Prolonged Rupture Of Membranes
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Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labour. Women usually experience a painless gush or a steady leakage of fluid from the
vagina In mammals and other animals, the vagina (: vaginas or vaginae) is the elastic, muscular sex organ, reproductive organ of the female genital tract. In humans, it extends from the vulval vestibule to the cervix (neck of the uterus). The #Vag ...
. Complications in the baby may include
premature birth Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is betwee ...
, cord compression, and infection. Complications in the mother may include
placental abruption Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and danger ...
and postpartum endometritis. Risk factors include infection of the amniotic fluid, prior PROM, bleeding in the later parts of pregnancy, smoking, and a mother who is
underweight An underweight person is a person whose body weight is considered too low to be healthy. A person who is underweight is malnourished. Assessment The body mass index, a ratio of a person's weight to their height, has traditionally been used t ...
. Diagnosis is suspected based on symptoms and speculum exam and may be supported by testing the vaginal fluid or by
ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...
. If it occurs before 37 weeks it is known as PPROM (preterm prelabor rupture of membranes) otherwise it is known as term PROM. Treatment is based on how far along a woman is in
pregnancy Pregnancy is the time during which one or more offspring gestation, gestates inside a woman's uterus. A multiple birth, multiple pregnancy involves more than one offspring, such as with twins. Conception (biology), Conception usually occurs ...
and whether complications are present. In those at or near term without any complications,
induction of labor Labor induction is the procedure where a medical professional starts the process of labor ( giving birth) instead of letting it start on its own. Labor may be induced (started) if the health of the mother or the baby is at risk. Induction of lab ...
is generally recommended. Time may also be provided for labor to begin spontaneously. In those 24 to 34 weeks of
gestation Gestation is the period of development during the carrying of an embryo, and later fetus, inside viviparous animals (the embryo develops within the parent). It is typical for mammals, but also occurs for some non-mammals. Mammals during pregn ...
without complications
corticosteroids Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are invol ...
and close observation is recommended. A 2017 Cochrane review found waiting generally resulted in better outcomes in those before 37 weeks.
Antibiotics An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
may be given for those at risk of '' Group B streptococcus''. Delivery is generally indicated in those with complications, regardless of how far along in pregnancy. About 8% of term pregnancies are complicated by PROM while about 30% of
preterm birth Preterm birth, also known as premature birth, is the Childbirth, birth of a baby at fewer than 37 weeks Gestational age (obstetrics), gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 ...
s are complicated by PROM. Before 24 weeks PROM occurs in fewer than 1% of pregnancies. Prognosis is primarily determined by complications related to prematurity such as
necrotizing enterocolitis Necrotizing enterocolitis (NEC) is an intestinal disease that affects premature or very low birth weight infants. Symptoms may include poor feeding, bloating, decreased activity, blood in the stool, vomiting of bile, multi-organ failure, and p ...
,
intraventricular hemorrhage Intraventricular hemorrhage (IVH), also known as intraventricular bleeding, is a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from p ...
, and
cerebral palsy Cerebral palsy (CP) is a group of movement disorders that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, spasticity, stiff muscles, Paresis, weak muscles, and tremors. There may b ...
.


Signs and symptoms

Most women will experience a painless leakage of fluid out of the vagina. They may notice either a distinct "gush" or a steady flow of small amounts of watery fluid in the absence of steady
uterine contraction Uterine contractions are muscle contractions of the uterine smooth muscle that can occur at various intensities in both the non-pregnant and pregnant uterine state. The non-pregnant uterus undergoes small, spontaneous contractions in addition to ...
s. Loss of fluid may be associated with the baby becoming easier to feel through the belly (due to the loss of the surrounding fluid), decreased uterine size, or
meconium Meconium is the earliest stool of a mammalian infant resulting from defecation. Unlike later feces, meconium is composed of materials ingested during the time the infant spends in the uterus: intestinal epithelial cells, lanugo, mucus, am ...
(fetal stool) seen in the fluid.


