1. Premature Rupture of Membranes
Assoc. Prof. Gazi YILDIRIM

2. Objectives
List the history, physical findings, and diagnostic methods to confirm the rupture of the membranes
Identify the risk factors for premature rupture of membranes
Describe the risks and benefits of expectant management versus immediate delivery, based on gestational age
Describe the methods to monitor maternal and fetal status during expectant management

3. Definition Premature rupture of membranes (PROM)
Rupture of the chorioamnionic membrane (amniorrhexis) prior to the onset of labor at any stage of gestation
Preterm premature rupture of membranes (PPROM)
PROM prior to 37-wk. gestation

4. Incidence PROM – 12% of all pregnancies PROM – 8% term pregnancies
PPROM – 30% of preterm deliveries

5. Risk factors Chorioamnionitis Vaginal infections
Cervical abnormalities
Vascular pathology (incl. abruptio)
Smoking
1st, 2nd, 3rd, or multiple trimester bleeding
Previous preterm delivery (PPROM)
Ethnicity
Acquired or congenital connective tissue disorder
Nutritional deficiencies (Vit.C, copper, zinc)

6. PROM/PPROM: Risk Factors
Prior PROM or PPROM
Prior preterm delivery
Multiple gestation
Polyhydramnios
Incompetent cervix
Vaginal/Cervical Infection
Gonorrhea, Chlamydia, GBS, S. Aureus
Antepartum bleeding (threatened abortion)
Smoking
Poor nutrition

7. Symptoms
Vaginal discharge
Gush of fluid
Leaking of fluid
Oligo/Anhydramnios
Cramping
Contractions
Back pain

8. Diagnosis
Sterile Speculum Exam (Pooling)
SSE-Free flow of fluid from cervical os
Nitrizine testing
Microscopic Fern testing
Fetal Fibronectin
AmniSure
Ultrasonography
Transabdominal Indigo dye injection

9. Diagnosis Latency period Infection
Digital Vaqinal exams significantly decrease the latency period in patients compared to those who only received a SSE.
In addition, the necessity in doing a digital exam is to determine cervical status, which in Preterm patients rarely alters the POC, unless delivery is imminent.
Studies also show an increase in the incidence of infection in patients with PROM who have had a digital exam, especially a higher incidence of neonatal infection in patients who had a digital exam > 24 hrs prior to delivery.

10. PROM/PPROM: History & Physical Exam
“Gush” of fluid
Steady leakage of small amounts of fluid
Physical
Sterile vaginal speculum exam
Minimize digital examination of cervix, regardless of gestational age, to avoid risk of ascending infection/amnionitis
Assess cervical dilation and length
Obtain cervical cultures (Gonorrhea, Chlamydia)
Obtain amniotic fluid samples (for fetal fibronectin ect.)
Findings
Pooling of amniotic fluid in posterior vaginal fornix
Fluid per cervical os

11. PROM/PPROM: Diagnosis
Test
Nitrazine test
Fluid from vaginal exam placed on strip of nitrazine paper
Paper turns blue in presence of alkaline (pH > 7.1) amniotic fluid
Fern test
Fluid from vaginal exam placed on slide and allowed to dry
Amniotic fluid narrow fern vs. cervical mucus broad fern

12. PROM/PPROM: Diagnosis
False positive Nitrazine test
Alkaline urine
Semen (recent coitus)
Cervical mucus
Blood contamination
Vaginitis (e.g. Trichomonas)
False-Negative Nitrazine test
Remote PROM with no residual fluid
Minimal amniotic leakage

13. PROM/PPROM: Diagnosis
AmniSure
Detects trace amounts of placental alpha microglobulin-1 protein in vaginal fluid.
Newer test
Point of Care test
Cost-up to $50 each
Sensitivity %
Specificity %

14. PROM/PPROM: Diagnosis
Test
Ultrasound
Assess amniotic fluid level and compatibility with PROM
Indigo-carmine Amnioinfusion
Ultrasound guided indigo carmine dye amnioinfusion (“Blue tap”)
Observe for passage of blue fluid from vagina
Amnisure tests detect trace amounts of placental alpha microglobulin-1 protein in vaginal fluid.
Test enhanced to eliminate hook effect which caused false negative results in grossly ruptured patients.
Again, once diagnostic tool, Be sure to step back and look at the entire clinical picture.

