Premature Rupture
of Membranes
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Objectives for PROM
 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
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
Incidence
 PROM – 12% of all pregnancies
 PROM – 8% term pregnancies
 PPROM – 30% of preterm deliveries
PROM/PPROM: History & Physical Exam
 History
 “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
 Findings
 Pooling of amniotic fluid in posterior vaginal fornix
 Fluid per cervical os
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
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
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
PROM/PPROM: Risk Factors
 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
Management: PPROM
(< 24 wk gestation – “previable”)




Patient counseling
Expectant management vs. induction of labor
GBS prophylaxis NOT recommended
Antibiotics
 Incomplete data
 Corticosteriods NOT recommended
Management: PPROM
(< 24 wk gestation – “previable”)
 Patient counseling
Outcomes at 18 to 22 Months Corrected Age*
Gestational Age
(In Completed
Weeks)
Death Before
NICU Discharge
22 Weeks
23 Weeks
24 Weeks
25 Weeks
95%
74%
44%
24%
Death
Death/ Profound
Neurodevelopmental
Impairment
Death/Moderate to Severe Neurodevelopmental Impairment
95%
74%
44%
25%
98%
84%
57%
38%
99%
91%
72%
54%
 Fetal complications of prolonged PPROM




Pulmonary hypoplasia
Skeletal malformations
Fetal growth restriction
IUFD
 Maternal complications of prolonged PPROM
 Chorioamnionitis
http://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/dataShow.cfm
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
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
Management: PROM
(> 34 wk gestation)
 Proceed to delivery
 Induction of labor
 GBS prophylaxis
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
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
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
Courtesy of Thomas Shipp, MD.
Management: Surveillance
 Maternal: Monitor for signs of infection

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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)
Management: Surveillance
 Immediate Delivery



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Intrauterine infection
Abruptio placenta
Repetitive fetal heart rate decelerations
Cord prolapse
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
Expectant Management
vs. Preterm Delivery
 Preterm Delivery Risks: use NICHD calculator
 http://www.nichd.nih.gov/about/org/cdbpm/pp/prog_ep
bo/epbo_case.cfm
Gestation
(w)
Weight
Sex
Steroids
Survival
Survival w/o
profound ND
impairment
25
550
Female
Yes
64%
50%
24
500
Male
Yes
35%
22%
23
450
Male
Yes
16%
9%
22
401g
Female
No
2%
1%
Bottom Line Concepts
 Preterm premature rupture of membranes refers to rupture of fetal
membranes prior to labor in pregnancies < 37 weeks.
 A history of PPROM or PROM, genital tract infection, antepartum bleeding,
and smoking are risk factors for PPROM and PROM.
 A clinical history suggestive of PPROM or PROM should be confirmed with
visual inspection and laboratory tests including ferning and nitrazine
paper.
 Management of PPROM at < 24 wks includes a discussion with the family
reviewing the maternal risks against the fetal risks of significant morbidity
and mortality during expectant management.
 For women with PPROM or PROM in whom intrauterine infection,
abruptio placenta, repetitive fetal heart rate decelerations, or a high risk of
cord prolapse is present, immediate delivery is recommended.
 Counseling after the delivery for the recurrence risk of PROM should
occur, and modifiable risk factors addressed
References and Resources
 APGO Medical Student Educational Objectives, 9th edition, (2009),
Educational Topic 25 (p52-53).
 Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 22 (p213-217).
 Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
Calvin J Hobel. Chapter 12 (p150-153).