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Preterm Rupture of

Membranes

Melissa Zahnd, RNC, MSN


Definition

Premature ROM: Amniorrhexis


(SROM) Prior to the onset of labor at
any gestation (PROM)
Preterm ROM: PROM prior to 37
weeks gestation
Use PPROM/PROM
Definitions

Latency Period: time interval between


ROM and onset of labor
Expectant management:
management of patients with the goal
of prolonging gestation (watchful
waiting until delivery indication arises)
Documentation

E.F. a 22 y.o. MWF, G1P0 with


PPROM at 32 3/7 weeks gestation

M.R. a 32 y.o. female, G3P2 with


PROM at 38 3/7 weeks gestation
Incidence-Preterm ROM

Complicates up to
3.5% of all
pregnancies
30-40% of Preterm
births
PPROM ~25%
cases of all PROM

Garite (2007), Santaloya-Forgas et al., (2007), Svigos, Robinson, et Vigneswaran,


2007)
Risk Factors
Chorioamnionitis Previous preterm
Vaginal infections delivery (PPROM)
Cervical AA ethnicity
abnormalities Acquired or
Vascular pathology congenital
(incl. abruptio) connective tissue
Smoking disorder
1st, 2nd, 3rd, or Nutritional
multiple trimester deficiencies (Vit.C,
bleeding copper, zinc)
The Patient

Vaginal discharge
Gush of fluid
Leaking of fluid
Oligo/Anhydramnios
Cramping
Contractions
Back pain
Diagnosis

Sterile Speculum exam (Pooling)


SSE-Free flow of fluid from cervical os
Nitrizine testing
Microscopic Fern testing
Fetal Fibronectin
AmniSure
Ultrasonography
Transabdominal Indigo dye injection
Why not do a digital vaginal
exam?

Latency period
Infection
Sterile Speculum Exam
Sterile
No lubricating jelly
Pooling of fluid in
Assess for

posterior fornix
Free flow of fluid
from cervix
Cervical dilation
Nitrazine
Collect slide for Consider need to collect other
fern (dry 10 mins) cervical tests/cultures such fetal
fibronectin while doing the SSE.
Nitrazine paper testing
Vaginal pH (3.5-
4.5)
Turns blue in
presence of
alkaline Amniotic
fluid
93.3% sensitivity
False positive (1-
17%) for urine,
blood, semen, BV,
Trichomonas
Fern slide

Must allow slide to dry


thoroughly prior to
examination under
microscope. Assess for
arborization of fluid.
Cervical mucous has
broad, ferning pattern
that is different than the
fern of amniotic fluid.
Fetal Fibronectin
fFn present in cervical
secretions <22 wks,
>34 wks
Used for assessment
of potential PTB
Positive result (>50
ng/dl) may be
indicative of PROM
and represents
disruption of decidua-
chorionic interface
In PPROM, Sensitivity-98.2%, Specificity-26.8%.
AmniSure

Newer test
Point of Care test
Cost-up to $50 each
Sensitivity-98.7-98.9%
Specificity-87.5-100%
Awaiting further testing prior to
recommendations
AmniSure
Remove swab
and rotate in
solvent x 1 min.

Read
results
after 5-
10 mins
have
passed.

Place Swab 2-3


in. into vaginal
canal x 1 min. Discard swab and
place test stick into
solvent.
Ultrasonography
50-70% of women with
PPROM have low AFV
on US
Mild reduction requires
further investigation
Rule out other causes
(Renal agenesis,
utero-placental
insufficiency,
obstructive uropathy)
Measure for pockets of
fluid and quantitate
AFV into AFI
Ultrasound showing 7 cm pocket of fluid
Transabdominal Injection of
Dye
Amniocentesis
Collect Fluid
samples
Inject dye (Indigo
Carmine)
Tampon placed in
vagina and
checked for blue
staining 30-60 mins
after procedure
How would I manage this
patient?

Gestational age Active distress


Availability of NICU (maternal/fetal)
Fetal presentation Is she in labor?
FHR pattern Cervical
assessment
Initial Assessment

Assess for Maternal-Fetal distress


Assess for Proper dating/GA
Assess for infection
Exclude occult cord prolapse
Secondary Assessment

Fetal position
Cervical
assessment
Determine lung
maturity, if
indicated
Quantify AFV*
Delivery Indication

Maternal-Fetal
Distress
Infection
Abruption
Cord Prolapse
Expectant Management

Typical for GA 32 weeks or less


Steroids
Tocolysis if indicated for lung maturity
Antibiotics
Fetal Surveillance
Majority Inpatient Observation
Assess for Chorioamnionitis
Goal: Mature Lung Profile, reduction of PTB risks!
Risk-Benefit Expectant
Management
Risks Benefits
Abruption Mature lung profile
Chorioamnionitis Advancing GA
Cord Prolapse (reducing risks
Pulmonary associated with
Hypoplasia (<19 PTB)
weeks PPROM
Skeletal
Deformities
Endometritis (1/3)
Risks-Benefits Profile of
Pre-term Birth
Risks Benefits
Assoc. w/ PTB Elimination of risks
NEC of expectant
IVH/CP management
RDS
Cesarean Delivery
Endometritis (1/3)
Outcomes

1/3 develop Neonatal outcomes


intraamniotic dependent on GA
infections, and indication for
endometritis, or delivery
septicemia
References
Duff, Patrick, MD. Preterm premature rupture of membranes.
UpToDate. Ed. Charles J Lockwood, MD and Vanessa A
Barss, MD. 1-16. 27 June 2008 <http://utdol.com>.
Garite, Thomas J, MD. Premature Rupture of the
Membranes. Clinics in Perinatalogy. N.p.: n.p., n.d. 723-736.
Hacker, and Moore. Essentials of Obstetrics and Gynecology.
4th ed. N.p.: n.p., 2004.
Santolaya-Forgas, Joaquin, et al. Prelabor rupture of the
membranes. Clinical Obstetrics-Handbook: The Fetus and
Mother. By E Albert Reece and John Hobbins. N.p.: n.p.,
2007. 1130-1173.
Svigos, John Micheal, Jeffrey S Robinson, and Rasniah
Vigneswaran. Prelabor Rupture of Membranes. High-Risk
Pregnancy. N.p.: n.p., n.d. 1321-1330.