15. PROM/PPROM: Management
Gestational age
Availability of NICU
Fetal presentation
FHR pattern
Active distress (maternal/fetal)
Labor?
Cervical assessment
Amnisure tests detect trace amounts of placental alpha microglobulin-1 protein in vaginal fluid.
Test enhanced to eliminate hook effect which caused false negative results in grossly ruptured patients.
Again, once diagnostic tool, Be sure to step back and look at the entire clinical picture.

16. Management: PPROM (< 24 wk gestation – “previable”)
Patient counseling
Expectant management vs. induction of labor
GBS prophylaxis NOT recommended
Antibiotics
Incomplete data
Corticosteriods NOT recommended

17. Management: PPROM (< 24 wk gestation – “previable”)
Patient counseling
Fetal complications of prolonged PPROM
Pulmonary hypoplasia
Skeletal malformations
Fetal growth restriction
IUFD
Maternal complications of prolonged PPROM
Chorioamnionitis
Gestational Age (In Completed Weeks)
Death Before NICU Discharge
Outcomes at 18 to 22 Months Corrected Age*
Death
Death/ Profound Neurodevelopmental Impairment
Death/Moderate to Severe Neuro- developmental Impairment
22 Weeks
95%
98%
99%
23 Weeks
74%
84%
91%
24 Weeks
44%
57%
72%
25 Weeks
24%
25%
38%
54%

18. Management: PPROM (24 – 31 wk gestation)
Expectant management
Deliver at 34 wks
Unless documented fetal lung maturity
GBS prophylaxis
Antibiotics
Single course corticosteroids
Tocolytics
No consensus

19. Management: PPROM (32 – 33 wk gestation)
Expectant management
Deliver at 34 wks
Unless documented fetal lung maturity
GBS prophylaxis
Antibiotics
Corticosteroids
No consensus, some experts recommend

20. Management: PROM (> 34 wk gestation)
Proceed to delivery
Induction of labor
GBS prophylaxis

21. Management: Rationale
Antibiotics
Prolong latency period
Prophylaxis of GBS in neonate
Prevention of maternal chorioamnionitis and neonatal sepsis
Corticosteroids
Enhance fetal lung maturity
Decrease risk of RDS, IVH, and necrotizing enterocolitis
Tocolytics
Delay delivery to allow administration of corticosteroids
Controversial, randomized trials have shown no pregnancy prolongation

22. Management: Drug Regimen
Antibiotics
Ampicillin 2 g IV Q6 x 48 hrs
Amoxicillin 500 mg po TID x 5 days
Azithromycin 1 g po x 1
Corticosteroids
Betamethasone 12 mg IM q24 x 2
Dexamethasone 6 mg IM q12 x 4
Tocolytics
Nifedipine 10 mg po q20min x 3, then q6 x 48 hrs

23. Management: Amniocentesis
Typically performed after 32 wks
Tests for fetal lung maturity (FLM)
Lecethin/Sphingomyelin ratio (not commonly used, more for historic interest)
L/S ratio > 2 indicates pulmonary maturity
Phosphatidylglycerol
> 0.5 associated with minimal respiratory distress
Flouresecence polarization (FLM-TDx II)
> 55 mg/g of albumin
Lamellar body count
30,000-40,000
If negative, proceed with expectant management until 34 wks

24. Management: Surveillance
Maternal: Monitor for signs of infection
Temperature
Maternal heart rate
Fetal heart rate
Uterine tenderness
Contractions
Fetal: Monitor for fetal well-being
Kick counts
Nonstress tests (NST’s)
Biophysical profile (BPP)

25. Management: Surveillance
Immediate Delivery
Intrauterine infection
Abruptio placenta
Repetitive fetal heart rate decelerations
Cord prolapse

26. Expectant Management vs. Preterm Delivery
Expectant Management Risks:
Maternal
Increase in chorioamnionitis
Increase in Cesarean delivery
Spontaneous labor in ~ 90% within 48 hr ROM
Increased risk of placental abruption
Fetal
Increase in RDS
Increase in intraventricular hemorrhage
Increase in neonatal sepsis and subsequent cerebral palsy
Increase in perinatal mortality
Increase in cord prolapse