Pre-Labor Rupture of Membranes (PROM)

Pre-labor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labor.
Women usually experience a painless gush or a steady leakage of fluid from the vagina.
If it occurs before 37 weeks it is known as PPROM (‘preterm’ prelabour rupture of membranes) otherwise it is known as term PROM.

1. PREMATURE RUPTURE OF MEMBRANES DEEPA MISHRA Assistant Professor (OBG)

2. INTRODUCTION Pre-labor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labor . Women usually experience a painless gush or a steady leakage of fluid from the vagina . If it occurs before 37 weeks it is known as PPROM (‘preterm’ prelabour rupture of membranes) otherwise it is known as term PROM.

3. DEFINITION Spontaneous rupture of membranes any time beyond 28 th week of pregnancy but before the onset of labour is known as pre-mature (pre- labour ) rupture of membranes. Pre-labor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labor.

4. INCIDENCE About 8% of term pregnancies are complicated by PROM 30% of preterm births are complicated by PROM . Before 24 weeks PROM occurs in fewer than 1% of pregnancies.

5. TYPES

6. Risk Factors Of PROM Infections:  urinary tract infection ,  sexually transmitted diseases , lower genital tract infections (e.g.  bacterial vaginosis ) Tobacco use during pregnancy Illicit drug use during pregnancy Having had PROM or preterm delivery in previous pregnancies Polyhydramnios : too much amniotic fluid  Multiple gestation : being pregnant with two or more fetuses at one time Having had episodes of bleeding anytime during the pregnancy [ Invasive procedures (e.g.  amniocentesis ) Nutritional deficits Cervical insufficiency : having a short or prematurely dilated cervix during pregnancy Low socioeconomic status Being underweight

7. PATHOPHYSIOLOGY

8. PATHOPHYSIOLOGY Infection Infection and inflammation likely explains why membranes break earlier than they are supposed to . bacteria have been found in the amniotic fluid from about one-third of cases of PROM. Often , testing of the amniotic fluid is normal, but a subclinical infection (too small to detect) or infection of maternal tissues adjacent to the amniotic fluid, may still be a contributing factor. In response to infection, the resultant infection and release of chemicals (cytokines) subsequently weakens the fetal membranes and put them at risk for rupture . PROM is also a risk factor in the development of neonatal infections . Genetics Many genes play a role in inflammation and collagen production, therefore inherited genes may play a role in predisposing a person to PROM

9. DIAGNOSIS

10. History: a person with PROM typically recalls a sudden "gush" of fluid loss from the vagina, or steady loss of small amounts of fluid. Sterile speculum exam : a clinician will insert a sterile speculum into the vagina in order to see inside and perform the following evaluations. Digital cervical exams, in which gloved fingers are inserted into the vagina to measure the cervix, are avoided until the women is in active labor to reduce the risk of infection. Pooling test : Pooling is when a collection of amniotic fluid can be seen in the back of the vagina (vaginal fornix). Sometimes leakage of fluid from the cervical opening can be seen when the person coughs or performs a valsalva maneuver .

11. Nitrazine test: A sterile cotton swab is used to collect fluid from the vagina and place it on nitrazine ( phenaphthazine ) paper. Amniotic fluid is mildly basic (pH 7.1–7.3) compared to normal vaginal secretions which are acidic (pH 4.5–6 ). Basic fluid, like amniotic fluid, will turn the nitrazine paper from orange to dark blue. Fern test: A sterile cotton swab is used to collect fluid from the vagina and place it on a microscope slide. After drying, amniotic fluid will form a crystallization pattern called arborization which resembles leaves of a fern plant when viewed under a microscope Fibronectin and alpha-fetoprotein blood tests

12. Additional tests The following tests should only be used if the diagnosis is still unclear after the standard tests above . Ultrasound : If the fluid levels are low, PROM is more likely. This is helpful in cases when the diagnosis is not certain, but is not, by itself, definitive. Immune- chromatological tests are helpful, if negative, to rule out PROM, but are not that helpful if positive since the false-positive rate is relatively high (19–30 %)

13. Indigo carmine dye test: a needle is used to inject indigo carmine dye (blue) into the amniotic fluid that remains in the uterus through the abdominal wall. In the case of PROM, blue dye can be seen on a stained tampon or pad after about 15–30 minutes.This method can be used to definitively make a diagnosis, but is rarely done because it is invasive and increases risk of infection. But, can be helpful if the diagnosis is still unclear after the above evaluations have been done . It is unclear if different methods of assessing the fetus in a woman with PPROM affects outcomes.

