Premature Rupture of Membranes (PROM)

by Veronica Gillispie, MD, FACOG

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    00:01 Now let's discuss preterm premature rupture of membranes.

    00:05 First let's go with some definitions.

    00:08 Preterm rupture of membranes means rupture of membranes that happens before 37 weeks of gestation.

    00:16 Premature rupture of membranes means rupture of membranes that happens before the onset of labor.

    00:24 So there are some key issues to address.

    00:26 The first is to confirm rupture of membranes.

    00:29 So there are four ways that we confirm rupture of membranes.

    00:32 Then we're going to talk about which one of these is the best.

    00:35 So the nitrazine test.

    00:36 This is similar to litmus paper.

    00:38 So litmus paper and nitrazine paper is placed inside the vagina and we expect it to change color because of the PH of amniotic fluid.

    00:47 The thing that you need to know however, is that the litmus paper or the nitrazine paper will also change colors because of infections with bacterial vaginosis, blood and semen.

    00:57 So this cannot be used by itself to determine if a patient has rupture of membranes.

    01:03 Another test we can do to confirm the rupture of membranes is the ferning test.

    01:08 To perform this test we take a small amount of fluid that we see in the vagina that we expect to be amniotic fluid.

    01:14 Place it on a slide.

    01:15 Allow it to dry.

    01:16 And we look under the microscope.

    01:20 This is an example of ferning.

    01:22 This is kind of what we would see for a patient that has rupture of membranes.

    01:25 But as the slide indicates there other things that can cause feming such as cervical mucus.

    01:30 So again ferning should be used along to confirm rupture of membranes.

    01:36 Another test we can do is pooling.

    01:38 To do the pooling test we place a speculum inside the vagina.

    01:42 And we ask for the mom to cough or to bare down.

    01:46 With that pressure on the uterus we expect to see fluid coming out of the cervix.

    01:50 If we see that we can be pretty sure that patient has rupture of membranes.

    01:55 This is the most diagnostic test for confirming rupture of membranes.

    02:00 The 4th test is ultrasound.

    02:02 When we do ultrasound we expect to see a maximum vertical pocket of 2 centimeters in a normal pregnancy.

    02:08 If we see less fluid than that, we can suspect rupture of membranes.

    02:12 However, we can also have that finding in the setting of oligohydramnios.

    02:17 So ultrasound alone should not be used to confirm rupture of membranes.

    02:22 So here's a question.

    02:24 When confirming rupture of membranes, which examination is the most accurate? Is it A. Nitrazine B. Ferning C. Pooling.

    02:33 or D. Amniotic fluid volume via ultrasound.

    02:37 Well the answer is pooling.

    02:38 And we've just said there are other things beside amniotic fluid that make the nitrazine test positive.

    02:43 We can see ferning with amniotic fluid and with cervical mucus.

    02:48 And a low amniotic fluid volume can be seen in rupture of membranes as well as in the case of oligohydramnios.

    02:53 Therefore, pooling is the best answer in this question.

    02:58 So some other key issues to address.

    03:01 Antibiotics to prevent infection.

    03:05 So at term, if a patient is ruptured, and then again this may be premature rupture of membranes if they have rupture before the onset of labor.

    03:12 And if the patient is GBS positive, so a carrier of GBS, we do want to give antibiotics.

    03:19 However, if they are GBS negative or GBS unknown and term, we do not give antibiotics.

    03:27 For late preterm and we're talking about 34 to the 36 weeks of gestation, we will give antibiotics to prevent GBS infection.

    03:35 Unless we for some reason had a culture that said the patient was GBS negative.

    03:41 So preterm and we're talking about our deliveries that had happened before 34 weeks.

    03:46 We want to give antibiotics for two different reasons.

    03:49 We want to give antibiotics to increase the latency period.

    03:52 And that's the period from the time of rupture of membranes to when a patient actually delivers.

    03:57 And we also want to give antibiotics if delivery is eminent, to prevent GBS transmission if GBS is unknown.

    04:05 The next key issue to address in preterm in rupture of membranes is steroids.

    04:13 Now there are three areas of concern for fetus when they are born early.

    04:17 Intraventicular hemorrhage.

    04:19 Respiratory distress syndrome.

    04:21 And necrotizing enterocolitis.

    04:24 We give the steroids to help in all three areas but most specifically for respiratory distress syndrome.

