Premature Rupture

of Membranes
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
 Objectives for PROM
List the history, physical findings, and
diagnostic methods to confirm the rupture of
the membranes
Identify the risk factors for premature rupture
of membranes
Describe the risks and benefits of expectant
management versus immediate delivery,
based on gestational age
Describe the methods to monitor maternal
and fetal status during expectant
management
 Definition

Premature rupture of membranes (PROM)

Rupture of the chorioamnionic membrane
(amniorrhexis) prior to the onset of labor at any
stage of gestation

Preterm premature rupture of membranes

(PPROM)
PROM prior to 37-wk. gestation
 Incidence

PROM 12% of all pregnancies

PROM 8% term pregnancies
PPROM 30% of preterm deliveries
 PROM/PPROM: History & Physical
Exam
History
Gush of fluid
Steady leakage of small amounts of fluid

Physical
Sterile vaginal speculum exam
Minimize digital examination of cervix, regardless of
gestational age, to avoid risk of ascending
infection/amnionitis
Assess cervical dilation and length
Obtain cervical cultures (Gonorrhea, Chlamydia)
Obtain amniotic fluid samples
Findings
Pooling of amniotic fluid in posterior vaginal fornix
Fluid per cervical os
 PROM/PPROM: Diagnosis

Test
Nitrazine test
Fluid from vaginal exam
placed on strip of nitrazine
paper
Paper turns blue in
presence of alkaline (pH >
7.1) amniotic fluid

Fern test
Fluid from vaginal exam
placed on slide and allowed
to dry
Amniotic fluid narrow fern
vs. cervical mucus broad
fern
 PROM/PPROM: Diagnosis

False positive Nitrazine test

Alkaline urine
Semen (recent coitus)
Cervical mucus
Blood contamination
Vaginitis (e.g. Trichomonas)

False-Negative Nitrazine test

Remote PROM with no residual fluid
Minimal amniotic leakage
 PROM/PPROM: Diagnosis

Test
Ultrasound
Assess amniotic fluid level and compatibility with PROM
Indigo-carmine Amnioinfusion
Ultrasound guided indigo carmine dye amnioinfusion
(Blue tap)
Observe for passage of blue fluid from vagina
 PROM/PPROM: Risk Factors

Risk Factors:
Prior PROM or PPROM
Prior preterm delivery
Multiple gestation
Polyhydramnios
Incompetent cervix
Vaginal/Cervical Infection
Gonorrhea, Chlamydia, GBS, S. Aureus
Antepartum bleeding (threatened abortion)
Smoking
Poor nutrition
 Management: PPROM
(< 24 wk gestation previable)

Patient counseling
Expectant management vs. induction of labor
GBS prophylaxis NOT recommended
Antibiotics
Incomplete data
Corticosteriods NOT recommended
 Management: PPROM
(< 24 wk gestation previable)

Patient counseling
Gestational
Outcomes at 18 to 22 Months Corrected Age*
Age
Death Before Death/ Profound Death/Moderate to Severe
(In
NICU Discharge Death Neurodevelopmental Neuro-
Completed
Impairment developmental Impairment
Weeks)

22 Weeks 95% 95% 98% 99%

23 Weeks 74% 74% 84% 91%
24 Weeks 44% 44% 57% 72%
25 Weeks 24%
Fetal complications 25%
of prolonged 38%
PPROM 54%
Pulmonary hypoplasia
Skeletal malformations
Fetal growth restriction
IUFD
Maternal complications of prolonged PPROM
Chorioamnionitis
http://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/dataShow.cfm
 Management: PPROM
(24 31 wk gestation)

Expectant management
Deliver at 34 wks
Unless documented fetal lung maturity
GBS prophylaxis
Antibiotics
Single course corticosteroids
Tocolytics
No consensus
 Management: PPROM
(32 33 wk gestation)

Expectant management
Deliver at 34 wks
Unless documented fetal lung maturity
GBS prophylaxis
Antibiotics
Corticosteroids
No consensus, some experts recommend
 Management: PROM
(> 34 wk gestation)

