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Overview 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 premature rupture of the membranes (SPROM) is ROM after or with the onset of labor. 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] Eighty-five percent of neonatal morbidity and mortality is a result of prematurity. PPROM is associated with 30-40% of preterm deliveries and is the leading identifiable cause of preterm delivery. PPROM complicates 3% of all pregnancies and occurs in approximately 150,000 pregnancies yearly in the United States. When PPROM occurs remote from term, significant risks of morbidity and mortality are present for both the fetus and the mother. Thus, the physician caring for the pregnant woman whose pregnancy has been complicated with PPROM plays an important role in management and needs to be familiar with potential complications and possible interventions to minimize risks and maximize the probability of the desired outcome. This article focuses on information the physician needs to achieve these goals.[2, 1, 3] For more information, see Medscape's Pregnancy Resource Center. For excellent patient education resources, visit eMedicineHealth's Pregnancy Center. Also, see eMedicineHealth's patient education article Labor Signs. Premature Rupture of Membranes (at Term) Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset of labor at or beyond 37 weeks' gestation. PROM occurs in approximately 10% of pregnancies. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure, but they are not having contractions. ROM is diagnosed by speculum vaginal examination of the cervix and vaginal cavity. Pooling of fluid in the vagina or leakage of fluid from the cervix, ferning of the dried fluid under microscopic examination, and alkalinity of the fluid as determined by Nitrazine paper confirm the diagnosis. Blood contamination of the Nitrazine paper and ferning of cervical mucus may produce false-positive results. Pooling of fluid is by far the most accurate for diagnosis of ROM. If all fluid has leaked out as in early PROM, an ultrasonographic examination may then show absence of or very low amounts of amniotic fluid in the uterine cavity. A new product, AmniSure, is being marketed with claims of positive and negative agreement with results of criterion standard for the diagnoses of PROM with 2 out of the 3 criteria that exceeds 95%. The use of this product in certain instances when a speculum examination cannot be performed may be of some use as an initial evaluation. Given the importance of the correct diagnoses, the associated morbidity with hospitalization and delivery prior to term in PROM reaching 34 weeks and

expectant management and waiting for spontaneous labor may be considered in selected patients for the first 12-24 hours if a patient desires expectant management.[4. fetal presentation should be documented to avoid discovering malpresentation of the fetus long after admission for ROM. (See the Gestational Age from Estimated Date of Delivery calculator. as opposed to expectant management. prognosis is good after 32 weeks' gestation as long as no other complicating factor. Other smaller studies have shown results with higher cesarean and/or operative delivery rates when the cervix was unfavorable. However. Most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at term. however. decreases the risk of chorioamnionitis without increasing the cesarean delivery rate. Digital vaginal examinations should be avoided until labor is initiated. induction with oxytocin resulted in a lower risk of maternal infection (endometritis) when compared with expectant management. fetal distress. The use of expectant management after the first 24 hours is questionable. however. again stressing the importance of conservative management when possible. exists. and fetal/neonatal death. the potential neonatal morbidity resulting from prematurity in cases of incorrect diagnoses of PROM. The primary determinant of neonatal morbidity and mortality is gestational age at delivery. the women in the study viewed induction of labor more favorably than expectant management. induction of labor and expectant management resulted in similar rates of cesarean delivery and neonatal infection.beyond. placental abruption. such as congenital malformation or pulmonary hypoplasia. infection remains the most serious complication associated with PROM for the mother and the neonate. Fetal death does occur in approximately 1% of patients with PROM after viability who have been expectantly managed[1] and in about 1:1000 term PROM[8] . The major question regarding management of these patients is whether to allow them to enter labor spontaneously or to induce labor.[7] This points out the importance of appropriate management strategies for PROM at term. Evidence supports the idea that induction of labor. in women with PROM. At term. In large part. it is mandatory to confirm the diagnosis of PROM with pooling of amniotic fluid with some evidence of decreased or absence of amniotic fluid in all cases of suspected PROM. The risk of chorioamnionitis with term PROM has been reported to be less than 10% and to increase to 40% after 24 hours of PROM. Premature Preterm Rupture of Membranes . All patients with ROM should be asked to come to the hospital to ensure fetal well being. The risk of intrauterine infection increases with the duration of ROM. the management of these patients depends on their desires. 5] Hannah et al studied 5041 women with PROM who were randomly assigned to induction of labor with intravenous oxytocin or vaginal prostaglandin E2 gel versus expectant management for as many as 4 days with induction of labor for complications. Additionally. fetal restriction deformities and pulmonary hypoplasia. The neonatal risks of expectant management of PROM include infection. the major maternal risk at this gestational age is intrauterine infection.[6] They concluded that. Since risk of infection at term with ROM is small during the first 24 hours.) In general.

