Premature Rupture of Membranes (at Term)

Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset
of labor at or beyond 37 weeks' gestation. PROM occurs in approximately 10% of
pregnancies. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal
bleeding, and pelvic pressure, but they are not having contractions.

ROM is diagnosed by speculum vaginal examination of the cervix and vaginal cavity.
Pooling of fluid in the vagina or leakage of fluid from the cervix, ferning of the dried fluid
under microscopic examination, and alkalinity of the fluid as determined by Nitrazine paper
confirm the diagnosis.

Blood contamination of the Nitrazine paper and ferning of cervical mucus may produce false-
positive results. Pooling of fluid is by far the most accurate for diagnosis of ROM. If all fluid
has leaked out as in early PROM, an ultrasonographic examination may then show absence of
or very low amounts of amniotic fluid in the uterine cavity.

New evidence suggests that the use of biochemical markers to diagnose ROM in uncertain
cases may be appropriate and cost effective. Echebiri et al reported cost effectiveness
compared to standard methods of diagnoses between 34 and 37 weeks. [5]

Ng et al reported placental alpha-microglobulin-1 levels have a 95.7% sensitivity, 100%

specificity, 100% positive predictive value, and 75% negative predictive value. [6] In select
cases when the diagnoses or ROM is not clear, placental alpha-microglobulin-1 should be
used to provide additional information for appropriate management.

Given the importance of making the correct diagnoses, the associated morbidity with
hospitalization and delivery prior to term in PROM reaching 34 weeks and beyond, and the
potential neonatal morbidity resulting from prematurity in cases of incorrect diagnoses of
PROM, it is mandatory to confirm the diagnosis of PROM with pooling of amniotic fluid
with some evidence of decreased or absence of amniotic fluid in all cases of suspected
PROM.

Most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at
term. The major question regarding management of these patients is whether to allow them to
enter labor spontaneously or to induce labor. In large part, the management of these patients
depends on their desires; however, the major maternal risk at this gestational age is
intrauterine infection. The risk of intrauterine infection increases with the duration of ROM.
Evidence supports the idea that induction of labor, as opposed to expectant management,
decreases the risk of chorioamnionitis without increasing the cesarean delivery rate. [7, 8, 9]

Hannah et al studied 5041 women with PROM who were randomly assigned to induction of
labor with intravenous oxytocin or vaginal prostaglandin E2 gel versus expectant
management for as many as 4 days with induction of labor for complications. [10] They
concluded that, in women with PROM, induction of labor and expectant management
resulted in similar rates of cesarean delivery and neonatal infection. However, induction with
oxytocin resulted in a lower risk of maternal infection (endometritis) when compared with
expectant management. Additionally, the women in the study viewed induction of labor more
favorably than expectant management.
Other smaller studies have shown results with higher cesarean and/or operative delivery rates
when the cervix was unfavorable.

At term, infection remains the most serious complication associated with PROM for the
mother and the neonate. The risk of chorioamnionitis with term PROM has been reported to
be less than 10% and to increase to 40% after 24 hours of PROM. [11] This points out the
importance of appropriate management strategies for PROM at term.

Since risk of infection at term with ROM is small during the first 24 hours, expectant
management and waiting for spontaneous labor may be considered in selected patients for the
first 12-24 hours if a patient desires expectant management. The use of expectant
management after the first 24 hours is questionable.

Digital vaginal examinations should be avoided until labor is initiated; however, fetal
presentation should be documented to avoid discovering malpresentation of the fetus long
after admission for ROM. All patients with ROM should be asked to come to the hospital to
ensure fetal well being.

The neonatal risks of expectant management of PROM include infection, placental abruption,
fetal distress, fetal restriction deformities and pulmonary hypoplasia, and fetal/neonatal death.
Fetal death does occur in approximately 1% of patients with PROM after viability who have
been expectantly managed [1] and in about 1:1000 term PROM. [12]

The primary determinant of neonatal morbidity and mortality is gestational age at delivery,
again stressing the importance of conservative management when possible. (See the
Gestational Age from Estimated Date of Delivery calculator.)

In general, prognosis is good after 32 weeks' gestation as long as no other complicating

factor, such as congenital malformation or pulmonary hypoplasia, exists.

