Premature rupture of membranes resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords:

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

Common risk factors in the development of PROM include :

• Maternal risk factors:
  • Sepsis
  • Previous history of PROM, recurrence risk is 16%–32% as compared with 4% in women with a prior uncomplicated term delivery.
  • Chronic steroid therapy
  • Abnormal bleeding during the second trimester or late in the pregnancy.
  • Low body mass index (BMI < 19.8 kg/m2)
  • Smoking and drug abuse
  • Low socioeconomic status
  • Deficiency of copper or vitamin C, along with connective tissue disorders such as Ehlers-Danlos syndrome, Systemic Lupus Erythematosus are also linked to increased risk of PROM.
  • Direct abdominal trauma
  • Preterm labor
  • Anemia

• Uteroplacental Factors:
  • Uterine anomalies (such as uterine septum)
  • Placental abruption
  • Advanced cervical dilation (cervical insufficiency)
  • Prior cervical conization
  • Cervical shortening in the 2nd trimester (< 2.5 cm)
  • Uterine overdistention (Polyhydramnios, Multiple pregnancy)
  • Intra-amniotic infection (Chorioamnionitis)
  • Multiple bimanual vaginal examinations (but not sterile speculum or transvaginal ultrasound examinations)

• Fetal factors include :
  • Multiple pregnancy ( preterm PROM complicates 7%–10% of twin pregnancies)
  • Prematurity
  • Infection
  • Cord prolapse
  • Malpresentation.

Diagnosis

Shown below is an algorithm summarizing the diagnosis of

Pregnant woman comes with Premature rupture of membranes

Take complete history

Record the vitals: ❑ Blood pressure ❑ Temperature ❑ Respiratory rate ❑ Heart rate

Take obstetric history : ❑ Date of last menstrual period? ❑ Estimated date of delivery. ❑ Confirm the gestational age, gravidity and parity. ❑ Check if this is a single or multiple gestation.

Ask about previous obstetric history if she was previously pregnant : ❑ Ask about previous pregnancies including miscarriages and terminations. ❑ Length of gestation. ❑ Ask about mode of delivery. ❑ Ask if there was similar complaints during previous pregnancy? ❑ Was there any complications throughout the pregnancy or during delivery such as shoulder dystocia, postpartum haemorrhage ?

Ask the following questions about menstrual history : ❑ Age of menarche ❑ Last menstrual period ❑ Is the menstrual flow normal? How many pads she has to use in a day? ❑ Is there any foul smell or colour change? ❑ How many days does the menstruation stay? ❑ Contraceptive history for example oral contraceptives, intrauterine device

Perform physical examination : ❑ Visualization of amniotic fluid (AF) leaking through the cervix. ❑ Vaginal pooling. ❑ Fern test of dried vaginal fluid seen under microscope. ❑ pH testing : Normal vaginal pH: 3.8 to 4.5 Normal amniotic fluid pH: 7.1 to 7.3 False positives: Blood or semen, alkaline antiseptics or bacterial vaginosis. False negatives: Minimal remaining amniotic fluid following rupture. ❑ Sterile speculum examination assess dilation.

If above are not conclusive, do the following tests : ❑ Ultrasound for AFV may be helpful but not diagnostic . ❑ Fetal fibronectin is sensitive with high negative predictive value but positive result is not diagnostic. ❑ Amniotic protein tests have high sensitivity for PROM but false-positive rates are high.

Conclusive test – dye instillation : ❑ Intra-amniotic dye instillation is a helpful tool for evaluation of preterm pre-labor rupture of membranes and for genetic amniocentesis in multifetal gestation. Ultrasound guided dye is passed into the vagina and detected with tampon or pad stain. ❑ Indigo carmine is the most used and studied dye which is no longer available. Maternal urine may turn blue following instillation of indigo carmine. ❑ As an alternative, Sodium fluorescein is clinically useful but has side effects when used intravenously.the test includes speculum examination of cervix at 15 and 45 minutes post injection using a long-wave ultraviolet light. Yellow-green fluorescent fluid leaking from cervix confirms the diagnosis. Fluorescence will rapidly appear in urine and confusion may be resolved with either visualization of cervical leak or tampon. ❑ Phenol-sulfonphthalein has reported clinical utility with no maternal, fetal or neonatal side effects. But, it is not currently available in the United States.It is a pH indicator dye, also known as phenol red. ❑ Indocyanine green has been used in pregnancy for other indications. ❑ Oral phenazopyridine hydrochloride may lead to a false-positive diagnosis of preterm prelabor rupture of membranes. ❑ Evans blue and methylene blue have adverse fetal and neonatal outcomes.

Treatment

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Do's

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Don'ts

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References

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