If evidence of frequent cord compression is present as determined by moderate-tosevere variables. Several issues need to be considered in formulating a plan of management. prophylaxis to reduce this risk should be instituted. The vast majority of women proceed to active labor and deliver soon after PPROM. transfer of the pregnant mother to a qualified facility is urgent and should be facilitated immediately upon diagnoses. has been associated with short latency and chorioamnionitis. antibiotics. Controversies exist as to interventions such as steroids for acceleration of lung maturity. See Medical Treatment. approximately 50% of all remaining pregnancies deliver each subsequent week after PPROM. mostly after PPROM that has occurred subsequent to amniocentesis. . All plans for management of PPROM remote from term should include the family and the medical team caring for the pregnancy. The patient should be placed on the obstetric floor for bed rest. Several areas of controversies exist regarding the best medical approach or management of PROM remote from term. while infection morbidity and its complications are the primary maternal risks. With appropriate care. Maternal vitals need to be monitored closely. This is important information to give the woman considering expectant management remote from viability. continuous monitoring should be reinstituted. including the neonatal and maternal medical team. and each has its own advantages and disadvantages. Maternal and Fetal Surveillance After an initial period of continuous monitoring of fetal heart rate and uterine contractions (24-48 h). With appropriate therapy and conservative management. Expectant management and immediate delivery are potential options in these patients. Because most PPROM pregnancies deliver within a week of ROM. it alone is not an indication for delivery when other means of surveillance are reassuring. however. While oligohydramnios. Prematurity is the principal risk to the fetus. Remote from term. Fetal monitoring should be performed at least once a day. Ultrasonographic examination for amniotic fluid index and fetal growth and well being should be used liberally to ensure appropriateness of continued expectant management.Premature preterm rupture of membranes (PPROM) occurring from 24-37 weeks' gestation is far more difficult to manage than premature rupture of membranes (PROM) at term. very few women remain pregnant more than 3-4 weeks after PPROM. Because bed rest in pregnancy is associated with an increased chance of deep venous thrombosis. defined as an amniotic fluid index of less than 2 cm. Thus. if findings are suggestive of reassuring surveillance.[1] Spontaneous sealing of the membranes does occur occasionally (< 10% of all cases). White blood cell count is not predictive of outcome and does not need to be monitored other than to support clinical suspicion of chorioamnionitis. in which case delivery and initiation of broad-spectrum antibiotics should be promptly facilitated. then the patient would be a candidate for expectant management. PPROM should only be cared for in facilities where a NICU is available and capable of caring for the neonate. this is the exception rather than the rule. and tocolytics. the maternal risks of expectant management are generally accepted to be minimal and a clear neonatal advantage exists by reducing risks of prematurity. Tachycardia and fever are both suggestive of chorioamnionitis and require careful evaluation to determine the presence of intra-amniotic infections.

