PROM

Question 1

What are some of the functions of amniotic fluid?

Answer 1

• protection against infection, fetal trauma, and umbilical cord compression
• allows fetal movement, breathing, and development

Question 2

How do we define PROM and PPROM?

Answer 2

• PROM is rupture of the chorioamniotic membrane before the onset of labor
• PPROM is PROM that occurs before 37 weeks gestation

Question 3

What is the primary complication of PROM?

Answer 3

intrauterine infection, a risk that increases with the duration of membrane rupture and with pre-exising lower genital tract infections like GBS, BV, etc.

Question 4

What is thought to cause PROM?

Answer 4

possibly subclinical intra-amniotic infections with bacteria that then produce metabolites and inflammatory mediators, which weaken the fetal membranes or initiate uterine contractions

Question 5

What risk factors exist for PROM?

Answer 5

• history of prior PROM
• short cervical length
• second or third trimester bleeding
• low BMI, low SES, cigarette smoking, or illicit drug use

Question 6

What is chorioamnionitis?

Answer 6

an infection of the fetal membranes and amniotic fluid

Question 7

What are common signs of intra-amniotic infection?

Answer 7

• fever
• maternal and fetal tachycardia
• uterine tenderness
• purulent cervical discharge is a late finding
• elevated maternal WBC
• bacteria on gram stain, low glucose level, or positive culture of amniotic fluid

Question 8

What two tests can be used to diagnose PROM by distinguishing amniotic fluid from other vaginal fluids? What is the most definitive way to diagnose PROM?

Answer 8

• the nitrazine test: amniotic fluid has an alkaline pH while most other fluids you would find are acidic
• the fern test: when amniotic fluid is placed on a slide and allowed to dry in room air it forms a distinct fern pattern with multiple, fine branches
• ultrasound can be, but is infrequently, used to guide transabdominal instillation of indigo carmine dye and this is followed by observation for passage of blue fluid from the vagina

Question 9

Amniotic fluid in those with PROM may be mistaken for what other things?

Answer 9

• intermittent urinary leakage
• increased vaginal secretions
• perineal moisture (aka perspiration)

Question 10

What is the recommended management of PROM in these cases:

• term
• 34-36 weeks
• 32-33 weeks
• 24-31 weeks

Answer 10

• term: proceed to delivery, using induction if spontaneous labor does not ensue, to limit risk of chorioamnionitis
• 34-36 weeks: proceed to delivery, consider corticosteroids for lung maturation if not already given
• 32-33 weeks: expectant management unless fetal pulmonary maturity has been documented; consider antibiotics to prolong latency
• 24-31 weeks: expectant management; consider antibiotics to prolong latency; give magnesium for neuroprotection if delivery is imminent

Question 11

After PROM, what is given to extent the latency period?

Answer 11

antibiotics

Question 12

In those with PPROM, what would be two indications to induce delivery regardless of fetal lung maturity?

Answer 12

evidence of an intra-uterine infection or oligohydramnios complicated by cord compression