MoonDragon's Pregnancy Information
PREMATURE RUPTURE OF MEMBRANES
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Rupture of membranes (ROM) or amniorrhexis is a term used during pregnancy to describe a rupture of the amniotic sac. Normally, it occurs spontaneously at full term either during or at the beginning of labor. Rupture of the membranes is known colloquially as "breaking the water." A premature rupture of membranes (PROM) is a rupture of the amnion that occurs prior to the onset of labor.
When the amniotic sac ruptures, production of prostaglandins increases and the cushioning between the fetus and uterus is decreased, both of which processes increase the frequency and intensity of contractions. On occasion, with the rupture of membranes, particularly if the head is not engaged, the umbilical cord may prolapse. A cord prolapse is an obstetrical emergency, as the descending head may block fetal-placental circulation. Once the membranes are ruptured, bacteria may ascend and could lead to amnionitis and fetal infection.
- SROM: Spontaneous Rupture of Membranes. This term describes the normal, spontaneous rupture of the membranes at full term. The rupture is usually at the bottom of the uterus, over the cervix, causing a gush of fluid. This gush may be quite small (such as 50 ml), or it can be significantly large (200 to 300 ml) depending upon amount of fluid in the amniotic sac, and to what extent the fetal head is plugging the hole and retaining fluid in the sac.
- PROM: Premature Rupture of Membranes. This term describes a rupture of the membranes that occurs before the onset of labor.
- PPROM: Preterm, Premature Rupture of Membranes. This term describes a rupture of the membranes that occurs before 37 weeks gestation.
- AROM: Artificial Rupture of Membranes. This term describes a rupture of the membranes by a third party, usually a midwife or obstetrician in order to induce or accelerate labor.
PREMATURE RUPTURE OF MEMBRANES OR PRELABOR RUPTURE OF MEMBRANES (PROM)
Premature rupture of membranes or prelabor rupture of membranes (PROM) is a spontaneous break or tear in the amniotic fluid sac before the onset of labor. It may happen at any time during a pregnancy and occurs in approximately 10 to 15 percent of all pregnancies. It is a condition that occurs in pregnancy when there is a rupture of the membrane of the amniotic sac and chorion more than one hour before the onset of labor. PROM is considered prolonged when it occurs more than 18 hours before labor. PROM is considered preterm when it occurs before 37 weeks gestation, and is called Preterm Premature Rupture of Membranes (PPROM). Risk factors for PROM include bacterial infection, smoking, or anatomic defect in the structure of the amniotic sac, uterus, or cervix. In some cases, the rupture can spontaneously heal, but in most cases of PROM, labor begins within 48 hours. When PROM occurs, it is necessary that the mother receives treatment to avoid possible infection in the newborn.
PROM vs PPROM
PROM is rupture of the membranes prior to the onset of labor, while PPROM (Preterm Premature Rupture of Membranes) is rupture of the membranes with a gestation less than 37 weeks, prior to the onset of labor. These are two distinct entities with different causes, different management, and different outcomes - PROM is a variation of normal, whereas PPROM is often caused by subclinical infection and is quite dangerous. PPROM occurs in about 1 percent of all pregnancies, and about 1/3 of preterm births are associated with PPROM. The outcome is dependent on the gestational age, with those fetuses under 32 weeks gestation having increased risk of pulmonary problems due to lack of lung maturity. In a fetus under 32 weeks gestation with PPROM, antenatal steroids can be given in an effort to enhance lung maturity. If the risk of infection is thought to be less than the risk of premature delivery, then expectant management is done. The risk of premature delivery is thought to be less than the risk of infection after 34 weeks, so delivery is performed. The main determinant of lung maturity of the fetus is amniotic fluid (usually sampled from vaginally pooled fluid) that has phosphatidyl glycerol present.
FREQUENT SIGNS & SYMPTOMS
A leakage or a gush of blood-tinged amniotic fluid from the vagina. Fever or foul-smelling vaginal discharge associated with uterine tenderness (often indicates an infection).
CAUSES of PROM
The exact cause is unknown. There is often a combination of amniotic membrane rupture, preterm labor and infection involved.
PROM RISK FACTORS
These risk factors may increase the chances of complications associated with premature rupture or tearing of amniotic membranes.
Lack of proper prenatal care. Weak cervix (incompetent cervix). Defect in the strength of the membrane itself. Vaginal infection that spreads to the uterus. Excessive amniotic fluid or multiple pregnancies resulting in an increased intrauterine pressure. Poor nutrition and poor hygiene. Injury to the uterus.
Maternal risk factors for a premature rupture of membranes include chorioamniotis or sepsis. Association has been found between emotional states of fear and prelabor rupture of membranes at term. Fetal factors include prematurity, infection, cord prolapse, malpresentation or genetic mutations.
There are no specific preventive measures other than avoiding risk factors where possible. Be sure to follow a balanced and nutritious diet for strong amniotic membranes and a healthy baby.
In a term pregnancy, labor and delivery usually occur within 24 hours following the rupture. In some preterm pregnancies, the period after the rupture until delivery may extend into week, or even months.
Outcome for a preterm rupture varies depending on the length of the pregnancy. If prior to 24 weeks' gestation, the outlook is poor.
On rare occasions when the rupture is small, the leakage will cease, and the membranes are said to "seal over". The amniotic fluid re-accumulates.
PROM POSSIBLE COMPLICATIONS
Preterm labor initiated resulting in a premature baby or miscarriage (depending upon gestational age of fetus and viability).