14. Differential diagnosis Other conditions that may present similarly to premature rupture of membranes are the following : Urinary incontinence: leakage of small amounts of urine is common in the last part of pregnancy Normal vaginal secretions of pregnancy Increased sweat or moisture around the perineum Increased cervical discharge: this can happen when there is a genital tract infection Semen Douching Vesicovaginal fistula: an abnormal connection between the bladder and the vagina Loss of the mucus plug Prevention Women who have had PROM are more likely to experience it in future pregnancies. There is not enough data to recommend a way to specifically prevent future PROM. However, any woman that has had a history of preterm delivery, because of PROM or not, is recommended to take progesterone supplementation to prevent recurrence.

15. Management Summary Fetal age Management Term > 37 weeks Induction of labor Antibiotics if needed to prevent  group B streptococcus  (GBS) transmission Late pre-term 34–36 weeks Same as for term Preterm 24–33 weeks Watchful waiting  (expectant management) Tocolytics  to prevent the beginning of labor Magnesium sulfate  infusion for 24–48 hours to allow maximum efficacy of corticosteroids for fetal lungs and also confer benefit to fetal brain and gut before delivery One time dose of  corticosteroids  (two separate administrations, 12–24 hours apart) before 34 weeks Antibiotics if needed to prevent GBS transmission Pre-viable < 24 weeks Discussion of watchful waiting or induction of labor No antibiotics, corticosteroids, tocolysis , or magnesium sulfate

16. RECOMMENDED Monitoring for infection Steroids before birth Magnesium sulfate Latency antibiotics Prophylactic Antibiotics NOT RECOMMENDED Preventive tocolysis Therapeutic tocolysis Amnioinfusion Home care Sealing membranes after rupture

17. RECOMMENDED Monitoring for infection- signs of infection include a  fever  in the mother, fetal  tachycardia  (fast heart rate of the fetus, more than160 beats per minute), or tachycardia in the mother (more than 100 beats per minute).  Steroids before birth- corticosteroids ( betamethasone ) given to the mother of a baby at risk of being born prematurely can speed up fetal lung development and reduce the risk of death of the infant,  respiratory distress syndrome ,  brain bleeds , and  bowel necrosis one course of corticosteroids between 24 and 34 weeks when there is a risk of preterm delivery . Magnesium sulfate - when there is a risk of preterm birth before 32 weeks to protect the fetal brain and reduce the risk of  cerebral palsy .

18. RECOMMENDED Latency antibiotics- The time from PROM to labor is termed the latency period. (ACOG ) recommends a seven-day course intravenous   ampicillin  and  erythromycin  followed by oral  amoxicillin  and erythromycin if watchful waiting is attempted before 34 weeks Prophylactic Antibiotics- i f a woman is colonized with GBS, than the typical use of antibiotics during labor is recommended to prevent transmission of this bacteria to the fetus, regardless of earlier treatments.

19. NOT RECOMMENDED Preventative tocolysis (medications to prevent contractions )- it increases the risk of infection or chorioamnionitis . Therapeutic tocolysis (medications to stop contractions):  Once labor has started, using tocolysis to stop labor has not been shown to help, and is not recommended Amnioinfusion : Current data suggests that this treatment prevents infection, lung problems, and fetal death. However, there have not been enough trials to recommend its routine use in all cases of PPROM

20. NOT RECOMMENDED Home care : Typically women with PPROM are managed in the hospital, but, occasionally they opt to go home if watchful waiting is attempted. Since labor usually starts soon after PPROM, and infection, umbilical cord compression, and other fetal emergencies can happen very suddenly, it is recommended that women stay in the hospital in cases of PPROM after 24 weeks Sealing membranes after rupture : Infection is the major risk associated with PROM and PPROM. By closing the ruptured membranes, it is hoped that there would be a decrease in infection, as well as encouraging the re-accumulation of amniotic fluid in the uterus to protect the fetus and allow for further lung development. There is currently insufficient research to determine whether these or other resealing techniques improve maternal or neonatal outcomes when compared to the current standard of care.