II. Definitions

  1. Premature Rupture of Membranes (PROM)
    1. Rupture of Membranes >1 prior to labor onset
  2. Preterm Premature Rupture of Membranes (PPROM)
    1. PROM that occurs prior to 37 weeks gestation

III. Epidemiology

  1. Incidence
    1. Premature Rupture of Membranes (PROM): 8%
    2. Preterm Premature Rupture of Membranes (PPROM): 2%

IV. Symptoms

  1. Gushing of fluid from vagina
  2. Fluid leakage increases with movement change

V. Signs

  1. See evaluation below

VI. Differential diagnosis

  1. Urinary Incontinence
  2. Vaginal Discharge
  3. Water from recent bathing

VII. Complications

  1. Premature Birth (PPROM)
  2. Chorioamnionitis
  3. Cord compression
  4. Respiratory distress syndrome
  5. Abruptio Placentae
  6. Malpresentation

VIII. Course prior to delivery

  1. Term: Labor starts within 24 hours in 95% of cases
  2. Weeks 28 to 34
    1. Labor starts within 24 hours in 50% of cases
    2. Labor starts within 1 week in 80% of cases
  3. Weeks 24 to 26
    1. Labor starts within 1 week in >50%
    2. Labor delayed 4 weeks in 22%
  4. References
    1. Schucker (1996) Semin Perinatol 20:389-400 [PubMed]

IX. Risk Factors

  1. History of PROM in prior pregnancy
  2. Prior Cervical Cone Biopsy
  3. Amniocentesis or Cerclage
  4. Uterine distention
    1. Polyhydramnios
    2. Multiple Gestation pregnancy
  5. Tobacco abuse
  6. Cervical or vaginal infections
    1. Group B Streptococcus
    2. Bacterial Vaginosis
    3. Mycoplasma
    4. Ureaplasma
    5. NeisseriaGonorrhea
    6. Chlamydia
  7. Intercourse (unproven)

X. Evaluation

  1. Methods to confirm Rupture of Membranes
    1. AmniSure ROM Test (PAMG-1 Protein Marker Test) or
    2. Vaginal Pooling
    3. Vaginal Fluid Ferning
    4. Vaginal Fluid pH (Nitrazine)
  2. Other bedside evaluation
    1. Visualize Cervix with speculum to estimate dilation
    2. Chlamydia PCR and Gonorrhea PCR
    3. Group B Streptococcus Culture from vagina and Rectum
    4. Fetal Monitoring for well-being
  3. Advanced diagnostics to consider
    1. Ultrasound
      1. Ultrasound Exam of Uterine Cervical Length
      2. May help confirm PROM (e.g. oligohydramnios)
      3. Determines Fetal Position and placental location
      4. Estimates fetal weight
    2. Amniocentesis
      1. Evaluate Fetal Lung Maturity
      2. Method to confirm ROM in uncertain cases
        1. Uses Indigo carmine dye 1 ml in 9 ml sterile NS
        2. Instilled into Uterus via Amniocentesis
        3. Vaginal tampon turns blue within 30 min in ROM

XI. Precautions: Avoid digital cervical exam in PPROM

  1. Digital exam raises infection risk, other morbidities
    1. Alexander (2000) Am J Obstet Gynecol 183:1003-7 [PubMed]
  2. Digital exam reduces time to labor by 9 days
    1. Lewis (1992) Obstet Gynecol 80:630-4 [PubMed]
  3. Speculum visualization offers similar dilation estimate
    1. Munson (1985) Am J Obstet Gynecol 153:562-3 [PubMed]

XII. Precautions: Indications for imminent delivery

XIII. Management: Term Premature Rupture of Membranes (PROM)

  1. Indications
    1. Fetus 36 weeks gestation or
    2. Weight >2500 grams or
    3. Fetal Lung Maturity adequate by Amniocentesis
  2. Protocol
    1. Expectant management
    2. Consider Oxytocin induction of labor
      1. Spontaneous labor onset within 48 hours in 90%
      2. Oxytocin decreases PROM infection rates
      3. Oxytocin does not increase ceserean rates in PROM
    3. Consider Cervical Ripening if unfavorable Cervix
      1. Decreases risk of Chorioamnionitis in PROM
      2. Does not increase ceserean rate in PROM
    4. Indications for GBS Prophylaxis
      1. Prolonged ruptured membranes anticipated >18 hours
      2. Fever >38 degrees Celsius

