RELABOR RUPTURE OF THE MEMBRANES (PROM)

(Syn: Premature Rupture of Membranes)

DEFINITION: Spontaneous rupture of the membranes any time beyond 28th week of pregnancy but before the onset of
labor is called prelabor rupture of the membranes (PROM). When rupture of membranes occur beyond 37th week but
before the onset of labor it is called term PROM and when it occurs before 37 completed weeks, it is called preterm PROM.
Rupture of membranes for > 24 hours before delivery is called prolonged rupture of membranes.
INCIDENCE: PROM occurs in approximately 10% of all pregnancies.
CAUSES: In majority, the causes are not known. The possible causes are: (1) Increased friability of the membranes; (2) Decreased
tensile strength of the membranes; (3) Polyhydramnios; (4) Cervical incompetence; (5) Multiple pregnancy; (6) Infection—Chorioamnionitis,
urinary tract infection and lower genital tract infection (see p. 314); (7) Cervical length < 2.5 cm; (8) Prior preterm
labor; (9) Low BMI (< 19 kg/m2).
DIAGNOSIS: The only subjective symptom is escape of watery discharge per vaginam either in the form of a gush or slow
leak. This is often confused with : (a) Hydrorrhea gravidarum—a state where periodic watery discharge occurs probably due
to excessive decidual glandular secretion; (b) Incontinence of urine specially in the later months.
Confirmation of diagnosis: (1) Speculum examination is done taking aseptic precautions to inspect the liquor escaping out
through the cervix; (2) To examine the collected fluid from the posterior fornix (vaginal pool) for: (a) Detection of pH by
litmus or Nitrazine paper. The pH becomes 6–6.2 (Normal vaginal pH during pregnancy is 4.5–5.5 whereas that of liquor
amnii is 7–7.5). Nitrazine paper turns from yellow to blue at pH > 6; (b) To note the characteristic ferning pattern when a
smeared slide is examined under microscope; (c) Centrifuged cells stained with 0.1% Nile blue sulfate showing orange blue
coloration of the cells (exfoliated fat containing cells from sebaceous glands of the fetus); (3) Ultrasonography is to be done
not only to support the diagnosis but also to assess the fetal well being.
INVESTIGATIONS: (1) Full blood count; (2) Urine for routine analysis and culture; (3) High vaginal swab for culture; (4)
Vaginal pool for estimation of phosphatidyl glycerol and L: S ratio; (5) Ultrasonography for fetal biophysical profile (6)
Cardiotocography for nonstress test (p. 108).
DANGERS: The implications are less serious when the rupture occurs near term than earlier in pregnancy. (1) In term PROM
labor starts in 80–90% of cases within 24 hours. PROM is one of the important causes of preterm labor and prematurity; (2)
Chance of ascending infection is more if labor fails to start within 24 hours. Liquor gets infected (chorioamnionitis) and fetal
infection supervenes; (3) Cord prolapse specially when associated with malpresentation; (4) Continuous escape of liquor for
long duration may lead to dry labor; (5) Placental abruption; (6) Fetal pulmonary hypoplasia specially in preterm PROM is a
real threat when associated with oligohydramnios; (7) Neonatal sepsis, RDS, IVH and NEC in preterm PROM; (8) Perinatal
morbidities (cerebral palsy) are high.
MANAGEMENT
PRELIMINARIES: (1) Aseptic examination with a sterile speculum is done not only to confirm the diagnosis but also
to note the state of the cervix and to detect any cord prolapse; (2) Vaginal digital examination is generally avoided;
(3) Patient is put to bed rest and sterile vulval pad is applied to observe any further leakage. Once the diagnosis is confirmed,
management depends on—(i) Gestational age of the fetus (ii) Whether the patient is in labor or not (iii) Any evidence of sepsis
(iv) Prospect of fetal survival in that institution, if delivery occurs. Maternal pulse, temperature and fetal heart rate are
monitored 4 hourly.
Term PROM: If the patient is not in labor and there is no evidence of infection or fetal distress, she is observed carefully, in
the hospital. Generally in 90% of cases spontaneous labor ensue within 24 hours. If labor does not start within the stipulated
time or there are reasons not to wait, induction of labor with oxytocin is commenced forthwith. Cesarean section is performed
with obstetric indications.
318 TEXTBOOK OF OBSTETRICS
Preterm PROM: The main concern is to balance the risk of infection in expectant management (while pregnancy is
continued) versus the risk of prematurity in active intervention. Ideally the patient should be transferred with the “fetus in
utero” to an unit able to manage preterm neonates effectively.
If the gestational age is 34 weeks or more, perinatal mortality from prematurity is less compared to infection. Labor
generally starts spontaneously within 48 hours, otherwise induction with oxytocin is instituted. Presentation other than
cephalic merits cesarean section. When gestational age is less than 34 weeks, conservative attitude generally followed in
absence of any maternal or fetal indications. On rare occasion with bed rest, the leak seals spontaneously and pregnancy
continues.
USE OF ANTIBIOTICS: Prophylactic antibiotics are given to minimize maternal and perinatal risks of infection.
Intravenous ampicillin, amoxicillin or erythromycin for 48 hours followed by oral therapy for 5 days or until delivery is
recommended.
Use of corticosteroids to stimulate surfactant synthesis against RDS in preterm neonates is controversial. As such PROM
alone may accelerate fetal lung maturation. However, combine use of antibioitic and corticosteroids has reduced the risk of neonatal RDS, IVH,
and NEC.