Prelabor rupture of membranes (PROM) may occur at term (≥ 37 weeks) or earlier (called preterm PROM if < 37 weeks).
Preterm PROM predisposes to preterm delivery.
PROM at any time increases risk of the following:
Infection in the woman (intra-amniotic infection Intra-Amniotic Infection Intra-amniotic infection is infection of the chorion, amnion, amniotic fluid, placenta, or a combination. Infection increases risk of obstetric complications and problems in the fetus and neonate... read more [chorioamnionitis]), neonate (sepsis Neonatal Sepsis Neonatal sepsis is invasive infection, usually bacterial, occurring during the neonatal period. Signs are multiple, nonspecific, and include diminished spontaneous activity, less vigorous sucking... read more ), or both
Group B streptococci and Escherichia coli are common causes of infection. Other organisms in the vagina may also cause infection.
PROM can increase risk of intraventricular hemorrhage Intracranial Hemorrhage The forces of labor and delivery occasionally cause physical injury to the infant. The incidence of neonatal injury resulting from difficult or traumatic deliveries is decreasing due to increasing... read more in neonates; intraventricular hemorrhage may result in neurodevelopmental disability (eg, cerebral palsy Cerebral Palsy (CP) Syndromes Cerebral palsy refers to nonprogressive syndromes characterized by impaired voluntary movement or posture and resulting from prenatal developmental malformations or perinatal or postnatal central... read more ).
Prolonged preterm PROM before viability (at < 24 weeks) increases risk of limb deformities (eg, abnormal joint positioning) and pulmonary hypoplasia due to leakage of amniotic fluid (called Potter sequence or syndrome).
The interval between PROM and onset of spontaneous labor (latent period) and delivery varies inversely with gestational age. At term, > 90% of women with PROM begin labor within 24 hours; at 32 to 34 weeks, mean latency period is about 4 days.
Symptoms and Signs
Typically, unless complications occur, the only symptom of PROM is leakage or a sudden gush of fluid from the vagina.
Fever, heavy or foul-smelling vaginal discharge, abdominal pain, and fetal tachycardia, particularly if out of proportion to maternal temperature, strongly suggest intra-amniotic infection.
Vaginal pooling of amniotic fluid or visible vernix or meconium
Evaluation of vaginal fluid showing ferning or alkalinity (blue color) on Nitrazine paper
Sometimes ultrasound-guided amniocentesis with dye for confirmation
Sterile speculum examination is done to verify PROM, estimate cervical dilation, and obtain samples for cervical cultures. Digital pelvic examination, particularly multiple examinations, increases risk of infection and is best avoided unless imminent delivery is anticipated.
Fetal position should be assessed.
If subclinical intra-amniotic infection is a concern, amniocentesis (obtaining amniotic fluid using sterile technique) can confirm this infection.
Pearls & Pitfalls
The diagnosis of PROM is assumed if one of the following is present:
Amniotic fluid appears to be escaping from the cervix.
Vernix or meconium is visible.
Other less accurate indicators include vaginal fluid that ferns when dried on a glass slide or turns Nitrazine paper blue, indicating alkalinity and hence amniotic fluid; normal vaginal fluid is acidic. Nitrazine test results may be false positive if blood, semen, alkaline antiseptics, or urine contaminate the specimen or if the woman has bacterial vaginosis. Oligohydramnios, detected by ultrasonography, suggests the diagnosis.
If the diagnosis is questionable, indigo carmine dye can be instilled using ultrasound-guided amniocentesis. Appearance of the blue dye on a vaginal tampon or peripad confirms the diagnosis.
If the fetus is viable, women are typically admitted to the hospital for serial fetal assessment.
Delivery if there is fetal compromise, infection, or gestational age ≥ 34 weeks
Otherwise, pelvic rest, close monitoring, antibiotics, and sometimes corticosteroids
Guidelines for managing PROM in specific situations are available from the American College of Obstetricians and Gynecologists (ACOG).