    04:30 When we give steroids that helps the type 2 pneumocytes to mature and to increase surfactant production to recruit more alveoli.

    04:38 So this will help for our babies when they are born early and they have small lungs.

    04:43 This will recruit more alveolis so they can have better respiratory function.

    04:49 The next issue that we need to address is magnesium sulphate.

    04:53 It is recommended that we give magnesium sulphate for neuroprotection.

    04:56 And so this helps to prevent cerebral palsy in our very preterm events.

    05:03 So let's go over the overview of how we manage by some of the gestational age.

    05:08 So for patients that are 12 to 24 weeks of gestation so that means before viability we do expectant management.

    05:15 If they have premature rupture of membranes or we induce their labor.

    05:19 Now unfortunately, this is a pregnancy that's going to result in an infant that's not going to be viable.

    05:24 However, because rupture membranes poses a risks to mom because of chorioamnionitis, we do not want that pregnancy to continue.

    05:32 At 24 weeks to 33 weeks and 6 days, we give antibiotics to increase the latency period.

    05:39 And just as a reminder that's the period from the time the patient rupture membranes to when they go into labor.

    05:45 And then we also give antibiotics for GBS prophylaxis.

    05:48 We give steroids specifically for lung maturity but also to help with intraventicular hemorrhage and necrotizing enterocolitis.

    05:56 And we give magnesium sulphate for neuroprotection.

    05:58 For these patients we recommend delivery at 34 weeks.

    06:02 For patients that are between the gestational age of 34 weeks to 36 weeks and 6 days of gestation, we want to give antibiotics for GBS prophylaxis.

    06:13 And we would recommend delivery.

    06:16 In addition, steroids would be recommended during this period as well.

    06:20 For our patients that are over 37 weeks we give antibiotics for GBS prophylaxis, if their GBS positive by culture, and we will recommend delivery.

    06:31 So here's another question.

    06:34 When treating patients with premature rupture of membranes, which medication should not be used long term? A. Antibiotics.

    06:43 B. Magnesium sulphate.

    06:46 C. Tocolytics or D. None of the above.

    06:51 The answer is C.

    06:52 Now this may seem a little tricky.

    06:54 But the question indicates which of these should not be used long term.

    06:58 Tocolytics are often used in the first 48 hours after rupture of membranes as we are administering the steroids.

    07:05 We would like the patient to not establish into labor during that time to allow the steroids to have the greatest affect for long maturity for the fetus.

    07:13 We often give tocolytics during this time.

    07:16 However, we don't want to give tocolytics long term.

    07:19 Again our big concern with premature rupture of membranes is chorioamnionitis.

    07:24 One of the first ways that we know that infection is taking place is moms starts to contract.

    07:29 This will happen before she has a fever, before the baby is tachycardic, before we see the other signs of chorioamnionitis.

    07:36 We don't want to mask that by giving tocolytics.

    07:39 So that's we don't give it beyond the 48 hours.

    About the Lecture

    The lecture Premature Rupture of Membranes (PROM) by Veronica Gillispie, MD, FACOG is from the course Antenatal Care. It contains the following chapters:

    • Preterm Premature Rupture of Membranes
    • Overview Based on Gestational Age – Considerations

    Included Quiz Questions

    1. Pooling of amniotic fluid on speculum exam with valsalva manuever
    2. Ferning of suspected amniotic fluid seen under a microscope
    3. Nitrazine paper or swab changing color when placed in the vagina
    4. Maximum vertical pocket less than 2cm on ultrasound
    5. Reported history of a large gush of fluid
    1. If she has a positive group B streptococcus culture in urine or screening rectovaginal swab
    2. If she has an unknown group B streptococcus status
    3. If her membranes have been ruptured for over 4 hours prior to onset of labor
    4. If she has a group B streptococcus rectovaginal screening swab done prior to 35 weeks gestational age
    5. If she has a negative group B streptococcus rectovaginal screening swab
    1. Increases fetal lung surfactant production and alveolar recruitment
    2. Increases latency period to prevent delivery before 34 weeks
    3. Increases fetal risk for intraventricular hemorrhage
    4. Increases fetal risk for nectrotizing enterocoloitis
    5. Provides fetal neuroprotection against cerebral palsy

    Author of lecture Premature Rupture of Membranes (PROM)

     Veronica Gillispie, MD, FACOG

    Veronica Gillispie, MD, FACOG

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