|What Does PROM Mean?
Premature rupture of membranes (PROM) refers to sudden breaking of the amniotic sac (which contains the baby) and water gushes out before you go into labor. Labor usually follows soon after. While it may be of little significance if the pregnancy is near term, at an earlier stage the baby will be smaller, which increases the risk of fetal death. PROM is defined as where the membranes rupture after 37 weeks of gestation. Preterm premature rupture of membranes (PPROM) is where the membranes rupture before week 37. If childbirth and delivery does not occur within a few days of the rupture, bacteria can enter the womb and cause a dangerous infection. There is also a risk of umbilical cord prolapse (and stillbirth).
• PROM occurs in 3 percent of pregnancies.
• 95 percent of patients deliver within one day of PROM.
• 57 percent of patients deliver within one week of (preterm) PPROM, and 22 percent within 4 weeks.
• PPROM is associated with 30 to 40 percent of all preterm deliveries.
What Is My Baby’s Survival Rate?
The survival rate for babies born at 24 weeks is about 36 percent. This rises to 90 percent by week 30.
What Are The Signs?
• Sudden gush of fluid (waters breaking) or continued leakage of fluid.
• Feeling wet, the feeling that you can't stop urinating. The fluid can be clear or light yellow.
• No sign of contractions.
• Possible signs: Back pain, pain in the tummy and vaginal bleeding.
What Causes It?
PROM is associated with:
• Women pregnant with twins.
• High amniotic fluid levels (polyhydramnios).
• Low body mass index (check your BMI, BMI calculator).
• Tobacco use.
• History of preterm labors.
• Urinary tract infection.
• Some studies have linked it to bacterial vaginosis.
• Bleeding in pregnancy in the first or second trimester.
• History of sexually transmitted diseases (STDs).
• Black women are more prone than white women.
• Cerclage procedure: This procedure treats cervical incompetence, that is, where the cervix dilates too early. Under general or epidural anesthesia the cervix is stitched to tighten it again.
• Amniocentesis test: Often performed to test for signs of birth defects.
In less than 10 percent of PPROM cases, the membranes can spontaneously seal again - but this is mostly associated with PPROM after an amniocentesis.
How Is It Diagnosed?
The woman will notice a sudden gush of fluid which prompts her to seek medical attention on the assumption she is experiencing premature labor. The doctor will want to know if you:
• Have been feeling contractions.
• Are experiencing vaginal bleeding.
• Had intercourse recently.
• Have a fever.
Next he will perform a physical examination, to check:
• If cervical dilation and effacement are present. This will be done by using a speculum.
• If there is evidence of fluid pooling in the vagina.
• That the fluids are not urine. He will do this by testing a specimen on special nitrazine paper. Amniotic fluid has a higher pH balance than urine, and this will show up on the paper.
• For the presence of chlamydia and gonorrhea - women with these STDs are 7 times more likely to have PROM.
• For group B streptococcus by taking a swab from the anus.
If physical findings do not confirm a diagnosis, an ultrasound usually will. The ultrasound will also accurately date the pregnancy.
How Is It Treated?
32 To 36 Weeks
If the pregnancy has passed 32 weeks it is best to induce labor. Ideally the mother will be transported to a hospital equipped to deal with high-risk deliveries. Consultation with a neonatologist or doctor experienced in the management of PPROM will be beneficial. PPROM is not considered a reason to perform a c-section over vaginal delivery, both methods of delivery are usually equally viable. The mother may be prescribed antibiotics to prevent group B streptococcus prophylaxis (which can cause severe illness in the baby).
24 to 31 Weeks
Before 32 weeks it may better to delay labor until the baby is more mature (ideally until week 34). The mother will be confined to bed (in hospital) and advised that despite medical efforts, many patients still deliver within 1 week. Physicians will prescribe a course of corticosteroids and antibiotics. Corticosteroid injections reduce the risk of respiratory distress syndrome in the fetus by accelerating the growth of the lungs; and antibiotics reduce the risk of neonatal infections. Fetal monitoring for signs of distress and contractions will be carried out daily.
Before 24 Weeks
PPROM that occurs in the second trimester has a 30 percent rate of fetal death. Until the baby is viable, the doctor's primary concern is the safety of the mother who is at risk of hemorrhage and infection.
The majority of women with PPROM before 24 weeks deliver within 6 days. Many infants born so early develop long-term problems such as lung disease, brain disorders and cerebral palsy. It can also lead to Potter's syndrome - the baby may have physical abnormalities like a flattened nose or recessed chin, or heart problems, clubfoot or other limb contractures. 50 percent of babies born at 19 weeks develop Potter's syndrome, this reduces to 25 percent by week 22 and 10 percent after week 26. If you develop PPROM before 24 weeks your obgyn may refer you to a neonatologist or perinatologist for specialized care. Most physicians insist on bed rest and fetal monitoring in hospital, particularly if there is evidence of infection or active labor. Corticosteroids are not recommended this early and antibiotics have not been proven to prolong pregnancy.
What Complications Can PROM Cause?
The risks are associated primarily with PPROM, and these are:
• Delivery within one week: 50 to 75 percent.
• Fetal respiratory distress syndrome: 35 percent.
• Umbilical cord compression (cutting off oxygen and food supplies to the baby): 32 to 76 percent.
• Chorioamnionitis (bacterial infection): 13 to 60 percent.
• Placenta abruption: 4 to 12 percent.
• Antepartum fetal death.
Most patients are referred to a sub specialist consultant who is experienced in the management of PPROM. The following guidelines are usually followed:
1. A clinical diagnosis needs to be made. Ultrasound should be performed to confirm the gestational age of the baby, the baby's weight, level of amniotic fluid presence and to study the baby's anatomy.
2. The rule is hospitalization in a center where care for premature babies can be given.
3. Antibiotics are usually prescribed. Corticosteroids should be given between weeks 24 and 34 to speed up lung growth. Corticosteroids are not prescribed before week 24.
4. Fetal monitoring should be performed daily and the baby's growth periodically monitored on ultrasound.
5. PROM at term should be managed by inducing labor unless there are other reasons to consider waiting.
The impact of digital cervical examination on expectantly managed preterm rupture of membranes. Am J Obstet Gynecol (2000) by Alexander and Mercer.
Epidemiologic characteristics of preterm delivery: etiologic heterogeneity. Am J Obstet Gynecology (1991) by Savitz, Blackmore and Thorp.
Premature rupture of membranes. Clinical management guidelines for obstetrician-gynecologists. ACOG bulletin (1998) by the American College of Obstetricians and Gynecologists.
Antibiotic therapy for reduction of infant morbidity after preterm premature rupture of the membranes. A randomized controlled trial. JAMA (1997) by Mercer, Miodovnik and Ramsey.