PROM management requires balancing risk of infection when delivery is delayed with risks due to fetal immaturity when delivery is immediate. No one strategy is correct, but generally, signs of fetal compromise or infection (eg, persistently nonreassuring fetal testing results, uterine tenderness plus fever) should prompt delivery. Otherwise, delivery can be delayed for a variable period if fetal lungs are still immature or if labor could start spontaneously (ie, later in the pregnancy).
Induction of labor is recommended when gestational age is ≥ 34 weeks.
When appropriate management is unclear, amniotic fluid tests can be done to assess fetal lung maturity and thus guide management; the sample may be obtained from the vagina or by amniocentesis.
When expectant management is used, the woman’s activity is limited to modified bed rest and complete pelvic rest. Blood pressure, heart rate, and temperature must be measured ≥ 3 times a day.
Antibiotics (usually 48 hours of IV ampicillin and erythromycin, followed by 5 days of oral amoxicillin and erythromycin) are given; they lengthen the latency period and reduce risk of neonatal morbidity. Instead of erythromycin, a single dose of azithromycin 1 g can be given orally.
If pregnancies are ≥ 24 weeks and < 34 weeks, clinicians should give the woman corticosteroids Corticosteroids Labor (contractions resulting in cervical change) that begins before 37 weeks gestation is considered preterm. Risk factors include prelabor rupture of membranes, uterine abnormalities, infection... read more to accelerate fetal lung maturity. Another course of corticosteroids can be considered if all of the following are present:
The pregnancy is < 34 weeks.
Women are at risk of delivering within 7 days.
The last course was given ≥ 14 days prior.
Corticosteroids should also be considered in the following circumstances:
At gestational age 34 weeks 0 days to 36 weeks 6 days if women are at risk of delivering within 7 days and no prior corticosteroids have been given (1 Treatment reference Prelabor rupture of membranes is leakage of amniotic fluid before onset of labor. Diagnosis is clinical. Delivery is recommended when gestational age is ≥ 34 weeks and is generally indicated... read more )
Starting at gestational age 23 weeks 0 days if there is a risk of preterm delivery within 7 days (1 Treatment reference Prelabor rupture of membranes is leakage of amniotic fluid before onset of labor. Diagnosis is clinical. Delivery is recommended when gestational age is ≥ 34 weeks and is generally indicated... read more )
Corticosteroids are contraindicated if there are signs of chorioamnionitis.
IV magnesium sulfate should be considered in pregnancies < 32 weeks; in utero exposure to this drug appears to reduce the risk of severe neurologic dysfunction (eg, due to intraventricular hemorrhage), including cerebral palsy, in neonates.
Use of tocolytics (drugs that stop uterine contractions) to manage preterm PROM is controversial; their use must be determined case by case.
1. American College of Obstetricians and Gynecologists: Committee Opinion No. 713 Summary: Antenatal corticosteroid therapy for fetal maturation. Obstet Gynecol 130 (2):493–494, 2017. doi: 10.1097/AOG.0000000000002231
Assume that membranes are ruptured if amniotic fluid pools in the vagina or if vernix or meconium is visible.
Less specific indicators of PROM are ferning of vaginal fluid, alkaline vaginal fluid (detected by Nitrazine paper), and oligohydramnios.
ACOG has provided guidelines for managing PROM in specific situations.
Consider inducing delivery if there is fetal compromise, infection, or evidence of fetal lung maturity or if gestational age is ≥ 34 weeks.
If delivery is not indicated, treat with bed rest and antibiotics.
If pregnancies are ≥ 24 weeks and < 34 weeks (in some cases, < 37 weeks), give corticosteroids to accelerate fetal lung maturity.
Consider giving corticosteroids starting at gestational age 23 weeks if women are at risk of preterm delivery within 7 days.
If pregnancies are < 32 weeks, consider magnesium sulfate to reduce risk of severe neurologic dysfunction.
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