Risk factors

The cause of PROM is not clearly understood, but the following are risk factors that increase the chance of it occurring. In many cases, however, no risk factor is identified. * Infections:
urinary tract infection A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. Lower urinary tract infections may involve the bladder (cystitis) or urethra (urethritis) while upper urinary tract infections affect the kidney (pyel ...
,
sexually transmitted diseases A sexually transmitted infection (STI), also referred to as a sexually transmitted disease (STD) and the older term venereal disease (VD), is an infection that is spread by sexual activity, especially vaginal intercourse, anal sex, oral ...
, lower genital tract infections (e.g.
bacterial vaginosis Bacterial vaginosis (BV) is an infection of the vagina caused by excessive growth of bacteria. Common symptoms include increased vaginal discharge that often smells like fish. The discharge is usually white or gray in color. Burning with urina ...
), infections within the amniotic sac membranes (
chorioamnionitis Chorioamnionitis, also known as amnionitis and intra-amniotic infection (IAI), is inflammation of the fetal membranes (amnion and chorion), usually due to bacterial infection. In 2015, a National Institute of Child Health and Human Development W ...
) * Tobacco use during pregnancy * Illicit drug use during pregnancy * Having had PROM or preterm delivery in previous pregnancies *
Polyhydramnios Polyhydramnios is a medical condition describing an excess of amniotic fluid in the amniotic sac. It is seen in about 1% of pregnancies. It is typically diagnosed when the amniotic fluid index (AFI) is greater than 24 cm. There are two clini ...
: too much amniotic fluid * Multiple gestation: being pregnant with two or more fetuses at one time * Having had episodes of bleeding anytime during the pregnancy * Invasive procedures (e.g.
amniocentesis Amniocentesis is a medical procedure used primarily in the prenatal diagnosis of genetic conditions. It has other uses such as in the assessment of infection and fetal lung maturity. Prenatal diagnostic testing, which includes amniocentesis, is ...
) * Nutritional deficits * Cervical insufficiency: having a short or prematurely dilated cervix during pregnancy * Low socioeconomic status * Being underweight


Pathophysiology


Weak membranes

Fetal membranes likely break because they become weak and fragile. This weakening is a normal process that typically happens at term as the body prepares for labor and delivery. However, this can be a problem when it occurs before 37 weeks (preterm). The natural weakening of fetal membranes is thought to be due to one or a combination of the following. In PROM, these processes are activated too early: *
Cell death Cell death is the event of a biological cell ceasing to carry out its functions. This may be the result of the natural process of old cells dying and being replaced by new ones, as in programmed cell death, or may result from factors such as di ...
: when cells undergo programmed cell death, they release biochemical markers that are detected in higher concentrations in cases of PPROM. * Poor assembly of
collagen Collagen () is the main structural protein in the extracellular matrix of the connective tissues of many animals. It is the most abundant protein in mammals, making up 25% to 35% of protein content. Amino acids are bound together to form a trip ...
: collagen is a molecule that gives fetal membranes, as well as other parts of the human body such as the skin, their strength. In cases of PPROM, proteins that bind and
cross-link In chemistry and biology, a cross-link is a bond or a short sequence of bonds that links one polymer chain to another. These links may take the form of covalent bonds or ionic bonds and the polymers can be either synthetic polymers or natural ...
collagen to increase its
tensile strength Ultimate tensile strength (also called UTS, tensile strength, TS, ultimate strength or F_\text in notation) is the maximum stress that a material can withstand while being stretched or pulled before breaking. In brittle materials, the ultimate ...
are altered. * Breakdown of collagen: collagen is broken down by enzymes called
matrix metalloproteinase Matrix metalloproteinases (MMPs), also known as matrix metallopeptidases or matrixins, are metalloproteinases that are calcium-dependent zinc-containing endopeptidases; other family members are adamalysins, serralysins, and astacins. The MMPs be ...
s (MMPs), which are found at higher levels in PPROM amniotic fluid. This breakdown results in
prostaglandin Prostaglandins (PG) are a group of physiology, physiologically active lipid compounds called eicosanoids that have diverse hormone-like effects in animals. Prostaglandins have been found in almost every Tissue (biology), tissue in humans and ot ...
production which stimulates uterine contractions and cervical ripening. MMPs are inhibited by tissue inhibitors of matrix metalloproteinases (TIMPs) which are found at lower levels in PPROM amniotic fluid.


Infection

Infection and
inflammation Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...
likely explains why membranes break earlier than they are supposed to. In studies,
bacteria Bacteria (; : bacterium) are ubiquitous, mostly free-living organisms often consisting of one Cell (biology), biological cell. They constitute a large domain (biology), domain of Prokaryote, prokaryotic microorganisms. Typically a few micr ...
have been found in the amniotic fluid from about one-third of cases of PROM. Often, testing of the amniotic fluid is normal, but a
subclinical infection A subclinical infection—sometimes called a preinfection or inapparent infection—is an infection by a pathogen that causes few or no signs or symptoms of infection in the host. Subclinical infections can occur in both humans and animals. Dep ...
(too small to detect) or infection of maternal tissues adjacent to the amniotic fluid, may still be a contributing factor. In response to infection, the resultant infection and release of chemicals (
cytokine Cytokines () are a broad and loose category of small proteins (~5–25 kDa) important in cell signaling. Cytokines are produced by a broad range of cells, including immune cells like macrophages, B cell, B lymphocytes, T cell, T lymphocytes ...
s) subsequently weakens the fetal membranes and put them at risk for rupture. PROM is also a risk factor in the development of neonatal infections.


