Preterm Rupture of

Membranes
Melissa Zahnd, RNC, MSN

Definition

Premature ROM: Amniorrhexis

(SROM) Prior to the onset of labor at
any gestation (PROM)
Preterm ROM: PROM prior to 37
weeks gestation
Use PPROM/PROM

Definitions

Latency Period: time interval between

ROM and onset of labor
Expectant management:
management of patients with the goal
of prolonging gestation (watchful
waiting until delivery indication arises)

Documentation

E.F. a 22 y.o. MWF, G1P0 with

PPROM at 32 3/7 weeks gestation

M.R. a 32 y.o. female, G3P2 with

PROM at 38 3/7 weeks gestation

Incidence-Preterm ROM

Complicates up to
3.5% of all
pregnancies
30-40% of Preterm
births
PPROM ~25%
cases of all PROM

Garite (2007), Santaloya-Forgas et al., (2007), Svigos, Robinson, et Vigneswaran,

2007)

Risk Factors

Chorioamnionitis
Vaginal infections
Cervical
abnormalities
Vascular pathology
(incl. abruptio)
Smoking
1st, 2nd, 3rd, or
multiple trimester
bleeding

Previous preterm
delivery (PPROM)
AA ethnicity
Acquired or
congenital
connective tissue
disorder
Nutritional
deficiencies (Vit.C,
copper, zinc)

The Patient

Vaginal discharge
Gush of fluid
Leaking of fluid
Oligo/Anhydramnios
Cramping
Contractions
Back pain

Diagnosis

Sterile Speculum exam (Pooling)

SSE-Free flow of fluid from cervical os
Nitrizine testing
Microscopic Fern testing
Fetal Fibronectin
AmniSure
Ultrasonography
Transabdominal Indigo dye injection

Why not do a digital vaginal

exam?

Latency period
Infection

Sterile Speculum Exam

Assess for

Sterile
No lubricating jelly
Pooling of fluid in
posterior fornix
Free flow of fluid
from cervix
Cervical dilation
Nitrazine
Collect slide for fern
(dry 10 mins)

Consider need to collect other

cervical tests/cultures such fetal
fibronectin while doing the SSE.

Nitrazine paper testing

Vaginal pH (3.54.5)
Turns blue in
presence of
alkaline Amniotic
fluid
93.3% sensitivity
False positive (117%) for urine,
blood, semen, BV,
Trichomonas

Fern slide

Must allow slide to dry

thoroughly prior to
examination under
microscope. Assess for
arborization of fluid.
Cervical mucous has
broad, ferning pattern
that is different than the
fern of amniotic fluid.

Fetal Fibronectin

fFn present in cervical

secretions <22 wks,
>34 wks
Used for assessment
of potential PTB
Positive result (>50
ng/dl) may be
indicative of PROM
and represents
disruption of deciduachorionic interface

In PPROM, Sensitivity-98.2%, Specificity-26.8%.

AmniSure

Newer test
Point of Care test
Cost-up to $50 each
Sensitivity-98.7-98.9%
Specificity-87.5-100%
Awaiting further testing prior to
recommendations

AmniSure
Remove swab
and rotate in
solvent x 1 min.
Read
results
after 510 mins
have
passed.

Place Swab 2-3

in. into vaginal
canal x 1 min.

Discard swab and

place test stick into
solvent.

Ultrasonography

50-70% of women with

PPROM have low AFV
on US
Mild reduction requires
further investigation
Rule out other causes
(Renal agenesis, uteroplacental insufficiency,
obstructive uropathy)
Measure for pockets of
fluid and quantitate
AFV into AFI
Ultrasound showing 7 cm pocket of fluid

Transabdominal Injection of
Dye

Amniocentesis
Collect Fluid
samples
Inject dye (Indigo
Carmine)
Tampon placed in
vagina and
checked for blue
staining 30-60 mins
after procedure

How would I manage this

patient?

Gestational age
Availability of NICU
Fetal presentation
FHR pattern

Active distress
(maternal/fetal)
Is she in labor?
Cervical
assessment

Initial Assessment

Assess for Maternal-Fetal distress

Assess for Proper dating/GA
Assess for infection
Exclude occult cord prolapse

Secondary Assessment

Fetal position
Cervical
assessment
Determine lung
maturity, if
indicated
Quantify AFV*

Delivery Indication

Maternal-Fetal
Distress
Infection
Abruption
Cord Prolapse

Expectant Management

Typical for GA 32 weeks or less

Steroids
Tocolysis if indicated for lung maturity
Antibiotics
Fetal Surveillance
Majority Inpatient Observation
Assess for Chorioamnionitis

Goal: Mature Lung Profile, reduction of PTB risks!

Risk-Benefit Expectant
Management
Risks

Abruption
Chorioamnionitis
Cord Prolapse
Pulmonary
Hypoplasia (<19
weeks PPROM
Skeletal
Deformities
Endometritis (1/3)

Benefits

Mature lung profile

Advancing GA
(reducing risks
associated with
PTB)

Risks-Benefits Profile of
Pre-term Birth
Risks

Assoc. w/ PTB

NEC
IVH/CP
RDS

Cesarean Delivery
Endometritis (1/3)

Benefits
Elimination of risks
of expectant
management

Outcomes

1/3 develop
intraamniotic
infections,
endometritis, or
septicemia

Neonatal outcomes
dependent on GA
and indication for
delivery

References

Duff, Patrick, MD. Preterm premature rupture of membranes.

UpToDate. Ed. Charles J Lockwood, MD and Vanessa A
Barss, MD. 1-16. 27 June 2008 <http://utdol.com>.
Garite, Thomas J, MD. Premature Rupture of the
Membranes. Clinics in Perinatalogy. N.p.: n.p., n.d. 723-736.
Hacker, and Moore. Essentials of Obstetrics and Gynecology.
4th ed. N.p.: n.p., 2004.
Santolaya-Forgas, Joaquin, et al. Prelabor rupture of the
membranes. Clinical Obstetrics-Handbook: The Fetus and
Mother. By E Albert Reece and John Hobbins. N.p.: n.p.,
2007. 1130-1173.
Svigos, John Micheal, Jeffrey S Robinson, and Rasniah
Vigneswaran. Prelabor Rupture of Membranes. High-Risk
Pregnancy. N.p.: n.p., n.d. 1321-1330.