Premature Rupture of Membranes (at Term)

Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset
of labor at or beyond 37 weeks' gestation. PROM occurs in approximately 10% of
pregnancies. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal
bleeding, and pelvic pressure, but they are not having contractions.

ROM is diagnosed by speculum vaginal examination of the cervix and vaginal cavity.
Pooling of fluid in the vagina or leakage of fluid from the cervix, ferning of the dried fluid
under microscopic examination, and alkalinity of the fluid as determined by Nitrazine paper
confirm the diagnosis.

Blood contamination of the Nitrazine paper and ferning of cervical mucus may produce false-
positive results. Pooling of fluid is by far the most accurate for diagnosis of ROM. If all fluid
has leaked out as in early PROM, an ultrasonographic examination may then show absence of
or very low amounts of amniotic fluid in the uterine cavity.
New evidence suggests that the use of biochemical markers to diagnose ROM in uncertain
cases may be appropriate and cost effective. Echebiri et al reported cost effectiveness
compared to standard methods of diagnoses between 34 and 37 weeks. [5]

Ng et al reported placental alpha-microglobulin-1 levels have a 95.7% sensitivity, 100%

specificity, 100% positive predictive value, and 75% negative predictive value. [6] In select
cases when the diagnoses or ROM is not clear, placental alpha-microglobulin-1 should be
used to provide additional information for appropriate management.

Given the importance of making the correct diagnoses, the associated morbidity with
hospitalization and delivery prior to term in PROM reaching 34 weeks and beyond, and the
potential neonatal morbidity resulting from prematurity in cases of incorrect diagnoses of
PROM, it is mandatory to confirm the diagnosis of PROM with pooling of amniotic fluid
with some evidence of decreased or absence of amniotic fluid in all cases of suspected
PROM.

Most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at
term. The major question regarding management of these patients is whether to allow them to
enter labor spontaneously or to induce labor. In large part, the management of these patients
depends on their desires; however, the major maternal risk at this gestational age is
intrauterine infection. The risk of intrauterine infection increases with the duration of ROM.
Evidence supports the idea that induction of labor, as opposed to expectant management,
decreases the risk of chorioamnionitis without increasing the cesarean delivery rate. [7, 8, 9]

Hannah et al studied 5041 women with PROM who were randomly assigned to induction of
labor with intravenous oxytocin or vaginal prostaglandin E2 gel versus expectant
management for as many as 4 days with induction of labor for complications. [10] They
concluded that, in women with PROM, induction of labor and expectant management
resulted in similar rates of cesarean delivery and neonatal infection. However, induction with
oxytocin resulted in a lower risk of maternal infection (endometritis) when compared with
expectant management. Additionally, the women in the study viewed induction of labor more
favorably than expectant management.

Other smaller studies have shown results with higher cesarean and/or operative delivery rates
when the cervix was unfavorable.

At term, infection remains the most serious complication associated with PROM for the
mother and the neonate. The risk of chorioamnionitis with term PROM has been reported to
be less than 10% and to increase to 40% after 24 hours of PROM. [11] This points out the
importance of appropriate management strategies for PROM at term.

Since risk of infection at term with ROM is small during the first 24 hours, expectant
management and waiting for spontaneous labor may be considered in selected patients for the
first 12-24 hours if a patient desires expectant management. The use of expectant
management after the first 24 hours is questionable.

Digital vaginal examinations should be avoided until labor is initiated; however, fetal
presentation should be documented to avoid discovering malpresentation of the fetus long
after admission for ROM. All patients with ROM should be asked to come to the hospital to
ensure fetal well being.
The neonatal risks of expectant management of PROM include infection, placental abruption,
fetal distress, fetal restriction deformities and pulmonary hypoplasia, and fetal/neonatal death.
Fetal death does occur in approximately 1% of patients with PROM after viability who have
been expectantly managed [1] and in about 1:1000 term PROM. [12]

The primary determinant of neonatal morbidity and mortality is gestational age at delivery,
again stressing the importance of conservative management when possible. (See the
Gestational Age from Estimated Date of Delivery calculator.)

In general, prognosis is good after 32 weeks' gestation as long as no other complicating

factor, such as congenital malformation or pulmonary hypoplasia, exists.