Genetics

Many
gene In biology, the word gene has two meanings. The Mendelian gene is a basic unit of heredity. The molecular gene is a sequence of nucleotides in DNA that is transcribed to produce a functional RNA. There are two types of molecular genes: protei ...
s play a role in inflammation and collagen production, therefore inherited genes may play a role in predisposing a person to PROM.


Diagnosis

To confirm if a woman has experienced PROM, a clinician must prove that the fluid leaking from the vagina is amniotic fluid, and that labor has not yet started. To do this, a careful
medical history The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and ev ...
is taken, a gynecological exam is conducted using a sterile speculum, and an
ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...
of the uterus is performed. * History: a person with PROM typically recalls a sudden "gush" of fluid loss from the vagina, or steady loss of small amounts of fluid. * Sterile speculum exam: a clinician will insert a sterile speculum into the vagina in order to see inside and perform the following evaluations. Digital cervical exams, in which gloved fingers are inserted into the vagina to measure the cervix, are avoided until the women is in active labor to reduce the risk of infection. ** Pooling test: Pooling is when a collection of amniotic fluid can be seen in the back of the vagina (
vaginal fornix The fornices of the vagina (: fornix of the vagina or fornix vaginae) are the superior portions of the vagina, extending into the recesses created by the vaginal portion of cervix. There is an anterior fornix and a posterior fornix. The word i ...
). Sometimes leakage of fluid from the cervical opening can be seen when the person coughs or performs a
valsalva maneuver The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air, as if blowing up a balloon. Variations of the maneuver can be ...
. ** Nitrazine test: A sterile cotton swab is used to collect fluid from the vagina and place it on nitrazine (phenaphthazine) paper. Amniotic fluid is mildly
basic Basic or BASIC may refer to: Science and technology * BASIC, a computer programming language * Basic (chemistry), having the properties of a base * Basic access authentication, in HTTP Entertainment * Basic (film), ''Basic'' (film), a 2003 film ...
( pH 7.1–7.3) compared to normal vaginal secretions which are
acid An acid is a molecule or ion capable of either donating a proton (i.e. Hydron, hydrogen cation, H+), known as a Brønsted–Lowry acid–base theory, Brønsted–Lowry acid, or forming a covalent bond with an electron pair, known as a Lewis ...
ic (pH 4.5–6). Basic fluid, like amniotic fluid, will turn the nitrazine paper from orange to dark blue. **
Fern test The fern test is a medical laboratory test used in obstetrics and gynecology. The name refers to the detection of a characteristic "fern like" pattern of vaginal secretions when a specimen is allowed to dry on a glass slide and is viewed under a ...
: A sterile cotton swab is used to collect fluid from the vagina and place it on a
microscope slide A microscope slide is a thin flat piece of glass, typically 75 by 26 mm (3 by 1 inches) and about 1 mm thick, used to hold objects for examination under a microscope. Typically the object is mounted (secured) on the slide, and then ...
. After drying, amniotic fluid will form a
crystallization Crystallization is a process that leads to solids with highly organized Atom, atoms or Molecule, molecules, i.e. a crystal. The ordered nature of a crystalline solid can be contrasted with amorphous solids in which atoms or molecules lack regu ...
pattern called arborization which resembles leaves of a
fern The ferns (Polypodiopsida or Polypodiophyta) are a group of vascular plants (plants with xylem and phloem) that reproduce via spores and have neither seeds nor flowers. They differ from mosses by being vascular, i.e., having specialized tissue ...
plant when viewed under a microscope. **
Fibronectin Fibronectin is a high- molecular weight (~500-~600 kDa) glycoprotein of the extracellular matrix that binds to membrane-spanning receptor proteins called integrins. Fibronectin also binds to other extracellular matrix proteins such as col ...
and
alpha-fetoprotein Alpha-fetoprotein (AFP, α-fetoprotein; also sometimes called alpha-1-fetoprotein, alpha-fetoglobulin, or alpha fetal protein) is a protein that in humans is encoded by the ''AFP'' gene. The ''AFP'' gene is located on the ''q'' arm of chromosome ...
blood test A blood test is a medical laboratory, laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a hypodermic needle, or via fingerprick. Multiple tests for specific blood components, such as a glucose ...
s


