PREMATURE RUPTURE OF MENBRANES

PROM is a rupture of membranes before the start of labour.

It can occur either:

  • When foetus is mature/term at or after 37 weeks (PROM)
  • Or when foetus is immature/preterm between 24-37 weeks of gestation. This is referred to as Pre-term PROM
    (PPROM).

In all cases of PPROM, prematurity and its attendant problems are the principal concerns for the foetus, while
infection morbidity and its complications are the primary concerns for the mother

Risk factors associated with PPROM

  • Low socioeconomic status, tobacco use
  • Low body mass index
  • Prior history of PV bleeding during pregnancy
  • History of preterm labour
  • Urinary tract infection, chorioamnionitis
  • Cervical cerclage, amniocentesis

Clinical features associated with PROM

  • Leakage of fluid or vaginal discharge
  • May be with or without vaginal bleeding
  • Pelvic pressure but no contractions
  • If ROM has been prolonged, the patient may present with fever, abdominal pain, and a foul smelling vaginal
    discharge

Investigation

  • The typical odour of amniotic fluid is diagnostic
    • Place a vaginal pad over the vulva; examine visually and by smell after 1 hour
    • Use a high-level disinfected or sterile speculum for vagina examination: fluid may be seen coming from the cervix or forming a pool in the posterior fornix
    • Ask patient to cough: this may cause a gush of fluid
    • If membrane rupture is not recent or leakage is gradual, confirming the diagnosis may be difficult
    • Abdominal US scan may show absence of or very low amounts of amniotic fluid
    • If available, do Nitrazine test and Ferning test
Caution
  • Do NOT do digital vaginal examination – it does not help diagnosis and may cause infection

MANAGEMENT OF PROM (>37 WEEKS)

  • Over 90% of patients with PROM go into spontaneous labour within 24 hours
  • Expectant management carries a risk of infection
  • Induction of labour decreases the risk of infection without increasing the C/S delivery rate
  • Expectant management also carries a risk of neonatal issues, e.g., infection, abruptio placenta, foetal distress,
    foetal restriction deformities, and death

MANAGEMENT

  • Refer all patients to hospital and keep in hospital until delivery

If the membranes have been ruptured for >18 hours and no signs of infection

  • Give prophylactic antibiotics until delivery to help reduce neonatal group B streptococcus
    infection: Ampicillin 2 g IV every 6 hours or benzylpenicillin 2 MU IV every 6 hours
  • Assess the cervix
  • Refer to with facilities for emergency obstetric management for induction
    with oxytocin

MANAGEMENT OF PPROM (<37 WEEKS)

  • The primary determinant of neonatal morbidity and mortality is gestational age at delivery, hence stressing the
    need for conservative management whenever possible for Pre-PROM
  • All patients with Pre-PROM should receive antenatal steroids for foetal lung maturity
  • All patients with PPROM should receive prophylactic antibiotics since there is a high risk of infection
  • Administration of tocolytics for 48 hours may allow administration of steroids to accelerate lung maturity
  • In general, prognosis is good after 34 weeks of gestation
  • All patients with PPROM should be cared for in a facility where a Neonatal Intensive Care Unit (NICU) is available

TREATMENT

  • Refer all patients to hospital, and keep in hospital until delivery

If no signs of infection and pregnancy 24-34 weeks (if gestational age is accurate)

  • Give dexamethasone 6 mg IM every 12 hours for a total of 4 doses (or betamethasone 12 mg IM, 2
    doses 24 hours apart)
  • Routine antibiotics: Erythromycin 250 mg every 8 hours plus amoxicillin 500 mg every 8 hours
    • Stop them after delivery if no signs of infection
  • Deliver at 34 weeks

If palpable contractions and blood- stained mucus

  • Suspect preterm labour
  • Hydrate with IV fluids before administering nifedipine
  • Consider administration of tocolytics
    • Tocolytics: Nifedipine 10 mg sublingual tablet placed under the tongue every 15 minutes if
      necessary, up to a maximum of 40 mg in the first hour. Then 60-160 mg daily in 3-4 divided doses,
      adjusted to uterine activity, for max 48 hours

If vaginal bleeding with abdominal pain (intermittent or constant)

  • Suspect and treat as abruptio placentae

If signs of infection (fever, foul-smelling vaginal discharge)

  • Give antibiotics as for Amnionitis
  • Deliver immediately
Caution
  • Do not use steroids in presence of infection