Premature Rupture of Membranes (at Term)

Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset
of labor at or beyond 37 weeks' gestation. PROM occurs in approximately 10% of
pregnancies. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal
bleeding, and pelvic pressure, but they are not having contractions.

ROM is diagnosed by speculum vaginal examination of the cervix and vaginal cavity.
Pooling of fluid in the vagina or leakage of fluid from the cervix, ferning of the dried fluid
under microscopic examination, and alkalinity of the fluid as determined by Nitrazine paper
confirm the diagnosis.

Blood contamination of the Nitrazine paper and ferning of cervical mucus may produce false-
positive results. Pooling of fluid is by far the most accurate for diagnosis of ROM. If all fluid
has leaked out as in early PROM, an ultrasonographic examination may then show absence of
or very low amounts of amniotic fluid in the uterine cavity.

New evidence suggests that the use of biochemical markers to diagnose ROM in uncertain
cases may be appropriate and cost effective. Echebiri et al reported cost effectiveness
compared to standard methods of diagnoses between 34 and 37 weeks. [5]

Ng et al reported placental alpha-microglobulin-1 levels have a 95.7% sensitivity, 100%

specificity, 100% positive predictive value, and 75% negative predictive value. [6] In select
cases when the diagnoses or ROM is not clear, placental alpha-microglobulin-1 should be
used to provide additional information for appropriate management.

Given the importance of making the correct diagnoses, the associated morbidity with
hospitalization and delivery prior to term in PROM reaching 34 weeks and beyond, and the
potential neonatal morbidity resulting from prematurity in cases of incorrect diagnoses of
PROM, it is mandatory to confirm the diagnosis of PROM with pooling of amniotic fluid
with some evidence of decreased or absence of amniotic fluid in all cases of suspected
PROM.

Most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at
term. The major question regarding management of these patients is whether to allow them to
enter labor spontaneously or to induce labor. In large part, the management of these patients
depends on their desires; however, the major maternal risk at this gestational age is
intrauterine infection. The risk of intrauterine infection increases with the duration of ROM.
Evidence supports the idea that induction of labor, as opposed to expectant management,
decreases the risk of chorioamnionitis without increasing the cesarean delivery rate. [7, 8, 9]

Hannah et al studied 5041 women with PROM who were randomly assigned to induction of
labor with intravenous oxytocin or vaginal prostaglandin E2 gel versus expectant
management for as many as 4 days with induction of labor for complications. [10] They
concluded that, in women with PROM, induction of labor and expectant management
resulted in similar rates of cesarean delivery and neonatal infection. However, induction with
oxytocin resulted in a lower risk of maternal infection (endometritis) when compared with
expectant management. Additionally, the women in the study viewed induction of labor more
favorably than expectant management.

Other smaller studies have shown results with higher cesarean and/or operative delivery rates
when the cervix was unfavorable.

At term, infection remains the most serious complication associated with PROM for the
mother and the neonate. The risk of chorioamnionitis with term PROM has been reported to
be less than 10% and to increase to 40% after 24 hours of PROM. [11] This points out the
importance of appropriate management strategies for PROM at term.

Since risk of infection at term with ROM is small during the first 24 hours, expectant
management and waiting for spontaneous labor may be considered in selected patients for the
first 12-24 hours if a patient desires expectant management. The use of expectant
management after the first 24 hours is questionable.

Digital vaginal examinations should be avoided until labor is initiated; however, fetal
presentation should be documented to avoid discovering malpresentation of the fetus long
after admission for ROM. All patients with ROM should be asked to come to the hospital to
ensure fetal well being.

The neonatal risks of expectant management of PROM include infection, placental abruption,
fetal distress, fetal restriction deformities and pulmonary hypoplasia, and fetal/neonatal death.
Fetal death does occur in approximately 1% of patients with PROM after viability who have
been expectantly managed [1] and in about 1:1000 term PROM. [12]

The primary determinant of neonatal morbidity and mortality is gestational age at delivery,
again stressing the importance of conservative management when possible. (See the
Gestational Age from Estimated Date of Delivery calculator.)

In general, prognosis is good after 32 weeks' gestation as long as no other complicating

factor, such as congenital malformation or pulmonary hypoplasia, exists.