Classification

* Prelabor rupture of membranes (PROM): when the
fetal membranes The fetal membranes are the four extraembryonic membranes, associated with the developing embryo, and fetus in humans and other mammals. They are the amnion, chorion, allantois, and yolk sac. The amnion and the chorion are the chorioamniotic ...
rupture early, at least one hour before labor has started. * Prolonged PROM: a case of prelabor rupture of membranes in which more than 18 hours has passed between the rupture and the onset of labor. * Preterm prelabor rupture of membranes (PPROM): prelabor rupture of membranes that occurs before 37 weeks gestation. * Midtrimester PPROM or pre-viable PPROM: prelabor rupture of membranes that occurs before 24 weeks' gestation. Before this age, the fetus cannot survive outside of the mother's womb.


Additional tests

The following tests should only be used if the diagnosis is still unclear after the standard tests above. * Ultrasound: Ultrasound can measure the amount of fluid still in the uterus surrounding the fetus. If the fluid levels are low, PROM is more likely. This is helpful in cases when the diagnosis is not certain, but is not, by itself, definitive. * Immune-chromatological tests are helpful, if negative, to rule out PROM, but are not that helpful if positive since the false-positive rate is relatively high (19–30%). *
Indigo carmine Indigo carmine, or 5,5′-indigodisulfonic acid sodium salt, is an wikt:organic salt#English, organic salt derived from Indigo dye, indigo by aromatic sulfonation, which renders the compound soluble in water. Like indigo, it Blue#Colourants, ...
dye test: a needle is used to inject indigo carmine dye (blue) into the amniotic fluid that remains in the uterus through the abdominal wall. In the case of PROM, blue dye can be seen on a stained tampon or pad after about 15–30 minutes. This method can be used to definitively make a diagnosis, but is rarely done because it is invasive and increases risk of infection. But, can be helpful if the diagnosis is still unclear after the above evaluations have been done. It is unclear if different methods of assessing the fetus in a woman with PPROM affects outcomes.


False positives

Like amniotic fluid,
blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood is com ...
,
semen Semen, also known as seminal fluid, is a bodily fluid that contains spermatozoon, spermatozoa which is secreted by the male gonads (sexual glands) and other sexual organs of male or hermaphrodite, hermaphroditic animals. In humans and placen ...
, vaginal secretions in the presence of infection, soap,
urine Urine is a liquid by-product of metabolism in humans and many other animals. In placental mammals, urine flows from the Kidney (vertebrates), kidneys through the ureters to the urinary bladder and exits the urethra through the penile meatus (mal ...
, and
cervical mucus The cervix (: cervices) or cervix uteri is a dynamic fibromuscular sexual organ of the female reproductive system that connects the vagina with the uterine cavity. The human female cervix has been documented anatomically since at least the tim ...
also have an alkaline pH and can also turn nitrazine paper blue. Cervical mucus can also make a pattern similar to ferning on a microscope slide, but it is usually patchy and with less branching.


Differential diagnosis

Other conditions that may present similarly to premature rupture of membranes are the following: *
Urinary incontinence Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a significant effect on quality of life. Urinary incontinence is common in older women ...
: leakage of small amounts of urine is common in the last part of pregnancy * Normal vaginal secretions of pregnancy * Increased sweat or moisture around the perineum * Increased cervical discharge: this can happen when there is a genital tract infection * Semen *
Douching A douche is a term for a device used to introduce a stream of water into the body for medical or hygienic reasons, or for the stream of water itself. Douche usually refers to vaginal irrigation, the rinsing of the vagina, but it can also refer ...
* Vesicovaginal fistula: an abnormal connection between the bladder and the vagina * Loss of the mucus plug


Prevention

Women who have had PROM are more likely to experience it in future pregnancies. There is not enough data to recommend a way to specifically prevent future PROM. However, any woman that has had a history of preterm delivery, because of PROM or not, is recommended to take progesterone supplementation to prevent recurrence.