Extensive intra-amniotic infection, which will generally result in intensive uterine tenderness, fever, and fast heart rates for both mother and fetus. If this occurs, intravenous antibiotics and induction of labor are necessary regardless of gestational age. In some cases, intra-amniotic infection can lead to serious consequences for both mother and child.
PROM CONVENTIONAL MEDICAL TREATMENT
Detection of rupture of membranes mainly include:
- Pooling Test: Visualization of amniotic fluid pooling in the vagina.
- Nitrazine Paper Test: Nitrazine or phenaphthazine is a pH indicator dye often used in medicine. More sensitive than litmus, nitrazine indicated pH in the range of 4.5 to 7.5. Nitrazine is usually used as the disodium salt. It is used to test vaginal pH during late pregnancy to determine the breakage of the amniotic sac. While vaginal pH is normally acidic, a ph above 7.0 can indicate that the amniotic sac has ruptured. However, elevated pH can also be associated with bacterial vaginosis.
- Fern Test: Fern test refers to visualization of a characteristic 'fern-like' pattern on a slide (pre-cleaned, saline free slides are required), viewed under low power on a microscope.
To verify the presence of amniotic fluid where membrane rupture is suspected, ferning permits positive identification of amniotic fluid by its fern-type crystallization. It permits a rapid and certain differential diagnosis between leukorrhea, hydrorrhea, urinary incontinence and spontaneous amniotomy. The crystallization test was shown to be most reliable and the few sources of error are easily avoided. The test is inhibited by cellular debris or blood when it is in a concentration greater than 1:10. Centrifugation permits the reappearance of fern-leaf crystallization. The typical image resembles that of the crystallization of cervical mucus. However, amniotic fluid crystallizes on the entire smear, whereas mucus crystallizes in a linear fashion. Cervical mucus crystallization is normally absent during pregnancy. It may occur in cases of threatened abortion. The authors have performed the test in combination with a nitrazine paper test in a series of 192 patients. In their hands it has given nearly perfect results.
Hospitalization may be indicated for further diagnostic studies and to make determination about treatment and delivery.
With a pregnancy longer than 36 weeks or where fetal lung maturity has been established, treatment leans toward delivery. Eighty percent of women go into spontaneous labor within 12 to 24 hours. For some women, labor may be induced immediately, particularly if there are any signs of infection. This may require a cesarean birth.
For a pregnancy of longer than 24 to 26 weeks duration, hospitalization may be indicated until delivery is recommended for some women. Others may be allowed to return home after 72 hours in the hospital to await labor. In either instance, careful monitoring of vital signs and laboratory blood studies will continue to check for infections and fetal distress. Labor will need to be induced if problems develop. Avoid any vaginal douches, sexual intercourse and putting anything into the vagina. If a midwife needs to do a vaginal exam, sterile techniques and supplies should be used. Avoid baths or hot tubs. Showers are acceptable.
For a pregnancy of less than 24 to 26 weeks, the fetal risks increase. These include compression deformities due to the collapse of amniotic membranes around the fetus and pulmonary problems (hypoplasia). In the case of PROM occurring before 24 weeks, the fetal survival rates are less than 20 percent and among those fetuses that survive, there is a high frequency of developmental defects. Termination of a pregnancy may need to be discussed with the parents.
In a term pregnancy where premature rupture of membranes has occurred, spontaneous labor can be permitted. Current obstetrical management includes an induction of labor at approximately 12 hours if it has not already begun, though many practitioners believe it to be safe to induce labor immediately, and consideration of Group B Streptococcal (GBS) prophylaxis at 18 hours.
- Tocolysis is also sometimes used, though its use in this context is controversial. The mother should be admitted to hospital and put under careful surveillance for preterm labor and chorioamnionitis. Induction of labor should happen at around 34 weeks.
- Antenatal steroids if the gestational age is less than 32 weeks.
- Maternal: If chorioamnionitis is present at the time of PPROM, antibiotic therapy is usually given to avoid sepsis, and delivery is indicated. If chorioamnionitis is not present, prompt antibiotic therapy can significantly delay delivery, giving the fetus crucial additional time to mature. In preterm premature rupture of membranes (PPROM), antibiotic therapy should be given to decrease the risk of sepsis. Ampicillin or erythromycin should be administered for 7 days.
- Fetal: If the GBS status of the mother is not known, penicillin or other antibiotics may be administered for prophylaxis against vertical transmission of Group B streptococcal infection.
Oxytocin (Pitocin) or other oxytocic herbal remedies or labor inducing methods may be used to induce labor. Antibiotics, if an intrauterine infection is present, and sometimes as an infection prevention therapy while awaiting spontaneous labor. Corticosteroid therapy may be considered to accelerate fetal lung maturity.
ACTIVITY RECOMMENDATION & RESTRICTIONS
Bed rest while awaiting labor and delivery is usually recommended. You may be allowed some walking around with your midwife's approval. Discontinue work or other physical activities. Avoid any sexual activity.
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DIET & NUTRITION
No special diet unless labor and delivery are immediate. Maintain a healthy pregnancy diet that may include dietary supplements.
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NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER
If you or a family member has a leakage or gush of amniotic fluid (water) from the vagina. Call your midwife immediately. This may be an emergency! If you are being treated as an outpatient for PROM and any new sign or symptoms develop or there is further leakage of the fluid. If you have abdominal pain, chills and fever, headache, muscle aches or a bad-smelling vaginal discharge or any other signs of infection. If new, unexplained symptoms develop. Drugs used in treatment may produce side effects.
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