Premature rupture of membranes

Refers to a patient who is beyond 37 weeks’ gestation and has presented with rupture of membranes prior to the onset of labor

Preterm premature rupture of membranesoccurs prior to 37 weeks’ gestation.

Spontaneous premature rupture of the membranes occurs after or with the onset of labor.

Prolonged premature rupture of the membrnes is any rupture of membranes that persists for more than 24 hours and prior to the onset of labor.

PROM occurs in approximately 10% of pregnancies.

Occurs in 20% of all births and 40% of all preterm births.

At term immediate delivery is associated with lower incidence of maternal infections and increased maternal satisfaction compared to expectant management without risks of perinatal morbidity or mortality.

Delivery within 2 days in 60-70% of patients between 20-32 weeks and 80% between 33-36 weeks.

250,000 births/year in U.S.

90% deliver within 1 week, and 90% term pregnancies will deliver within 24 hours.

Programmed cell death and activation of catabolic enzymes, such as collagenase and mechanical forces, result in ruptured membranes.

Preterm premature rupture of the membranes occurs probably due to the same mechanisms and premature activation of these pathways.

Early premature rupture of the membranes also appears to be linked to underlying pathologic processes, like inflammation and/or infection of the membranes.

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.

Eighty-five percent of neonatal morbidity and mortality is a result of prematurity.

Preterm PROM is associated with 30-40% of preterm deliveries and is the leading identifiable cause of preterm delivery.

Preterm PROM complicates 3% of all pregnancies and occurs in approximately 150,000 pregnancies yearly in the United States.

When preterm PROM occurs remote from term, significant risks of morbidity and mortality are present for both the fetus and the mother.

Delivery is pursued actively when chorioamnionitis is present, evidence of fetal compromise is present or pulmonary maturity is proven.

Most common neonatal morbidity associated is respiratory distress syndrome.

Patients present with leakage of fluid, vaginal discharge, bleeding, and pelvic pressure.

Not associated with uterine contractions.

Diagnosed by speculum vaginal examination of the cervix and vaginal cavity with findings of pooled fluid and ferning of the dried fluid under microscopic examination.

Alkalinity of the fluid as determined by Nitrazine paper confirms the diagnosis.

Ultrasonographic examination may show absence of or decreased amounts of amniotic fluid in the uterine cavity.

Management considerations are whether to allow them to enter labor spontaneously or to induce labor.

Major maternal risk at this gestational age is intrauterine infection.

Risk of intrauterine infection increases with the duration of the process.

Induction of labor, as opposed to expectant management, decreases the risk of chorioamnionitis without increasing the cesarean delivery rate.

At term, infection remains the most serious complication associated with PROM for the mother and the neonate.

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.

Risk of infection at term with ROM is small during the first 24 hours and waiting for spontaneous labor may be considered for the first 12-24 hours.

The use of expectant management after the first 24 hours is not appropriate at term PROM.

Digital vaginal examinations is avoided until labor is initiated as examination of the cervix with preterm PROM has been shown to shorten latency and increase risk of infections without providing any additional useful clinical information.

The neonatal risks of observation include infection, placental abruption, fetal distress, fetal restriction deformities and pulmonary hypoplasia, and fetal/neonatal death.

Fetal death does occur in approximately 1% of patients with PROM after viability who have been expectantly managed, and in about 1:1000 term PROM[.

The primary determinant of neonatal morbidity and mortality is gestational age at delivery.

Prognosis is good after 32 weeks’ gestation.

Premature preterm rupture of membranes occurring from 24-37 weeks’ gestation is more difficult to manage than premature rupture of membranes at term.

With preterm premature separation of the membranes prematurity is the principal risk to the fetus, while infection and its complications are the primary maternal risks.

Management with preterm pure rupture of the membranes includes decision making by the patient, family and medical team.

Because most such preterm premature rupture of the membrane patients deliver within 1 week patients should be hospitalized in a facility capable of caring for such complex obsterical and neonatal processes.

Approximately 50% of all remaining pregnancies deliver each subsequent week after preterm PROM.

Very few women remain pregnant more than 3-4 weeks after preterm PROM.

In fewer than 10% of cases the leakage of amniotic fluid may spontaneously stop, and this is usually in casaes associated with amniocentesis.

Expectant management and immediate delivery are the options in preterm PROM.

The maternal risks of expectant management are minimal and neonatal benefits accrue by reducing risks of prematurity.