Management

The management of PROM remains controversial, and depends largely on the gestational age of the fetus and other complicating factors. The risks of quick delivery (induction of labor) vs. watchful waiting in each case is carefully considered before deciding on a course of action. As of 2012, the
Royal College of Obstetricians and Gynaecologists The Royal College of Obstetricians and Gynaecologists (RCOG) is a professional association based in London, United Kingdom. Its members, including people with and without medical degrees, work in the field of obstetrics and gynaecology, that is ...
advised, based on expert opinion and not clinical evidence, that attempted delivery during maternal instability increases the rates of both fetal death and
maternal death Maternal death or maternal mortality is defined in slightly different ways by several different health organizations. The World Health Organization (WHO) defines maternal death as the death of a pregnant mother due to complications related to p ...
, unless the source of instability is an intrauterine infection. In all women with PROM, the age of the fetus, its position in the uterus, and its well-being should be evaluated. This can be done with ultrasound, Doppler fetal heart rate monitoring, and uterine activity monitoring. This will also show whether or not uterine contractions are happening which may be a sign that labor is starting. Signs and symptoms of infection should be closely monitored, and, if not already done, a group B streptococcus (GBS) culture should be collected. At any age, if the fetal well-being appears to be compromised, or if intrauterine infection is suspected, the baby should be delivered quickly by induction of labour.


Term

Both expectant management (watchful waiting) and an induction of labor (artificially stimulating labor) are considered in this case. 90% of women start labor on their own within 24 hours, and therefore it is reasonable to wait for 12–24 hours as long as there is no risk of infection. However, if labor does not begin soon after the PROM, an induction of labor is recommended because it reduces rates of infections, decreases the chances that the baby will require a stay in the
neonatal intensive care unit A neonatal intensive care unit (NICU), also known as an intensive care nursery (ICN), is an intensive care unit (ICU) specializing in the care of ill or premature newborn infants. The NICU is divided into several areas, including a critical c ...
(NICU), and does not increase the rate of
caesarean section Caesarean section, also known as C-section, cesarean, or caesarean delivery, is the Surgery, surgical procedure by which one or more babies are Childbirth, delivered through an incision in the mother's abdomen. It is often performed because va ...
s. If a woman strongly does not want to be induced, watchful waiting is an acceptable option as long as there is no sign of infection, the fetus is not in distress, and she is aware and accepts the risks of PPROM. There is not enough data to show that the use of prophylactic antibiotics (to prevent infection) is beneficial for mothers or babies at or near term because of the potential side effects and development of
antibiotic resistance Antimicrobial resistance (AMR or AR) occurs when microbes evolve mechanisms that protect them from antimicrobials, which are drugs used to treat infections. This resistance affects all classes of microbes, including bacteria (antibiotic resis ...
.


34 to 37 weeks

When the fetus is 34 to 37 weeks gestation, the risk of being born prematurely must be weighed against the risk of PROM. Previously it was recommended that delivery be carried out as if the baby was term. A 2017 Cochrane review however found waiting resulted in better outcomes when pregnancy is before 37 weeks.


24 to 34 weeks

Before 34 weeks, the fetus is at a much higher risk of the complications of prematurity. Therefore, as long as the fetus is doing well, and there are no signs of infection or
placental abruption Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and danger ...
, watchful waiting (expectant management) is recommended. The younger the fetus, the longer it takes for labor to start on its own, but most women will deliver within a week. Waiting usually requires a woman to stay in the hospital so that health care providers can watch her carefully for infection, placental abruption, umbilical cord compression, or any other fetal emergency that would require quick delivery by induction of labor. In 2017, a review of watchful waiting vs the early birth strategy was conducted to ascertain which was associated with a lower overall risk. Focusing on the 24–37-week range, the review analysed twelve randomised controlled trials from the " Cochrane Pregnancy and Childbirth's Trials Register", concluding that "In women with PPROM before 37 weeks' gestation with no
contraindication In medicine, a contraindication is a condition (a situation or factor) that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a rea ...
s to continuing the pregnancy, a policy of expectant management with careful monitoring was associated with better outcomes for the mother and baby." There is believed to be a correlation between volume of amniotic fluid retained and neonatal outcomes before 26 weeks' gestation. Amniotic fluid levels are an important consideration when debating expectant management vs clinical intervention, as low levels, or oligohydramnios, can result in lung and limb abnormalities. Additionally, labor and infection are less likely to occur when there are sufficient levels of amniotic fluid remaining in the uterus. Serial
amnioinfusion Amnioinfusion is a method in which isotonic fluid is instilled into the uterine cavity. It was introduced in the 1960s as a means of terminating pregnancy and inducing labor in intrauterine death, but is currently used as a treatment in order to c ...
in pregnancies with PPROM-related oligohydramnios at less than 26 weeks gestation, successfully alleviates
oligohydramnios Oligohydramnios is a medical condition in pregnancy characterized by a deficiency of amniotic fluid, the fluid that surrounds the fetus in the abdomen, in the amniotic sac. The limiting case is anhydramnios, where there is a complete absence of ...
, with perinatal outcomes that are significantly better than the outcome in those with the persistent condition and is comparable with gestations with PPROM in which oligohydramnios never develops.


