investigations Speculum Exam Check for contractions USS for liquor volume and fetal position Monitor for signs of infection; temp, CRP, WCC Monitor for fetal distress: fetal HR, meconium stained liquor Management Offered a choice of immediate induction or expectant management (should not exceed 24 hours). Risk of infection increases the longer the duration between ROM and labour. WHAT IT IS Premature rupture of membranes (PROM) refers to a patient who is beyond 37 weeks' gestation and has presented with rupture of membranes (ROM) prior to the onset of labor. Preterm premature rupture of membranes (PPROM) is ROM prior to 37 weeks' gestation. Spontaneous preterm rupture of the membranes (SPROM) is ROM after or with the onset of labor occurring prior to 37 weeks. Prolonged ROM is any ROM that persists for more than 24 hours and prior to the onset of labor. At term, programmed cell death and activation of catabolic enzymes, such as collagenase and mechanical forces, result in ruptured membranes. Preterm PROM occurs probably due to the same mechanisms and premature activation of these pathways. However, early PROM also appears to be linked to underlying pathologic processes, most likely due to inflammation and/or infection of the membranes. Clinical factors associated with preterm PROM include low socioeconomic status, low body mass index, tobacco use, preterm labor history, urinary tract infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis. [1] DIAGNOSIS (from nice cks) 1.3 Diagnosing preterm prelabour rupture of membranes (P‑PROM) 1.3.1 In a woman reporting symptoms suggestive of P-PROM, offer a speculum examination to look for pooling of amniotic fluid and: if pooling of amniotic fluid is observed, do not perform any diagnostic test but offer care consistent with the woman having P‑PROM (see sections 1.4, 1.5 and 1.9) if pooling of amniotic fluid is not observed, consider performing an insulin‑like growth factor binding protein‑1 test or placental alpha‑microglobulin‑1 test of vaginal fluid. 1.3.2 If the results of the insulin‑like growth factor binding protein‑1 or placental alpha‑microglobulin‑1 test are positive, do not use the test results alone to decide what care to offer the woman, but also take into account her clinical condition, her medical and pregnancy history and gestational age, and either: offer care consistent with the woman having P‑PROM (see sections 1.4, 1.5 and 1.9) or re-evaluate the woman's diagnostic status at a later time point. 1.3.3 If the results of the insulin-like growth factor binding protein‑1 or placental alpha‑microglobulin‑1 test are negative and no amniotic fluid is observed: do not offer antenatal prophylactic antibiotics explain to the woman that it is unlikely that she has P‑PROM, but that she should return if she has any further symptoms suggestive of P‑PROM or preterm labour. 1.3.4 Do not use nitrazine to diagnose P‑PROM. 1.3.5 Do not perform diagnostic tests for P‑PROM if labour becomes established in a woman reporting symptoms suggestive of P‑PROM. MANAGEMENT Most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at term. The major question regarding management of these patients is whether to allow them to enter labor spontaneously or to induce labor. In large part, the management of these patients depends on their desires; however, the major maternal risk at this gestational age is intrauterine infection. The risk of intrauterine infection increases with the duration of ROM. Evidence supports the idea that induction of labor, as opposed to expectant management, decreases the risk of chorioamnionitis without increasing the cesarean delivery rate. P-PROM In P-PROM: Speculum examination +/- other diagnostic tests Offer antenatal prophylactic antibiotics Oral erythromycin 250 mg QDS for 10 days or until the woman is in established labour. Identify infection via a combination of tests including: Maternal signs of infection including temperature, CRP, WCC Fetal signs of infection including fetal heart rate using CTG Depending on gestation, offer maternal corticosteroids

36 year old female G1P0, Primip, PROM Current pregnancy: 38+2 (EDD 18/12/18), uneventful, MLC Felt a ‘flooding’ sensation followed by intense pain – unable to sleep. Admitted ward 19 on 06/12/18 after midwife confirmed PROM in morning. PROM O/E: Speculum exam showed pooling of fluid. Longitudinal lie, cephalic presentation, 3/5 engaged Clear liquor, normal foetal movements, mild period type pains (experiences irregular tightening) Obs: Temp 36.6, BP 137/93, HR 72, RR 14, SpO2 100% Bloods: HB 117 CTG: Normal reassuring, foetal HR 135 USS: Normal 07/12/18 – reduced movements w/ irregular contractions overnight, back to normal during day (foetal HR 128) PMHx: Eczema, vaccinations upto date DHx: Nil FHx: Cardiac issues - father GynaeHx: Smears up to date and normal. ObsHx: Normal growth, scans, movements. Anterior placenta, OP presentation SHx: Lives in house with husband and 2 dogs ICE: Fed up with all the waiting around (delay as CDS was full). Concerned as had missed the ‘24 hour window’ she was given – worried about baby getting infection before being induced. Just wants a ‘normal’ birth – not keen on CS. “Try not to plan as nothing goes to plan!” Induced 08/12/18 – Syntocinon Delivery: SVD, 08/12/2018 @ 2348 Birth Wt: 3440g, female, Apgar 9, 10, 10

Learning points Most patients will labour within 24 hours of ROM The risk of intrauterine infection increases with the duration of ROM. The choice between induction and conservative management is due to maternal choice as well as the clinical picture. MANAGEMENT Most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at term. The major question regarding management of these patients is whether to allow them to enter labor spontaneously or to induce labor. In large part, the management of these patients depends on their desires; however, the major maternal risk at this gestational age is intrauterine infection. The risk of intrauterine infection increases with the duration of ROM. Evidence supports the idea that induction of labor, as opposed to expectant management, decreases the risk of chorioamnionitis without increasing the cesarean delivery rate.

References https://www.nice.org.uk/guidance/ng25?unlid=9291036072016213201257 https://emedicine.medscape.com/article/261137-overview#a1 https://patient.info/doctor/preterm-prelabour-rupture-of-membranes#nav-1 https://www.invitra.com/amniotic-fluid-leakage/ http://definedefinitions.blogspot.com/2013/06/define-preterm-premature-rupture- of-membranes-PPROM.html http://www.evidentlycochrane.net/prelabour-rupture-membranes-induce-wait/