Premature Rupture of Membranes (at Term)

Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset
of labor at or beyond 37 weeks' gestation. PROM occurs in approximately 10% of
pregnancies. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal
bleeding, and pelvic pressure, but they are not having contractions.
ROM is diagnosed by speculum vaginal examination of the cervix and vaginal cavity.
Pooling of fluid in the vagina or leakage of fluid from the cervix, ferning of the dried fluid
under microscopic examination, and alkalinity of the fluid as determined by Nitrazine paper
confirm the diagnosis.

Blood contamination of the Nitrazine paper and ferning of cervical mucus may produce false-
positive results. Pooling of fluid is by far the most accurate for diagnosis of ROM. If all fluid
has leaked out as in early PROM, an ultrasonographic examination may then show absence of
or very low amounts of amniotic fluid in the uterine cavity.

New evidence suggests that the use of biochemical markers to diagnose ROM in uncertain
cases may be appropriate and cost effective. Echebiri et al reported cost effectiveness
compared to standard methods of diagnoses between 34 and 37 weeks. [5]

Ng et al reported placental alpha-microglobulin-1 levels have a 95.7% sensitivity, 100%

specificity, 100% positive predictive value, and 75% negative predictive value. [6] In select
cases when the diagnoses or ROM is not clear, placental alpha-microglobulin-1 should be
used to provide additional information for appropriate management.

Given the importance of making the correct diagnoses, the associated morbidity with
hospitalization and delivery prior to term in PROM reaching 34 weeks and beyond, and the
potential neonatal morbidity resulting from prematurity in cases of incorrect diagnoses of
PROM, it is mandatory to confirm the diagnosis of PROM with pooling of amniotic fluid
with some evidence of decreased or absence of amniotic fluid in all cases of suspected
PROM.

Most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at
term. The major question regarding management of these patients is whether to allow them to
enter labor spontaneously or to induce labor. In large part, the management of these patients
depends on their desires; however, the major maternal risk at this gestational age is
intrauterine infection. The risk of intrauterine infection increases with the duration of ROM.
Evidence supports the idea that induction of labor, as opposed to expectant management,
decreases the risk of chorioamnionitis without increasing the cesarean delivery rate. [7, 8, 9]

Hannah et al studied 5041 women with PROM who were randomly assigned to induction of
labor with intravenous oxytocin or vaginal prostaglandin E2 gel versus expectant
management for as many as 4 days with induction of labor for complications. [10] They
concluded that, in women with PROM, induction of labor and expectant management
resulted in similar rates of cesarean delivery and neonatal infection. However, induction with
oxytocin resulted in a lower risk of maternal infection (endometritis) when compared with
expectant management. Additionally, the women in the study viewed induction of labor more
favorably than expectant management.

Other smaller studies have shown results with higher cesarean and/or operative delivery rates
when the cervix was unfavorable.

At term, infection remains the most serious complication associated with PROM for the
mother and the neonate. The risk of chorioamnionitis with term PROM has been reported to
be less than 10% and to increase to 40% after 24 hours of PROM. [11] This points out the
importance of appropriate management strategies for PROM at term.
Since risk of infection at term with ROM is small during the first 24 hours, expectant
management and waiting for spontaneous labor may be considered in selected patients for the
first 12-24 hours if a patient desires expectant management. The use of expectant
management after the first 24 hours is questionable.

Digital vaginal examinations should be avoided until labor is initiated; however, fetal
presentation should be documented to avoid discovering malpresentation of the fetus long
after admission for ROM. All patients with ROM should be asked to come to the hospital to
ensure fetal well being.

The neonatal risks of expectant management of PROM include infection, placental abruption,
fetal distress, fetal restriction deformities and pulmonary hypoplasia, and fetal/neonatal death.
Fetal death does occur in approximately 1% of patients with PROM after viability who have
been expectantly managed [1] and in about 1:1000 term PROM. [12]

The primary determinant of neonatal morbidity and mortality is gestational age at delivery,
again stressing the importance of conservative management when possible. (See the
Gestational Age from Estimated Date of Delivery calculator.)

In general, prognosis is good after 32 weeks' gestation as long as no other complicating

factor, such as congenital malformation or pulmonary hypoplasia, exists.