Recommended

* Monitoring for infection: signs of infection include a
fever Fever or pyrexia in humans is a symptom of an anti-infection defense mechanism that appears with Human body temperature, body temperature exceeding the normal range caused by an increase in the body's temperature Human body temperature#Fever, s ...
in the mother, fetal
tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ...
(fast heart rate of the fetus, more than160 beats per minute), or tachycardia in the mother (more than 100 beats per minute).
White blood cell White blood cells (scientific name leukocytes), also called immune cells or immunocytes, are cells of the immune system that are involved in protecting the body against both infectious disease and foreign entities. White blood cells are genera ...
(WBC) counts are not helpful in this case because WBC's are normally high in late pregnancy. * Steroids before birth: corticosteroids (
betamethasone Betamethasone is a corticosteroid, steroid medication. It is used for a number of diseases including rheumatic disorders such as rheumatoid arthritis and systemic lupus erythematosus, skin diseases such as dermatitis and psoriasis, allergic co ...
) given to the mother of a baby at risk of being born prematurely can speed up fetal lung development and reduce the risk of death of the infant, respiratory distress syndrome, brain bleeds, and bowel necrosis. It is recommended that mothers receive one course of corticosteroids between 24 and 34 weeks when there is a risk of preterm delivery. In cases of PPROM these medications do not increase the risk of infection even though steroids are known to suppress the immune system. More than two courses is not recommended because three or more can lead to small birth weight and small head circumference. In pregnancies between 32 and 34 weeks (right around the time that fetal lungs mature) vaginal fluid can be tested to determine fetal lung maturity using chemical markers which can help to decide if corticosteroids should be given. * Magnesium sulfate: Intravenous magnesium sulfate is given to the mother in cases when there is a risk of preterm birth before 32 weeks. This has been shown to protect the fetal brain and reduce the risk of
cerebral palsy Cerebral palsy (CP) is a group of movement disorders that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, spasticity, stiff muscles, Paresis, weak muscles, and tremors. There may b ...
. * Latency antibiotics: The time from PROM to labor is termed the latency period, and there is an inverse relationship between gestational age and the length of latency, meaning that the earlier the rupture, the longer it will take for labor to begin naturally. As expected, antibiotics given to mothers that experience PPROM serve to protect against infections during this lengthened latency period. Additionally, antibiotics increase the time that babies stay in the womb. Antibiotics don't seem to prevent death or make a difference in the long-term (years after the baby is born). But, because of the short-term benefits, routine use of antibiotics in PPROM is still recommended. The American Congress of Obstetricians and Gynecologists (ACOG) recommends a seven-day course of intravenous
ampicillin Ampicillin is an antibiotic belonging to the aminopenicillin class of the penicillin family. The drug is used to prevent and treat several bacterial infections, such as respiratory tract infections, urinary tract infections, meningitis, s ...
and
erythromycin Erythromycin is an antibiotic used for the treatment of a number of bacterial infections. This includes respiratory tract infections, skin infections, chlamydia infections, pelvic inflammatory disease, and syphilis. It may also be used ...
followed by oral
amoxicillin Amoxicillin is an antibiotic medication belonging to the aminopenicillin class of the penicillin family. The drug is used to treat bacterial infections such as middle ear infection, strep throat, pneumonia, skin infections, odontogenic inf ...
and erythromycin if watchful waiting is attempted before 34 weeks. Amoxicillin/clavulanic acid increases the risk of fetal bowel death (
necrotizing enterocolitis Necrotizing enterocolitis (NEC) is an intestinal disease that affects premature or very low birth weight infants. Symptoms may include poor feeding, bloating, decreased activity, blood in the stool, vomiting of bile, multi-organ failure, and p ...
) and should be avoided in pregnancy. * Prophylactic antibiotics: If a woman is colonized with GBS, than the typical use of antibiotics during labor is recommended to prevent transmission of this bacteria to the fetus, regardless of earlier treatments.