Proceed to delivery
Induction of labor
GBS prophylaxis
 Management: Rationale

Antibiotics
Prolong latency period
Prophylaxis of GBS in neonate
Prevention of maternal chorioamnionitis and neonatal
sepsis
Corticosteroids
Enhance fetal lung maturity
Decrease risk of RDS, IVH, and necrotizing enterocolitis

Tocolytics
Delay delivery to allow administration of corticosteroids
Controversial, randomized trials have shown no
pregnancy prolongation
 Management: Drug Regimen

Antibiotics
Ampicillin 2 g IV Q6 x 48 hrs
Amoxicillin 500 mg po TID x 5 days
Azithromycin 1 g po x 1

Corticosteroids
Betamethasone 12 mg IM q24 x 2
Dexamethasone 6 mg IM q12 x 4

Tocolytics
Nifedipine 10 mg po q20min x 3, then q6 x 48 hrs
 Management: Amniocentesis

Typically performed after 32 wks

Tests for fetal lung maturity (FLM)
Lecethin/Sphingomyelin ratio (not
commonly used, more for historic
interest)
L/S ratio > 2 indicates pulmonary maturity
Phosphatidylglycerol
> 0.5 associated with minimal respiratory
distress
Flouresecence polarization (FLM-TDx II)
> 55 mg/g of albumin
Lamellar body count
30,000-40,000

If negative, proceed with expectant

management until 34 wks

Courtesy of Thomas Shipp, MD.

 Management: Surveillance

Maternal: Monitor for signs of infection

Temperature
Maternal heart rate
Fetal heart rate
Uterine tenderness
Contractions

Fetal: Monitor for fetal well-being

Kick counts
Nonstress tests (NSTs)
Biophysical profile (BPP)
 Management: Surveillance

Immediate Delivery
Intrauterine infection
Abruptio placenta
Repetitive fetal heart rate decelerations
Cord prolapse
 Expectant Management
vs. Preterm Delivery
Expectant Management Risks:
Maternal
Increase in chorioamnionitis
Increase in Cesarean delivery
Spontaneous labor in ~ 90% within 48 hr ROM
Increased risk of placental abruption
Fetal
Increase in RDS
Increase in intraventricular hemorrhage
Increase in neonatal sepsis and subsequent cerebral palsy
Increase in perinatal mortality
Increase in cord prolapse
 Expectant Management
vs. Preterm Delivery
Preterm Delivery Risks: use NICHD calculator
http://
www.nichd.nih.gov/about/org/cdbpm/pp/prog_
epbo/epbo_case.cfm

Gestation Weight Sex Steroids Survival Survival

(w) w/o
profound
ND
impairme
nt
25 550 Female Yes 64% 50%
24 500 Male Yes 35% 22%
23 450 Male Yes 16% 9%
22 401g Female No 2% 1%
 Bottom Line Concepts
Preterm premature rupture of membranes refers to rupture of fetal
membranes prior to labor in pregnancies < 37 weeks.
A history of PPROM or PROM, genital tract infection, antepartum
bleeding, and smoking are risk factors for PPROM and PROM.
A clinical history suggestive of PPROM or PROM should be
confirmed with visual inspection and laboratory tests including
ferning and nitrazine paper.
Management of PPROM at < 24 wks includes a discussion with the
family reviewing the maternal risks against the fetal risks of
significant morbidity and mortality during expectant management.
For women with PPROM or PROM in whom intrauterine infection,
abruptio placenta, repetitive fetal heart rate decelerations, or a
high risk of cord prolapse is present, immediate delivery is
recommended.
Counseling after the delivery for the recurrence risk of PROM
should occur, and modifiable risk factors addressed
 References and
Resources
APGO Medical Student Educational Objectives, 9th edition,
(2009), Educational Topic 25 (p52-53).

Beckman & Ling: Obstetrics and Gynecology, 6th edition,

(2010), Charles RB Beckmann, Frank W Ling, Barabara M
Barzansky, William NPHerbert, Douglas WLaube, Roger
PSmith. Chapter 22 (p213-217).

Hacker & Moore: Hacker and Moore's Essentials of

Obstetrics and Gynecology, 5th edition (2009), Neville F
Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 12
(p150-153).