- Premature Rupture of Membranes (PROM): Spontaneous rupture of membranes before the onset of labor at ≥37 weeks gestation.
- Preterm Premature Rupture of Membranes (PPROM): Rupture of membranes before 37 weeks gestation and before labor onset.
Incidence:
- PROM: Occurs in 8–10% of term pregnancies.
- PPROM: Occurs in 2–4% of pregnancies and is associated with preterm birth & infections.
Etiology (Causes) of PROM & PPROM
Maternal Factors:
- History of PROM or PPROM.
- Infections (UTI, Bacterial vaginosis, Chorioamnionitis).
- Smoking, Poor nutrition.
Fetal & Placental Factors:
- Polyhydramnios (Excess amniotic fluid).
- Multiple pregnancy (Twins, Triplets).
- Placental abruption.
Uterine & Cervical Factors:
- Short cervix (<25 mm).
- Incompetent cervix.
- Previous cervical surgeries (LEEP, Cone biopsy).
Clinical Features of PROM & PPROM
- Gush or leakage of fluid from the vagina.
- Continuous watery vaginal discharge.
- No uterine contractions (before labor onset).
- Increased risk of intrauterine infection if prolonged (>18 hours).
Diagnosis of PROM & PPROM
1. Clinical Examination:
- Sterile speculum examination:
- Pooling of amniotic fluid in the posterior fornix.
- Fluid leakage on coughing or valsalva maneuver.
2. Confirmatory Tests:
- Nitrazine Test:
- Amniotic fluid turns Nitrazine paper blue (Alkaline pH >6.5).
- Fern Test:
- Microscopic examination shows fern-like crystallization of amniotic fluid.
- Amnisure/ROM Plus Test:
- Immunoassay detecting placental alpha-microglobulin-1 (PAMG-1).
3. Ultrasound:
- Oligohydramnios (Reduced amniotic fluid index, AFI <5 cm).
- Fetal well-being assessment (BPP, Doppler studies).
Complications of PROM & PPROM
Maternal Complications:
- Chorioamnionitis (Intra-amniotic infection).
- Preterm labor & delivery complications.
- Postpartum endometritis.
Fetal Complications:
- Prematurity (If PPROM).
- Neonatal sepsis.
- Cord prolapse (If fetal head is unengaged).
- Pulmonary hypoplasia (If PROM occurs <26 weeks).
Management of PROM & PPROM
1. Term PROM (≥37 Weeks Gestation):
- Induction of labor (IOL) if no contractions within 12–24 hours.
- Oxytocin or Prostaglandins used to induce labor.
- Monitor for signs of infection (Fever, Fetal tachycardia).
2. Preterm PROM (PPROM <37 Weeks):
Gestational Age-Based Management:
|
Gestation |
Management |
|
≥34 weeks |
Induce labor + Antibiotics |
|
32–34 weeks |
Expectant management + Steroids + Antibiotics |
|
<32 weeks |
Prolong pregnancy (If stable) + Steroids + Magnesium
sulfate + Antibiotics |
Medications Used in PPROM:
1. Corticosteroids (Fetal Lung Maturity):
- Indicated for <34 weeks gestation.
- Drugs:
- Betamethasone 12 mg IM every 24 hours (2 doses).
- Dexamethasone 6 mg IM every 12 hours (4 doses).
- Benefits:
- Reduces risk of Neonatal Respiratory Distress Syndrome (RDS).
- Reduces Intraventricular Hemorrhage (IVH).
2. Magnesium Sulfate (Neuroprotection):
- Given if <32 weeks gestation.
- Reduces risk of cerebral palsy.
- Dose:
- Loading: 4 g IV over 30 minutes.
- Maintenance: 1 g/hour IV infusion.
3. Antibiotics (For Infection Prevention):
- Given to all women with PPROM to reduce infection risk.
- Drugs:
- Ampicillin 2 g IV every 6 hours + Erythromycin for 7 days.
Indications for Immediate Delivery in PPROM:
Immediate delivery if:
- Signs of chorioamnionitis (Fever, Uterine tenderness, Fetal tachycardia).
- Non-reassuring fetal heart rate (Fetal distress).
- Severe oligohydramnios (<2 cm AFI).
Summary Table: PROM vs. PPROM
|
Feature |
PROM (≥37 weeks) |
PPROM (<37 weeks) |
|
Onset |
Before labor at term |
Before labor & preterm |
|
Management |
Induce labor if no contractions |
Expectant management if stable |
|
Steroids |
Not needed |
Given if <34 weeks |
|
Antibiotics |
Only if signs of infection |
Given to all cases |
|
Delivery |
Within 24 hours |
If infection, distress, or ≥34 weeks |
Key Takeaways
- PROM = Rupture of membranes at term before labor.
- PPROM = Rupture of membranes before 37 weeks.
- Diagnosis: Pooling, Nitrazine, Fern test.
- Management:
- PROM: Induce labor at ≥37 weeks.
- PPROM: Prolong pregnancy if stable, Give steroids & antibiotics.
- Immediate delivery if infection or fetal distress.