Controversial or not recommended

* Preventative tocolysis (medications to prevent contractions): the use of tocolytic medications to prevent labor contractions is controversial. On the one hand, this can delay delivery and allow the fetus more time to develop and benefit from antenatal corticosteroid medication, on the other hand it increases the risk of infection or chorioamnionitis. The use of tocolysis has not shown to benefit mom or baby and currently there is not enough data to recommend or discourage its use in the case of preterm PROM. * Therapeutic tocolysis (medications to stop contractions): Once labor has started, using tocolysis to stop labor has not been shown to help, and is not recommended. *
Amnioinfusion Amnioinfusion is a method in which isotonic fluid is instilled into the uterine cavity. It was introduced in the 1960s as a means of terminating pregnancy and inducing labor in intrauterine death, but is currently used as a treatment in order to c ...
: This treatment attempts to replace the lost amniotic fluid from the uterus by infusing normal saline fluid into the uterine cavity. This can be done through the vagina and cervix (transcervical amnioinfusion) or by passing a needle through the abdominal wall (transabdominal amnioinfusion). Current data suggests that this treatment prevents infection, lung problems, and fetal death. However, there have not been enough trials to recommend its routine use in all cases of PPROM. * Home care: Typically women with PPROM are managed in the hospital, but, occasionally they opt to go home if watchful waiting is attempted. Since labor usually starts soon after PPROM, and infection, umbilical cord compression, and other fetal emergencies can happen very suddenly, it is recommended that women stay in the hospital in cases of PPROM after 24 weeks. Currently, there is not enough evidence to determine meaningful differences in safety, cost, and women's views between management at home vs. the hospital. * Sealing membranes after rupture: Infection is the major risk associated with PROM and PPROM. By closing the ruptured membranes, it is hoped that there would be a decrease in infection, as well as encouraging the re-accumulation of amniotic fluid in the uterus to protect the fetus and allow for further lung development. Common techniques include placing a sponge over the ruptured membrane and the use of oral autoimmune stimulating drugs to encourage the body's immune system to repair the rupture. There is currently insufficient research to determine whether these or other resealing techniques improve maternal or neonatal outcomes when compared to the current standard of care.


Before 24 weeks

Before 24 weeks, a fetus is not viable meaning it cannot live outside the mother. In this case, either watchful waiting at home or an induction of labor done. Because the risk of infection is so high, the mother should check her temperature often and return to the hospital if she develops any signs or symptoms of infection, labor, or vaginal bleeding. These women are typically admitted to the hospital once their fetus reaches 24 weeks and then managed the same as women with PPROM before 34 weeks (discussed above). When possible, these deliveries should take place in a hospital that has expertise in the management of the potential maternal and neonatal complications, and has the necessary infrastructure in place to support the care of these patients (i.e. neonatal intensive care unit). Antenatal corticosteroids, latency antibiotics, magnesium sulfate, and tocolytic medications are not recommended until the fetus reaches viability (24 weeks). In cases of pre-viable PPROM, chance of survival of the fetus is between 15 and 50%, and the risk of chorioamnionitis is about 30%.


Chorioamnionitis

Chorioamnionitis Chorioamnionitis, also known as amnionitis and intra-amniotic infection (IAI), is inflammation of the fetal membranes (amnion and chorion), usually due to bacterial infection. In 2015, a National Institute of Child Health and Human Development W ...
is a bacterial infection of the fetal membranes, which can be life-threatening to both mother and fetus. Women with PROM at any age are at high risk of infection because the membranes are open and allow bacteria to enter. Women are checked often (usually every 4 hours) for signs of infection: fever (more than 38 °C or 100.5 °F), uterine pain, maternal tachycardia, fetal tachycardia, or foul-smelling amniotic fluid. Elevated white blood cells are not a good way to predict infection because they are normally high in labor. If infection is suspected, artificial induction of labor is started at any gestational age and broad antibiotics are given. Caesarean section should not be automatically done in cases of infection, and should only be reserved for the usual fetal emergencies.


Outcomes

The consequences of PROM depend on the gestational age of the fetus. When PROM occurs at term (after 36 weeks), it is typically followed soon thereafter by the start of labor and delivery. About half of women will give birth within 5 hours, and 95% will give birth within 28 hours without any intervention. The younger the baby, the longer the latency period (time between membrane rupture and start of labor). Rarely, in cases of preterm PROM, amniotic fluid will stop leaking and the amniotic fluid volume will return to normal. If PROM occurs before 37 weeks, it is called preterm prelabor rupture of membranes (PPROM), and the baby and mother are at greater risk of complications. PPROM causes one-third of all
preterm birth Preterm birth, also known as premature birth, is the Childbirth, birth of a baby at fewer than 37 weeks Gestational age (obstetrics), gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 ...
s. PROM provides a path for disease-causing organisms to enter the womb and puts both the mother and baby at risk for
infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...
. Low levels of fluid around the baby also increase the risk of umbilical cord compression and can interfere with lung and body formation of the baby in early pregnancy.