If initial period of monitoring of fetal heart rate and uterine contractions over 24-48 hours, are reassuring, then the patient can be managed expectantly with bed rest.

Fetal monitoring should be performed daily in the patient with preterm PROM, and the mother’s vital signs need to be monitored often for tachycardia and fever suggestive of chorioamnionitis.

The detection of an intra-amniotic infection requires braod spectrum antibiotics and delivery of the fetus.

Frequent ultrasound examination for amniotic fluid index and fetal growth and well being should be utilized to ensure continued expectant care.

Oligohydramnios, defined as an amniotic fluid index of less than 2 cm, is associated with short latency and chorioamnionitis.

Oligohydramnios alone is not an indication for delivery when other assays of surveillance are reassuring.

Leukocyte counts do not predict for outcome in this setting and are indicated to support the liklihood of the presence of chorioamniotis.

Digital cervical examinations in preterm premature rupture of the membranes should be avoided.

Continuous monitoring should be considered to avoid missing the diagnosis of cord prolapse in patients with noncephalic presentation, particularly in the presence of a dilated cervix.

Prompt delivery ir required for diagnosed with an infection in a patient with premature PROM as poor outcomes occur in an infected neonate compared to uninfected one.

Premature preterm rupture of membranes (PPROM) prior to fetal viability is a relatively rare problem, occurring in less than 0.4% of all pregnancies.

Premature preterm rupture of membranes (PPROM) prior to fetal viability is associated with infection, mainly chorioamnionitis, in about 35% of cases, abruptio, which occurs in 19% and sepsis less than 1% of the time.

Fetal death is common and occurs in more than 30% of cases at the midtrimester.

Fetal morbidity in the fetus with midtrimester rupture of the membranes is associated with is fatal pulmonary hypoplasia from prolonged, severe oligohydramnios, which occurs in about 20% of cases.

Other fetal complication with preterm rupture of the in the midtrimester are respiratory distress syndrome in two thirds of the cases, sepsis in 19% of cases, intraventricular hemorrhage in 5% of cases and contractures in 3% of cases.

Survival in midtrimester preterm rupture of the membranes is about 2/3 of cases.

Modern series in early premature rupture of the membranes fewer than 40% deliver in a week, and more than 30% remain pregnant after 5 weeks.

Outpatient management of early preterm PROM prior to viability is possible for patients that can adequately monitor their status for the development of infection.

Survival varies with gestational age at diagnosis from 12% when diagnosed at 16-19 wk, to as much as 60% when diagnosed at 25-26 wk.

Maternal safety is the primary concern until fetal viability is assumed.

The initial evaluation of premature preterm rupture of membranes includes a sterile speculum examination to document the process, obtaining cultures of the cervix and anogenital area for Chlamydia trachomatis and Neisseria gonorrhoeae and Streptococcus agalactiae.

Immediate delivery of the fetus with preterm PROM is indicated for chorioamnionitis, advanced labor, fetal distress, and placental abruption with nonreassuring fetal surveillance.

When fetal lung maturity has been documented by amniocentesis or collection of vaginal fluid, delivery should be facilitated.

In a noncephalic fetus with advanced cervical dilatation of 3 cm or more, the risk of cord prolapse may also outweigh the benefits of expectant management and delivery should be considered.

A patient managed expectantly should receive broad-spectrum antibiotics since their use is associated with prolongation of pregnancy and reduction in infant and maternal morbidity.

Patients with preterm PROM who are not in labor should receive intravenous group B streptococcus coverage for at least the first 48 hours of preterm PROM latency prophylaxis, until results are available.

Use of corticosteroids to accelerate lung maturity should be considered in all patients with preterm rupture of the membranes.

Use of corticosteroids not associated with increased infection risks.

Use of corticosteroids reduces neonatal morbidity and mortality, with reduction in respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage.

Corticosteroids is recommended for pregnant women 24-34 weeks’ gestation who are at risk of preterm delivery within 7 days.

Corticosteroids is recommended for women with PROM before 32 weeks’ gestation to reduce the risks of respiratory distress syndrome, perinatal mortality, and other morbidities.

Corticosteroid treatment at 32-33 weeks of gestation may be beneficial.

Corticosteroid use before fetal viability is not recommended.

Corticosteroid repeat courses or more than 2 courses are not recommended.

The most common cause of labor in the setting of preterm PROM is chorioamnionitis.

Tocolysis in preterm PROM is not valuable.

Magnesium sulfate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants.

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