XIV. Management: Preterm Premature Rupture Membranes (PPROM)

  1. Indications
    1. Fetus <32-34 weeks gestation or
    2. Weight <2500 grams or
    3. Indequate Fetal Lung Maturity
  2. Protocol: General
    1. See Preterm Labor Management
    2. Tocolysis
      1. Delay labor unless overt infection, Fetal Distress
    3. Maternal Corticosteroids for 2 days (single course)
      1. Betamethasone 12 mg IM 2 doses 24 hours apart or
      2. Dexamethasone 6 mg IM 4 doses 12 hours apart
    4. Maternal antibiotic prophylaxis
      1. See GBS Prophylaxis
      2. Antibiotic protocol improves neonatal outcomes
        1. Initial 48 hours start with IV agents
          1. Ampicillin 2 grams IV q6 hours and
          2. Erythromycin 250 mg IV q6 hours
        2. After 48 hours, switch to oral agents for 5 days
          1. Amoxicillin 250 mg PO q8 hours and
          2. Erythromycin base 333 mg PO q8 hours
        3. Reference
          1. Mercer (1997) JAMA 278:989-95 [PubMed]
    5. Consider transfer to tertiary care center
    6. Avoid digital cervical exam
    7. Observation
      1. Signs of Chorioamnionitis
      2. Fetal well-being
  3. Protocol: Gestational age specific
    1. Gestational age 34 weeks or older
      1. Consider transport to facility with NICU
      2. Antibiotics (see regimen above)
      3. Labor Induction
    2. Gastational age 32-33 weeks
      1. Transport to facility with NICU
      2. Antibiotics (see regimen above)
      3. Amniocentesis for Fetal Lung Maturity
        1. Fetal lungs mature: Labor Induction
        2. Fetal lungs not mature
          1. Maternal Corticosteroids as above
          2. Delay delivery 48 hours (preferably >34 weeks)
    3. Gestational age 24-31 weeks
      1. Transport to facility with NICU
      2. Antibiotics (see regimen above)
      3. Daily or continuous Fetal Monitoring
        1. Higher risk of cord compression
    4. Gestational age <24 weeks (pre-viability)
      1. Consultation with neonatology

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Ontology: Fetal Membranes, Premature Rupture (C0015944)