[12] Until viability. and sepsis. Survival varies with gestational age at diagnosis (from 12% when diagnosed at 16-19 wk. foul-smelling discharge.[11] The risk of infection increases with the duration of PPROM. resulting in intact survival rates of more than 67%. as products of conception (the amniotic fluid) have passed the cervical opening and into the vagina in these cases. Other heroic measures such as amnioinfusion.4°F (38°C). These signs include fever. which is rare and occurs in less than 1%.4% of all pregnancies. Intra-amniotic infection should invoke prompt delivery. This information is probably better suited to be used in counseling patients regarding early PROM. With appropriate therapy and conservative management. Frequent examinations are necessary to ensure maternal safety. abruption. severe. Management of PPROM The initial evaluation of premature preterm rupture of membranes (PPROM) should include a sterile speculum examination to document ROM. Practitioners should have a low threshold for diagnosing infection in a patient with PPROM as evidence clearly shows poor outcome in an infected neonate compared with a similar uninfected neonate. sepsis (19%). although more recent studies have reported better outcome. The woman should monitor her temperature at home at least 3 times daily and report any elevation beyond 100. Expectant management may be appropriate in select patients who are well informed and educated about the risks and the dismal prognosis for the neonate. Outpatient management of PPROM prior to viability is appropriate in the well-informed and educated patient. Cervical cultures including Chlamydia . early oligohydramnios. vaginal spotting. Fetal death is common and occurs in more than 30%. which occurs in 19%. grade III-IV IVH (5%). which occurs in about 35%. more recent studies have reported less than 40% delivering in a week and more than 30% remaining pregnant after 5 weeks. abdominal pain. The patient needs to be informed of warning signs that indicate the need for immediate evaluation. It occurs in less than 0.[10] The major morbidity in the fetus with midtrimester ROM is lethal pulmonary hypoplasia from prolonged. Delivery is also appropriate when the mother is concerned about her own risks.[10] The major maternal risk is infection. and they must take their temperature 3 times a day at home.[10] Older studies have reported that approximately 50% of all remaining pregnancies deliver each subsequent week after PPROM. Other morbidities such as RDS (66%). and contractures (3%) also occur with high frequency. tocolysis. PPROM in the Second Trimester Premature preterm rupture of membranes (PPROM) prior to fetal viability is a unique and relatively rare problem that is often difficult to manage. inpatient management needs to be considered. Patients must be educated about the warning signs of intra-amniotic infection. Midtrimester (13-26 wk) PPROM has a poor prognosis.Digital cervical examinations should be avoided. and cervical plug to seal the membranes are unproven and should be considered in research protocols. especially with a dilated cervix. continuous monitoring should be considered to avoid missing the diagnosis of cord prolapse. especially when PPROM has occurred prior to 20 weeks' gestation. and rapid heart rate. Incomplete abortion may be the appropriate term for the condition. After viability is reached. to as much as 60% when diagnosed at 25-26 wk).[9] In a noncephalic presentation. maternal safety should be the primary concern.[1] More recent studies have shown better prognosis and may be more relevant to today’s clinical practice. which occurs in about 20% of cases. namely chorioamnionitis.

Amniocentesis can provide information about lung maturity accuracy and correctness of the diagnoses of PROM and infection. If after initial evaluation of the mother and fetus. and the appropriate risks with potential for fetal complications and the need for immediate delivery should be discussed with patients before attempting amniocentesis. the risk of cord prolapse may also outweigh the benefits of expectant management and delivery should be considered. delivery should be facilitated. even if for a short period. fetal distress. the amount of fluid is scant. In a noncephalic fetus with advanced cervical dilatation (more than or equal to 3 cm). However. Medical Treatment of PPROM Antibiotics The initial step in management of PPROM is informed consent. amniocentesis should be performed only by individuals with experience in performing difficult amniocentesis. sepsis (< 1%).[9] In certain circumstances. intravenous antibiotics were used . Once maturity has been reached.trachomatis and Neisseria gonorrhoeae and anovaginal cultures for Streptococcus agalactiae should be obtained. If the condition remains stable. but visual inspection of the cervix can accurately estimate cervical dilatation. the immature fetus may benefit from expectant management. the institution of broad-spectrum antibiotics should be considered. If fetal lung maturity has been documented by either amniocentesis or collection of vaginal fluid. endometritis (2-13%). and amniotic fluid index should be established. and the safety and potential benefits of expectant management should be reassessed. a few studies have reported increased neonatal morbidity with certain types of antibiotics. fetal weight. Ultrasonographic documentation of gestational age. the benefit from expectant management of PPROM is unclear and the risks of infection outweigh any potential benefits. as discussed below. Digital examination should be avoided. The primary maternal risk with expectant management of PPROM is infection. advanced labor. use of antibiotics has been associated with prolongation of pregnancy and reduction in infant and maternal morbidity. However.[2] The risks and potential benefits of expectant management should be discussed with the patient and her family. fetal presentation. and placental abruption with nonreassuring fetal surveillance. Maternal vital signs should be documented as well as continuous fetal monitoring initially to establish fetal status. In most studies. The patient needs to be given risks and benefits information and must participate in decision making. The maternal and fetal status need to be reevaluated daily. to allow administration of steroids and antibiotics. Multiple trials have examined the advantages and disadvantages of using antibiotics and the choice of antibiotics. Once the decision to manage a patient expectantly has been made. and informed consent should be obtained. and maternal death (1-2 cases per 1000). thus. This includes chorioamnionitis (1360%).Maternal Fetal Medicine Units (NICHDMFMU) study of PROM and the ORACLE trial. Complications related to the placenta include abruption (4-12%) and retained placenta or postpartum hemorrhage requiring uterine curettage (12%). they are both determined to be clinically stable. immediate delivery of the fetus with PPROM is indicated. In the NICHD study. Two of the largest studies that have looked at the efficacy of antibiotic use in PPROM are the National Institute of Child Health and Human Development . expectant management of PPROM may be considered to improve fetal outcome. Digital examination of the cervix with PPROM has been shown to shorten latency and increase risk of infections without providing any additional useful clinical information. These circumstances include chorioamnionitis. in most cases of PPROM.