Premature Rupture of Membranes (at Term)

Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset
of labor at or beyond 37 weeks' gestation. PROM occurs in approximately 10% of
pregnancies. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal
bleeding, and pelvic pressure, but they are not having contractions.

ROM is diagnosed by speculum vaginal examination of the cervix and vaginal cavity.
Pooling of fluid in the vagina or leakage of fluid from the cervix, ferning of the dried fluid
under microscopic examination, and alkalinity of the fluid as determined by Nitrazine paper
confirm the diagnosis.

Blood contamination of the Nitrazine paper and ferning of cervical mucus may produce false-
positive results. Pooling of fluid is by far the most accurate for diagnosis of ROM. If all fluid
has leaked out as in early PROM, an ultrasonographic examination may then show absence of
or very low amounts of amniotic fluid in the uterine cavity.

New evidence suggests that the use of biochemical markers to diagnose ROM in uncertain
cases may be appropriate and cost effective. Echebiri et al reported cost effectiveness
compared to standard methods of diagnoses between 34 and 37 weeks. [5]

Ng et al reported placental alpha-microglobulin-1 levels have a 95.7% sensitivity, 100%

specificity, 100% positive predictive value, and 75% negative predictive value. [6] In select
cases when the diagnoses or ROM is not clear, placental alpha-microglobulin-1 should be
used to provide additional information for appropriate management.
Given the importance of making the correct diagnoses, the associated morbidity with
hospitalization and delivery prior to term in PROM reaching 34 weeks and beyond, and the
potential neonatal morbidity resulting from prematurity in cases of incorrect diagnoses of
PROM, it is mandatory to confirm the diagnosis of PROM with pooling of amniotic fluid
with some evidence of decreased or absence of amniotic fluid in all cases of suspected
PROM.

Most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at
term. The major question regarding management of these patients is whether to allow them to
enter labor spontaneously or to induce labor. In large part, the management of these patients
depends on their desires; however, the major maternal risk at this gestational age is
intrauterine infection. The risk of intrauterine infection increases with the duration of ROM.
Evidence supports the idea that induction of labor, as opposed to expectant management,
decreases the risk of chorioamnionitis without increasing the cesarean delivery rate. [7, 8, 9]

Hannah et al studied 5041 women with PROM who were randomly assigned to induction of
labor with intravenous oxytocin or vaginal prostaglandin E2 gel versus expectant
management for as many as 4 days with induction of labor for complications. [10] They
concluded that, in women with PROM, induction of labor and expectant management
resulted in similar rates of cesarean delivery and neonatal infection. However, induction with
oxytocin resulted in a lower risk of maternal infection (endometritis) when compared with
expectant management. Additionally, the women in the study viewed induction of labor more
favorably than expectant management.

Other smaller studies have shown results with higher cesarean and/or operative delivery rates
when the cervix was unfavorable.

At term, infection remains the most serious complication associated with PROM for the
mother and the neonate. The risk of chorioamnionitis with term PROM has been reported to
be less than 10% and to increase to 40% after 24 hours of PROM. [11] This points out the
importance of appropriate management strategies for PROM at term.

Since risk of infection at term with ROM is small during the first 24 hours, expectant
management and waiting for spontaneous labor may be considered in selected patients for the
first 12-24 hours if a patient desires expectant management. The use of expectant
management after the first 24 hours is questionable.

Digital vaginal examinations should be avoided until labor is initiated; however, fetal
presentation should be documented to avoid discovering malpresentation of the fetus long
after admission for ROM. All patients with ROM should be asked to come to the hospital to
ensure fetal well being.

The neonatal risks of expectant management of PROM include infection, placental abruption,
fetal distress, fetal restriction deformities and pulmonary hypoplasia, and fetal/neonatal death.
Fetal death does occur in approximately 1% of patients with PROM after viability who have
been expectantly managed [1] and in about 1:1000 term PROM. [12]

The primary determinant of neonatal morbidity and mortality is gestational age at delivery,
again stressing the importance of conservative management when possible. (See the
Gestational Age from Estimated Date of Delivery calculator.)
In general, prognosis is good after 32 weeks' gestation as long as no other complicating
factor, such as congenital malformation or pulmonary hypoplasia, exists.

