Premature Rupture Of Membranes And Its Impact On Labour?

It can be unsettling to hear terms like "premature rupture of membranes" during pregnancy. You might feel a mix of worry and curiosity, wondering how it could impact your baby and what signs to look out for. Understanding potential complications can prepare you to make informed decisions and seek medical support if the need arises.

In this article, we will cover one such pregnancy-related concern known as premature rupture of membranes or PROM. We'll delve into this condition, and explore its causes, types, and management strategies.  

PROM is a pregnancy complication in which the amniotic sac ruptures before labour begins. The amniotic sac is a fluid-filled membrane that surrounds and protects the developing baby. When PROM occurs, amniotic fluid leaks out of the vagina. This condition can occur at any gestational age and increases the risk of infection for the mother and the baby. In order to ensure the best possible outcome, prompt diagnosis and appropriate management are crucial.

Types of PROM: PROM vs PPROM

PROM can be classified into two main categories based on the gestational age at which the rupture occurs. Understanding the differences between these types is essential for determining the appropriate course of action.

• PROM:

1. Occurs after 37 weeks of gestation, when the pregnancy is considered full-term.
2. In most cases, labour will begin spontaneously within 24 hours of the rupture, especially if the pregnancy is close to the due date.
3. If labour does not start naturally, induction may be recommended to reduce the risk of infection.

• PPROM:

1. Preterm PROM occurs before 37 weeks of gestation when the baby is considered premature.
2. PPROM is responsible for approximately one-third to one-fourth of all preterm births.
3. This condition is associated with higher risks of infection, placental abruption, and umbilical cord compression, which can compromise the baby's well-being.
4. The time between the water breaking and delivery is typically longer in the case of PPROM.

A complex condition like PROM is influenced by various maternal and foetal factors.
Some of the causes and risk factors include:

• Infections: Sexually transmitted infections (STIs) like chlamydia and gonorrhoea, bacterial vaginosis, and intra-amniotic infections can increase the risk of PROM.
• Previous Obstetric History: A history of abortion, previous preterm birth, history of PROM, and history of caesarean section are considered some of the risk factors.
• Lifestyle Factors: Smoking during pregnancy is a significant risk factor for premature rupture of membranes.
• Other Medical Conditions: Short cervical length, polyhydramnios (high volume of amniotic fluid), multiple gestations, and connective tissue disorders can increase the likelihood of PROM.
• Genitourinary Infections: Abnormal vaginal discharge and urinary tract infections are associated with a higher risk of PROM.
• Maternal Age and Health: Hypertension during pregnancy, vaginal bleeding, and uterine distension are risk factors for PROM.

Now you might be wondering how to identify amniotic fluid leakage during pregnancy, right? Being able to identify the symptoms is critical for the diagnosis of PROM. Here are some of the key symptoms to look out for:

• Fluid Leakage: Continuous leaking of fluid, which may be clear or slightly cloudy. Also, a sudden gush of fluid from the vagina, often described as water breaking is a classified symptom of PROM.
• Wetness: Experiencing persistent feelings of wetness in the vagina and underwear.
• Vaginal Discharge: Abnormal vaginal discharge that may be coloured or malodorous is another classified symptom of PROM.
• Cramps and Bleeding: Although less common, mild abdominal cramps or contractions and vaginal bleeding have also been reported as symptoms of PROM.

If you experience any of these symptoms, especially fluid leakage, contact your doctor immediately. They will perform a thorough evaluation and determine the appropriate treatment if PROM is diagnosed. Timely identification and management of PROM are vital for safeguarding your as well as your premature baby's well-being.

In diagnosing premature rupture of membranes a combination of clinical examination, medical history, and specific tests is required. The primary symptom is the leakage or sudden gush of amniotic fluid from the vagina, which may be mistaken for urine but lacks the characteristic smell and colour. Accurately identifying PROM is crucial for ascertaining  the appropriate treatment plan and minimising risks to the mother and the baby.

Tests and Procedures for Confirming PROM

Several tests and procedures are used to confirm the diagnosis of PROM. The tests help doctors distinguish between PROM and other conditions that may cause vaginal discharge or wetness. Specific tests for PROM include:

• Nitrazine Test: This test involves placing a drop of vaginal fluid on nitrazine paper, which turns blue if the pH is greater than 6.0, indicating PROM. However, false positives can occur due to blood, infection, or recent sexual intercourse.
• Ferning Test: In this test, fluid is observed under a microscope for a fern-like pattern, which is characteristic of amniotic fluid.
• Dye Test: This test is performed only under special circumstances due to its invasive nature. It involves injecting dye into the amniotic sac. If the membranes are ruptured, the coloured fluid will appear in the vagina within 30 minutes.
• AmniSure ROM Test: This is a non-invasive test for detecting the placental alpha microglobulin-1 biomarker in the amniotic fluid. This test does not require a speculum examination.

Premature rupture of membranes has a profound impact on labour and delivery, as it significantly increases the likelihood of preterm birth and its associated complications. When PROM occurs, the period before the onset of labour is often shorter, particularly at earlier gestational ages. For example, at term, over 90% of women with PROM will begin labour within 24 hours. However, at 32-34 weeks, the average latency period is approximately four days. This shortened timeline can have serious implications for both the mother and the baby. Furthermore, another concern with PROM is the increased risk of infection for the mother and baby, as the amniotic sac no longer provides a protective barrier.

Complications Associated with PROM

PROM is associated with several complications that can affect both mother and baby, including:

• Intra-amniotic Infection (Chorioamnionitis): PROM increases the risk of infection in both the mother and the baby, as the protective barrier of the amniotic sac is no longer intact.
• Preterm Delivery: There is a high likelihood of delivery occurring soon after membrane rupture, especially at earlier gestational ages, which can lead to complications associated with prematurity, such as respiratory distress syndrome, intraventricular haemorrhage, and necrotising enterocolitis.
• Cord Prolapse: In some cases, the umbilical cord may prolapse through the cervix, which can compress the cord and compromise foetal blood flow and oxygenation.
• Placental Abruption: PROM may increase the risk of placental abruption, a serious complication in which the placenta partially or completely separates from the uterine wall before delivery.

Close monitoring and targeted interventions are required in managing a PROM pregnancy to minimise risks and optimise outcomes for both the mother and the baby. This involves regular checks for signs of labour, contractions, foetal well-being, and symptoms of infection. Hospitalisation is often recommended to ensure prompt intervention if complications arise. For a PPROM pregnancy, the decision to induce labour or continue expectant management depends on gestational age and the presence of complications. Early delivery may be necessary if there are signs of chorioamnionitis, placental abruption, or foetal distress.

Treatment Options for PROM and PPROM Pregnancies

Treatment for PROM and PPROM pregnancies aims to reduce the risk of infection, promote foetal lung maturity, and manage preterm labour. Options include:

• Corticosteroids: To help mature the baby's lungs, especially if delivery is anticipated before 34 weeks.
• Antibiotics: To prevent or treat infections, such as chorioamnionitis and group B streptococcus.
• Tocolytics: To delay preterm labour, though the use of the medicine is limited due to potential risks.
• Inducing Labour: May be recommended at or after 34 weeks if the baby's lungs are mature, or earlier if complications arise.
• Hospitalisation and Bed Rest: To monitor for complications and ensure immediate medical intervention if necessary.

Which treatment option is to be used will be decided by the doctor after considering numerous factors. Some important factors that will contribute to the doctor's decision could be the patient's health, gestational age, and the severity of the condition.