Most patients with PPROM remain pregnant at 48 hours and thus will benefit from corticosteroid therapy. an increased risk of necrotizing enterocolitis (1. In contrast to these concerns. In this study. as proposed by the NICHD-MFMU study of PROM. Decreased need for supplemental oxygen and positive blood culture results were apparent. this clearly does not appear to be the case. The rates of respiratory distress syndrome (RDS). a patient being treated with a cephalosporin for a urinary tract infection does not need penicillin therapy.[13] The ORACLE trial used erythromycin alone. If the patient completes the full 7-day course of antibiotic prophylaxis has no evidence of infection or labor. 17] Antenatal corticosteroid treatment The use of corticosteroids to accelerate lung maturity should be considered in all patients with PPROM with a risk of infant prematurity from 24-34 weeks' gestation. When another antibiotic is being used for other indications. should be the antibiotic regimen used in patients with PPROM who are being managed expectantly. When amoxicillin clavulanic acid was used either alone or in combination with erythromycin. The increased latency continued for up to 3 weeks after discontinuation of antibiotics.[18] Current ACOG recommendations[19] . Composite and individual morbidities for the neonate were lower in the antibiotic group. or amoxicillin clavulanic acid in combination with erythromycin. data indicate that the use of corticosteroids reduces neonatal morbidity and mortality. the control group. had a significantly shorter duration of latency. Their results were different in that no significant difference was noted in latency to delivery and neonatal morbidity was not decreased as defined in their primary outcome (death. The antibiotic group was twice as likely to remain undelivered after 7 days. until the GBS test results obtained on admission are available. However.[16. unless 5 weeks have passed. compared with the antibiotic group. necrotizing enterocolitis. and intraventricular hemorrhage were all lower when either 12 mg of betamethasone IM was given twice in a 24-hour interval or dexamethasone 6 mg q12h was given for 4 doses. The use of steroids has also been suggested to increase the risk of infection. was decreased.9% vs 0. erythromycin-base 333 mg q8h to complete a 7-day course of antibiotic therapy. including group B streptococci sepsis. This is because a negative GBS test result is considered valid for 5 weeks. Revised guidelines from the Centers for Disease Control and Prevention (CDC) recommend that women with preterm PROM who are not in labor should receive intravenous group B streptococcus (GBS) coverage for at least the first 48 hours of preterm PROM latency prophylaxis.5%. such as a urinary tract infection.[15] However. the current evidence does not support this concern based on individual studies and meta-analyses.[14] Based on current evidence. 7 days of antibiotics. intrapartum GBS prophylaxis can be managed based on the results of the baseline GBS test at the time of preterm PROM. The incidence of chorioamnionitis and neonatal sepsis. chronic lung disease. The latency period has been suggested to be too short for the effects of corticosteroids to make a difference in neonatal morbidity. Therapy longer than 7 days should be avoided. GBS test results should not affect the duration of antibiotic therapy.for 48 hours—ampicillin 2 g q6h and erythromycin 250 mg q6h. and major cerebral abnormality on ultrasonography). it has not been shown to be more effective and may promote the emergence of resistance organisms. amoxicillin clavulanic acid alone.001) was present. no difference (either higher or lower rates of infections) has been observed with corticosteroid use. p =0. attempts should be made to avoid duplicated therapy. The patients were then placed on oral amoxicillin 250 mg q8h and enteric-coated. however. For example.