Premature Rupture of Membranes (at Term)

Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset
of labor at or beyond 37 weeks' gestation. PROM occurs in approximately 10% of
pregnancies. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal
bleeding, and pelvic pressure, but they are not having contractions.

ROM is diagnosed by speculum vaginal examination of the cervix and vaginal cavity.
Pooling of fluid in the vagina or leakage of fluid from the cervix, ferning of the dried fluid
under microscopic examination, and alkalinity of the fluid as determined by Nitrazine paper
confirm the diagnosis.

Blood contamination of the Nitrazine paper and ferning of cervical mucus may produce false-
positive results. Pooling of fluid is by far the most accurate for diagnosis of ROM. If all fluid
has leaked out as in early PROM, an ultrasonographic examination may then show absence of
or very low amounts of amniotic fluid in the uterine cavity.

New evidence suggests that the use of biochemical markers to diagnose ROM in uncertain
cases may be appropriate and cost effective. Echebiri et al reported cost effectiveness
compared to standard methods of diagnoses between 34 and 37 weeks. [5]

Ng et al reported placental alpha-microglobulin-1 levels have a 95.7% sensitivity, 100%

specificity, 100% positive predictive value, and 75% negative predictive value. [6] In select
cases when the diagnoses or ROM is not clear, placental alpha-microglobulin-1 should be
used to provide additional information for appropriate management.

Given the importance of making the correct diagnoses, the associated morbidity with
hospitalization and delivery prior to term in PROM reaching 34 weeks and beyond, and the
potential neonatal morbidity resulting from prematurity in cases of incorrect diagnoses of
PROM, it is mandatory to confirm the diagnosis of PROM with pooling of amniotic fluid
with some evidence of decreased or absence of amniotic fluid in all cases of suspected
PROM.

Most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at
term. The major question regarding management of these patients is whether to allow them to
enter labor spontaneously or to induce labor. In large part, the management of these patients
depends on their desires; however, the major maternal risk at this gestational age is
intrauterine infection. The risk of intrauterine infection increases with the duration of ROM.
Evidence supports the idea that induction of labor, as opposed to expectant management,
decreases the risk of chorioamnionitis without increasing the cesarean delivery rate. [7, 8, 9]

Hannah et al studied 5041 women with PROM who were randomly assigned to induction of
labor with intravenous oxytocin or vaginal prostaglandin E2 gel versus expectant
management for as many as 4 days with induction of labor for complications. [10] They
concluded that, in women with PROM, induction of labor and expectant management
resulted in similar rates of cesarean delivery and neonatal infection. However, induction with
oxytocin resulted in a lower risk of maternal infection (endometritis) when compared with
expectant management. Additionally, the women in the study viewed induction of labor more
favorably than expectant management.

Other smaller studies have shown results with higher cesarean and/or operative delivery rates
when the cervix was unfavorable.

At term, infection remains the most serious complication associated with PROM for the
mother and the neonate. The risk of chorioamnionitis with term PROM has been reported to
be less than 10% and to increase to 40% after 24 hours of PROM. [11] This points out the
importance of appropriate management strategies for PROM at term.

Since risk of infection at term with ROM is small during the first 24 hours, expectant
management and waiting for spontaneous labor may be considered in selected patients for the
first 12-24 hours if a patient desires expectant management. The use of expectant
management after the first 24 hours is questionable.

Digital vaginal examinations should be avoided until labor is initiated; however, fetal
presentation should be documented to avoid discovering malpresentation of the fetus long
after admission for ROM. All patients with ROM should be asked to come to the hospital to
ensure fetal well being.

The neonatal risks of expectant management of PROM include infection, placental abruption,
fetal distress, fetal restriction deformities and pulmonary hypoplasia, and fetal/neonatal death.
Fetal death does occur in approximately 1% of patients with PROM after viability who have
been expectantly managed [1] and in about 1:1000 term PROM. [12]

The primary determinant of neonatal morbidity and mortality is gestational age at delivery,
again stressing the importance of conservative management when possible. (See the
Gestational Age from Estimated Date of Delivery calculator.)

In general, prognosis is good after 32 weeks' gestation as long as no other complicating

factor, such as congenital malformation or pulmonary hypoplasia, exists.

