Premature rupture of the membranes (PROM) refers to a patient who presents with rupture of fetal membranes (amniotic sac) more than one hour prior to the onset of labor. Patients present with leakage of fluid, vaginal discharge, vaginal bleeding and pelvic pressure without regular uterine contractions, evidence of cervical dilation or cervical effacement.
Infection in the vagina or cervix may lead to PROM.
Having a history of PROM with a previous pregnancy is a risk factor for developing PROM in subsequent pregnancies.
Cervical incompetence is a medical condition in which the cervix dilates and thins prematurely. This may lead to miscarriage or PROM. Women with known cervical incompetence or insufficiency may elect to have a cervical cerclage placed between 12 and 16 weeks gestation. A cerclage, also called a cervical stitch, closes the cervical os to prevent premature delivery. The stitch is then removed prior to delivery.
PROM can be diagnosed with a sterile speculum examination of the cervix and vaginal cavity. A sample of vaginal fluid is obtained for a fern test to determine if amniotic fluid is present in the vagina, indicating the membranes have ruptured. The vaginal fluid is placed on a glass slide and allowed to dry, if amniotic fluid is present, the dried fluid will have a fern leaf-like pattern seen on microscopy.
Normally, the vagina has an acidic pH. In PROM, the Nitrazine paper turns blue, due to the alkaline pH of amniotic fluid.
Ultrasound should be utilized to monitor fetal growth and the amount of amniotic fluid present. It is important to identify oligohydramnios (amniotic fluid index (AFI) ≤5 cm or single deepest pocket (SDP) <2 cm), as this may be associated with PROM.
Tocolysis is the inhibition of myometrial contractions. Therefore, tocolytic medications slow down or inhibit the onset of labor. If uterine contractions occur, tocolysis is contraindicated.
If signs and symptoms of chorioamnionitis are present (maternal fever and uterine tenderness in the presence of PROM, in the absence of UTI or URI), then obtain cervical cultures, and begin broad-spectrum IV antibiotic therapy and initiate delivery.
At less than 34 weeks gestation, corticosteroids are given.
Corticosteroids are given to women less than 34 weeks gestation to hasten fetal lung development.
At more than 34 weeks gestation, the preferred management is induction of labor.
Women with term PROM should undergo prompt induction of labor if they are more than 34 weeks gestation. Oxytocin (a synthetic analog of the hormone produced in the hypothalamus) or prostaglandins may be used as an inducing agent.
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