unlike corticosteroids and antibiotics. The obstetrician needs to be familiar with appropriate management of PPROM. and the woman is judged by the clinician to be likely to give birth within the next week. The use of tocolysis in that setting is not justified. the lack of evidence to support this practice should be discussed with patients to allow informed consent prior to the use of tocolytics and the potential complications and side effects. Summary PPROM is a common complication of pregnancy occurring in about 3% of all pregnancies. available evidence suggests that magnesium sulfate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants. Tocolytics The most common cause of labor in the setting of PPROM is underlying chorioamnionitis.[20] In one study. the gestational age is less than 32 6/7 weeks.[22] The use of tocolysis for 48 hours to administer steroids and allow acceleration of fetal lung maturity has been proposed and is being used by some obstetricians. The studies show a reduction in cerebral palsy in surviving infants who were exposed to magnesium.  A single course of antenatal corticosteroids is recommended for women with PROM before 32 weeks' gestation to reduce the risks of respiratory distress syndrome.or 6-g bolus and a maintenance dose of 1-2 g. A single course of corticosteroids is recommended for pregnant women 24-34 weeks' gestation who are at risk of preterm delivery within 7 days. and other morbidities.  A single rescue course of antenatal corticosteroids may be considered if the antecedent treatment was given more than 2 weeks prior. latency was shorter when magnesium sulfate was given. optimal dose. the following guidelines should be followed: . corticosteroid treatment at 32-33 weeks of completed gestation may be beneficial. In general. as such. regularly scheduled repeat courses or more than 2 courses are not recommended. perinatal mortality. Physicians electing to use magnesium sulfate for fetal neuroprotection should develop specific guidelines regarding inclusion criteria. However.  Corticosteroid use before fetal age of viability is not recommended. treatment regimens. such as in transport of the mother to a tertiary institution with a NICU. None of the individual studies found a benefit with regard to their primary outcome. concurrent tocolysis. as sparse data exists on the efficacy. High-risk consultation with a maternal-fetal medicine subspecialist should be considered in all cases to ensure appropriate current therapy is instituted. No data support the efficacy of this practice and.[21] The use of tocolysis.  Further research regarding the risks and benefits. should be considered only when a clear clinical benefit exists. when used in this manner. 12-24 hours of exposure was used with either a 4. These findings should be discussed with patients undergoing expectant management of PROM. In these studies. and timing of a single rescue course of steroid treatment is needed.  If pulmonary immaturity is documented. However. No data indicate that administering tocolysis benefits the neonate. prophylactic tocolysis was found to briefly prolong latency. and monitoring in accordance with one of the larger trials. In another study by Jazayeri et al. Many large clinical studies have evaluated neuroprotective benefits from exposure to magnesium sulfate in preterm neonates.

Corticosteroids should be given to accelerate lung maturity between 24 and 34 weeks. the rule should be hospitalization after viability in an institution where care for a premature neonate can be provided. Any evidence of infection or maternal instability due to complications of PPROM. Antibiotics need to be given based on present evidence. In PPROM. and fetal anatomy if not already fully evaluated. . Fetal monitoring should be performed at least daily until delivery. After 32 weeks and certainly after 34 weeks' gestation. Informed consent should be obtained for expectant management versus delivery with careful documentation in the chart.           ROM diagnosis needs to be confirmed. Large enough studies to document neonatal safety of expectant management of PROM at term do not exist. presentation. See Medical Treatment. PROM at term should be managed by delivery unless reasons exist to consider waiting for spontaneous labor. Maternal health is the primary indicator for the need to deliver. Ultrasonography should be performed to confirm gestational age. requires careful evaluation and determination of the appropriateness of expectant management. and fetal well being and growth should be evaluated periodically with ultrasonography. amniotic fluid index. estimated fetal weight. the appropriateness of expectant management of PPROM should be reevaluated individually for each case. such as bleeding. Digital vaginal examinations should be avoided.