Premature Rupture of Membranes (at Term)

Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset
of labor at or beyond 37 weeks' gestation. PROM occurs in approximately 10% of
pregnancies. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal
bleeding, and pelvic pressure, but they are not having contractions.

ROM is diagnosed by speculum vaginal examination of the cervix and vaginal cavity.
Pooling of fluid in the vagina or leakage of fluid from the cervix, ferning of the dried fluid
under microscopic examination, and alkalinity of the fluid as determined by Nitrazine paper
confirm the diagnosis.

Blood contamination of the Nitrazine paper and ferning of cervical mucus may produce false-
positive results. Pooling of fluid is by far the most accurate for diagnosis of ROM. If all fluid
has leaked out as in early PROM, an ultrasonographic examination may then show absence of
or very low amounts of amniotic fluid in the uterine cavity.

New evidence suggests that the use of biochemical markers to diagnose ROM in uncertain
cases may be appropriate and cost effective. Echebiri et al reported cost effectiveness
compared to standard methods of diagnoses between 34 and 37 weeks. [5]

Ng et al reported placental alpha-microglobulin-1 levels have a 95.7% sensitivity, 100%

specificity, 100% positive predictive value, and 75% negative predictive value. [6] In select
cases when the diagnoses or ROM is not clear, placental alpha-microglobulin-1 should be
used to provide additional information for appropriate management.

Given the importance of making the correct diagnoses, the associated morbidity with
hospitalization and delivery prior to term in PROM reaching 34 weeks and beyond, and the
potential neonatal morbidity resulting from prematurity in cases of incorrect diagnoses of
PROM, it is mandatory to confirm the diagnosis of PROM with pooling of amniotic fluid
with some evidence of decreased or absence of amniotic fluid in all cases of suspected
PROM.

Most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at
term. The major question regarding management of these patients is whether to allow them to
enter labor spontaneously or to induce labor. In large part, the management of these patients
depends on their desires; however, the major maternal risk at this gestational age is
intrauterine infection. The risk of intrauterine infection increases with the duration of ROM.
Evidence supports the idea that induction of labor, as opposed to expectant management,
decreases the risk of chorioamnionitis without increasing the cesarean delivery rate. [7, 8, 9]

Hannah et al studied 5041 women with PROM who were randomly assigned to induction of
labor with intravenous oxytocin or vaginal prostaglandin E2 gel versus expectant
management for as many as 4 days with induction of labor for complications. [10] They
concluded that, in women with PROM, induction of labor and expectant management
resulted in similar rates of cesarean delivery and neonatal infection. However, induction with
oxytocin resulted in a lower risk of maternal infection (endometritis) when compared with
expectant management. Additionally, the women in the study viewed induction of labor more
favorably than expectant management.

Other smaller studies have shown results with higher cesarean and/or operative delivery rates
when the cervix was unfavorable.

At term, infection remains the most serious complication associated with PROM for the
mother and the neonate. The risk of chorioamnionitis with term PROM has been reported to
be less than 10% and to increase to 40% after 24 hours of PROM. [11] This points out the
importance of appropriate management strategies for PROM at term.

Since risk of infection at term with ROM is small during the first 24 hours, expectant
management and waiting for spontaneous labor may be considered in selected patients for the
first 12-24 hours if a patient desires expectant management. The use of expectant
management after the first 24 hours is questionable.
Digital vaginal examinations should be avoided until labor is initiated; however, fetal
presentation should be documented to avoid discovering malpresentation of the fetus long
after admission for ROM. All patients with ROM should be asked to come to the hospital to
ensure fetal well being.

The neonatal risks of expectant management of PROM include infection, placental abruption,
fetal distress, fetal restriction deformities and pulmonary hypoplasia, and fetal/neonatal death.
Fetal death does occur in approximately 1% of patients with PROM after viability who have
been expectantly managed [1] and in about 1:1000 term PROM. [12]

The primary determinant of neonatal morbidity and mortality is gestational age at delivery,
again stressing the importance of conservative management when possible. (See the
Gestational Age from Estimated Date of Delivery calculator.)

In general, prognosis is good after 32 weeks' gestation as long as no other complicating

factor, such as congenital malformation or pulmonary hypoplasia, exists.