Preterm Rupture of
Membranes
Melissa Zahnd, RNC, MSN
Definition



Premature ROM: Amniorrhexis
(SROM) Prior to the onset of labor at
any gestation (PROM)
Preterm ROM: PROM prior to 37
weeks gestation
Use PPROM/PROM
Definitions


Latency Period: time interval between
ROM and onset of labor
Expectant management:
management of patients with the goal
of prolonging gestation (“watchful
waiting” until delivery indication arises)
Documentation

E.F. a 22 y.o. MWF, G1P0 with
PPROM at 32 3/7 weeks gestation…

M.R. a 32 y.o. female, G3P2 with
PROM at 38 3/7 weeks gestation…
Incidence-Preterm ROM



Complicates up to
3.5% of all
pregnancies
30-40% of Preterm
births
PPROM ~25%
cases of all PROM
Garite (2007), Santaloya-Forgas et al., (2007), Svigos, Robinson, et Vigneswaran,
2007)
Risk Factors






Chorioamnionitis
Vaginal infections
Cervical
abnormalities
Vascular pathology
(incl. abruptio)
Smoking
1st, 2nd, 3rd, or
multiple trimester
bleeding




Previous preterm
delivery (PPROM)
AA ethnicity
Acquired or
congenital
connective tissue
disorder
Nutritional
deficiencies (Vit.C,
copper, zinc)
The Patient







Vaginal discharge
Gush of fluid
Leaking of fluid
Oligo/Anhydramnios
Cramping
Contractions
Back pain
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
Why not do a digital vaginal
exam?


Latency period
Infection
Sterile Speculum Exam


Assess for





Sterile
No lubricating jelly
Pooling of fluid in
posterior fornix
Free flow of fluid
from cervix
Cervical dilation
Nitrazine
Collect slide for
fern (dry 10 mins)
Consider need to collect other
cervical tests/cultures such fetal
fibronectin while doing the SSE.
Nitrazine paper testing




Vaginal pH (3.54.5)
Turns blue in
presence of
alkaline Amniotic
fluid
93.3% sensitivity
False positive (117%) for urine,
blood, semen, BV,
Trichomonas
Fern slide
Must allow slide to dry
thoroughly prior to
examination under
microscope. Assess for
arborization of fluid.
Cervical mucous has
broad, ferning pattern
that is different than the
fern of amniotic fluid.
Fetal Fibronectin



fFn present in cervical
secretions <22 wks,
>34 wks
Used for assessment
of potential PTB
Positive result (>50
ng/dl) may be
indicative of PROM
and represents
disruption of deciduachorionic interface
In PPROM, Sensitivity-98.2%, Specificity-26.8%.
AmniSure






Newer test
Point of Care test
Cost-up to $50 each
Sensitivity-98.7-98.9%
Specificity-87.5-100%
Awaiting further testing prior to
recommendations
AmniSure
Remove swab
and rotate in
solvent x 1 min.
Read
results
after 510 mins
have
passed.
Place Swab 2-3
in. into vaginal
canal x 1 min.
Discard swab and
place test stick into
solvent.
Ultrasonography




50-70% of women with
PPROM have low AFV
on US
Mild reduction requires
further investigation
Rule out other causes
(Renal agenesis,
utero-placental
insufficiency,
obstructive uropathy)
Measure for pockets of
fluid and quantitate
AFV into AFI
Ultrasound showing 7 cm pocket of fluid
Transabdominal Injection of
Dye




Amniocentesis
Collect Fluid
samples
Inject dye (Indigo
Carmine)
Tampon placed in
vagina and
checked for blue
staining 30-60 mins
after procedure
How would I manage this
patient?




Gestational age
Availability of NICU
Fetal presentation
FHR pattern



Active distress
(maternal/fetal)
Is she in labor?
Cervical
assessment
Initial Assessment




Assess for Maternal-Fetal distress
Assess for Proper dating/GA
Assess for infection
Exclude occult cord prolapse
Secondary Assessment




Fetal position
Cervical
assessment
Determine lung
maturity, if
indicated
Quantify AFV*
Delivery Indication




Maternal-Fetal
Distress
Infection
Abruption
Cord Prolapse
Expectant Management







Typical for GA 32 weeks or less
Steroids
Tocolysis if indicated for lung maturity
Antibiotics
Fetal Surveillance
Majority Inpatient Observation
Assess for Chorioamnionitis
Goal: Mature Lung Profile, reduction of PTB risks!
Risk-Benefit Expectant
Management






Risks
Abruption
Chorioamnionitis
Cord Prolapse
Pulmonary
Hypoplasia (<19
weeks PPROM
Skeletal
Deformities
Endometritis (1/3)


Benefits
Mature lung profile
Advancing GA
(reducing risks
associated with
PTB)
Risks-Benefits Profile of
Pre-term Birth
Risks

Assoc. w/ PTB

NEC
IVH/CP
RDS




Cesarean Delivery
Endometritis (1/3)

Benefits
Elimination of risks
of expectant
management
Outcomes

1/3 develop
intraamniotic
infections,
endometritis, or
septicemia

Neonatal outcomes
dependent on GA
and indication for
delivery
References





Duff, Patrick, MD. “Preterm premature rupture of membranes.”
UpToDate. Ed. Charles J Lockwood, MD and Vanessa A
Barss, MD. 1-16. 27 June 2008 <http://utdol.com>.
Garite, Thomas J, MD. “Premature Rupture of the
Membranes.” Clinics in Perinatalogy. N.p.: n.p., n.d. 723-736.
Hacker, and Moore. Essentials of Obstetrics and Gynecology.
4th ed. N.p.: n.p., 2004.
Santolaya-Forgas, Joaquin, et al. “Prelabor rupture of the
membranes.” Clinical Obstetrics-Handbook: The Fetus and
Mother. By E Albert Reece and John Hobbins. N.p.: n.p.,
2007. 1130-1173.
Svigos, John Micheal, Jeffrey S Robinson, and Rasniah
Vigneswaran. “Prelabor Rupture of Membranes.” High-Risk
Pregnancy. N.p.: n.p., n.d. 1321-1330.