Definition (NCI) Spontaneous rupture of fetal membranes that occurs before the onset of labor. If rupture occurs before 37 weeks of gestation then the correct diagnosis is preterm premature rupture of membranes.(NICHD)
Definition (MSH) Spontaneous tearing of the membranes surrounding the FETUS any time before the onset of OBSTETRIC LABOR. Preterm PROM is membrane rupture before 37 weeks of GESTATION.
Concepts Pathologic Function (T046)
MSH D005322
ICD9 658.1
ICD10 O42 , O42.9
SnomedCT 156189000, 267338001, 157050000, 156191008, 199663005, 199657001, 44223004, 237266003
LNC LA20068-5
English Premature membrane rupture NOS, Premature rupture of membranes NOS, Premature membr.rupt.unspecif., Premature rupture of membranes unspecified, Premature rupture of membranes, unspecified, Fetal Membranes, Premature Rupture, PROM - Prem rupt membranes, premature rupture of membranes, premature rupture of membranes (diagnosis), Fetal Membranes, Premature Rupture [Disease/Finding], premature membrane rupture, premature rupture membrane, premature membranes rupture, Premature;rupture of membranes, membrane premature rupture, pregnancy prom, premature rupture membranes, preterm membrane rupture, membranes of premature rupture, membranes premature rupture, preterm rupture of membranes, prom pregnancy, Premature Rupture of Membrane, Rupture,prem.-membranes, Premature rupture of membranes unspecified (disorder), Membrane-prem. rupture, Prem. rupture-membranes, Premature rupture of membranes NOS (disorder), PROM, Premature Rupture of Membranes, Prelabor Rupture of Membranes, Term Premature Rupture of Membranes, Premature rupture of membranes, Rupture of amniotic sac under 24 hours before onset of labor, Preterm rupture of membranes, Rupture of amniotic sac under 24 hours before onset of labour, PROM - Premature rupture of membranes, Premature rupture of membranes (disorder), Preterm rupture of membranes (disorder), premature; rupture of membranes, rupture of membranes; premature, PROM (Pregnancy), Membrane Premature Rupture (Pregnancy), Membrane Premature Ruptures (Pregnancy), Premature Rupture of Fetal Membranes, Premature Rupture of Membrane (Pregnancy)
Swedish Fostervattenavgång, för tidig
Japanese ゼンキハスイ, 前期破水, 前期破膜, 早期破水, 破水-前期
Czech plodové obaly - předčasné protržení, Předčasný odtok plodové vody, předčasný odtok plodové vody
Finnish Sikiökalvojen ennenaikainen repeytyminen
Russian PLODNYKH OBOLOCHEK PREZHDEVREMENNYI RAZRYV, PLODNOGO PUZYRIA PREZHDEVREMENNYI RAZRYV, ПЛОДНОГО ПУЗЫРЯ ПРЕЖДЕВРЕМЕННЫЙ РАЗРЫВ, ПЛОДНЫХ ОБОЛОЧЕК ПРЕЖДЕВРЕМЕННЫЙ РАЗРЫВ
German Vorzeitiger Blasensprung, nicht naeher bezeichnet, Vorzeitiger Blasensprung, fruehzeitiger Blasensprung, Blasensprung, vorzeitiger, PROM (Schwangerschaft)
Italian Rottura prematura della membrana (Gravidanza), PROM (Gravidanza), Rottura prematura delle membrane
Korean 상세불명의 양막의 조기 파열, 양막의 조기 파열
Croatian FETUSNE MEMBRANE, PRIJEVREMENO PRSNUĆE
Polish Przedwczesne pęknięcie owodni, Pęknięcie pęcherza płodowego przedwczesne
Hungarian Korai burokrepedés
Norwegian For tidlig vannavgang, Prematur vannavgang
Spanish Rotura prematura de membranas, ruptura prematura de membranas no especificada, ruptura prematura de membranas no especificada (trastorno), ruptura prematura de membranas, SAI (trastorno), ruptura prematura de membranas, SAI, Rotura Prematura de Membranas (Embarazo), ruptura del saco amniótico antes de las 24 horas del comienzo del trabajo de parto, ruptura prematura de membranas (trastorno), ruptura prematura de membranas, ruptura pretérmino de membranas (trastorno), ruptura pretérmino de membranas, Rotura Prematura de Membranas Fetales, Rotura Prematura de Membrana (Embarazo)
Dutch breken van vliezen; voortijdig, voortijdig; breken van vliezen, Voortijdig breken van vliezen, niet gespecificeerd, voortijdige vliesbreuk, Voortijdig breken van vliezen, Prematuur gebroken vruchtvliezen, Voortijdig gebroken vruchtvlies, Voortijdig gebroken vruchtvliezen, Vruchtvlies, voortijdig gebroken, Vruchtvliezen, voortijdig gebroken
Portuguese Ruptura prematura da bolsa das águas, Ruptura Prematura de Membranas Fetais, Ruptura Prematura de Membrana (Gravidez)
French Rupture prématurée des membranes, Rupture prématurée des membranes (RPM), Rupture prématurée des membranes foetales

Ontology: Preterm premature rupture of membranes (disorder) (C0729264)

Definition (NCI) Spontaneous rupture of fetal membranes that occurs before the onset of labor and before 37 weeks.(NICHD)
Concepts Pathologic Function (T046)
MSH C563032
SnomedCT 312974005
English PPROM - Preterm prem rup, mem, PRETERM PREMATURE RUPTURE OF THE MEMBRANES, PPROM, Preterm premat rupt membranes, Preterm premature rupture of membranes (disorder), Preterm Premature Rupture of Membrane, Preterm Premature Rupture of the Membranes, Preterm Premature Rupture of Membranes, PPROM - Preterm premature rupture of membranes, Preterm premature rupture of membranes
Czech Předčasná ruptura plodových obalů
Dutch vroegtijdige vliesbreuk bij te vroege bevalling
French Rupture prématurée des membranes avant terme
German Vorzeitiger Blasensprung
Hungarian Terminus előtti korai burokrepedés
Italian Rottura prematura pretermine delle membrane
Japanese ニンシン37シュウミマンノゼンキハスイ, 妊娠37週未満の前期破水
Portuguese Rotura prematura de membranas pré-termo
Spanish Rotura prematura de membranas pretérmino, ruptura prematura pretérmino de membranas (trastorno), ruptura prematura pretérmino de membranas