Infection (any age)

At any gestational age, an opening in the fetal membranes provides a route for bacteria to enter the womb. This can lead to
chorioamnionitis Chorioamnionitis, also known as amnionitis and intra-amniotic infection (IAI), is inflammation of the fetal membranes (amnion and chorion), usually due to bacterial infection. In 2015, a National Institute of Child Health and Human Development W ...
(an infection of the fetal membranes and amniotic fluid) which can be life-threatening to both the mother and fetus. The risk of infection increases the longer the membranes remain open and baby undelivered. Women with preterm PROM will develop an intra-amniotic infection 15–25% of the time, and the chances of infection increase at earlier gestational ages.


Pre-term birth (before 37 weeks)

PROM occurring before 37 weeks (PPROM) is one of the leading causes of preterm birth. Thirty to 35% of all preterm births are caused by PPROM. This puts the fetus at risk for the many complications associated with prematurity such as respiratory distress, brain bleeds, infection,
necrotizing enterocolitis Necrotizing enterocolitis (NEC) is an intestinal disease that affects premature or very low birth weight infants. Symptoms may include poor feeding, bloating, decreased activity, blood in the stool, vomiting of bile, multi-organ failure, and p ...
(death of the fetal bowels), brain injury, muscle dysfunction, and death. Prematurity from any cause leads to 75% of perinatal mortality and about 50% of all long-term morbidity. PROM is responsible for 20% of all fetal deaths between 24 and 34 weeks' gestation.


Fetal development (before 24 weeks)

Before 24 weeks the fetus is still developing its organs, and the amniotic fluid is important for protecting the fetus against infection, physical impact, and for preventing the umbilical cord from becoming compressed. It also allows for fetal movement and breathing that is necessary for the development of the lungs, chest, and bones. Low levels of amniotic fluid due to mid-trimester or previable PPROM (before 24 weeks) can result in fetal deformity (e.g. Potter-like facies), limb
contracture In pathology, a contracture is a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement. A contracture is usually permanent, but less commonly can be temp ...
s,
pulmonary hypoplasia Pulmonary hypoplasia is an incomplete development of the lungs, resulting in an abnormally low number or small size of bronchopulmonary segments or alveoli. A congenital malformation, most often occurs secondary to other fetal abnormalities tha ...
(underdeveloped lungs), infection (especially if the mother is colonized by group B streptococcus or bacterial vaginosis), prolapsed umbilical cord or compression, and placental abruption.


PROM after second-trimester amniocentesis

Most cases of PROM occur spontaneously, but the risk of PROM in women undergoing a second trimester amniocentesis for prenatal diagnosis of genetic disorders is 1%. Although no studies are known to account for all cases of PROM that stem from amniocentesis. This case, the chances of the membranes healing on their own and the amniotic fluid returning to normal levels is much higher than spontaneous PROM. Compared to spontaneous PROM, about 70% of women will have normal amniotic fluid levels within one month, and about 90% of babies will survive.


Epidemiology

Of term pregnancies (more than 37 weeks) about 8% are complicated by PROM, 20% of these become prolonged PROM. About 30% of all preterm deliveries (before 37 weeks) are complicated by PPROM, and rupture of membranes before viability (before 24 weeks) occurs in less than 1% of all pregnancies. Since there are significantly fewer preterm deliveries than term deliveries, the number of PPROM cases make up only about 5% of all cases of PROM.


See also

* Placental alpha microglobulin-1 (PAMG-1) *
IGFBP1 Insulin-like growth factor-binding protein 1 (IBP-1) also known as placental protein 12 (PP12) is a protein that in humans is encoded by the ''IGFBP1'' gene. Function This gene is a member of the Insulin-like growth factor-binding protein (IGF ...
(Insulin-like growth factor binding protein-1)


References


External links

{{DEFAULTSORT:Premature Rupture Of Membranes Health issues in pregnancy Disorders originating in the perinatal period Maternal disorders predominantly related to pregnancy Wikipedia medicine articles ready to translate Preterm birth