Preterm Premature (Prelabor) Rupture of Membranes

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    1/11/2016 Preterm premature (prelabor) rupture of membranes

    http://www.uptodate.com/contents/preterm-premature-prelabor- rupture-of-membranes?topicKey=OBGYN%2F6754&elapsedTimeMs=0&source=search_result…

    Official reprint from UpToDate www.uptodate.com ©2016 UpToDate

    Author 

    Patrick Duff, MD

    Section Editor 

    Charles J Lockwood, MD, MHCM

    Deputy Editor 

    Vanessa A Barss, MD, FACOG

    Preterm premature (prelabor) rupture of membranes

     All topics are updated as new evidence becomes available and our peer review process is complete.

    Literature review current through: Dec 2015. | This topic last updated: Jan 04, 2016.

    INTRODUCTION — Premature rupture of membranes (PROM) refers to membrane rupture before the onset of 

    uterine contractions (also known as prelabor rupture of membranes); preterm PROM (PPROM) refers to PROM

    before 37 weeks of gestation.

    The management of PPROM is among the most controversial issues in perinatal medicine. Points of contention

    include:

    Risk factors, diagnosis, and management of PPROM at 23 to 37 weeks of gestation will be discussed here. Issues

    specifically relating to management of PROM prior to 23 weeks of gestation and at term are discussed separately.

    (See "Midtrimester preterm premature rupture of membranes" and "Management of premature rupture of the fetal

    membranes at term".)

    INCIDENCE — Preterm premature rupture of membranes (PPROM) occurs in 3 percent of pregnancies and is

    responsible for, or associated with, approximately one-third of preterm births [1].

    PATHOGENESIS — The pathogenesis of spontaneous membrane rupture is not completely understood. The

    strength and integrity of fetal membranes derive from extracellular membrane proteins, including collagens,

    fibronectin, and laminin. Matrix metalloproteases (MMPs) decrease membrane strength by increasing collagen

    degradation [2]. Tissue inhibitors of MMPs (TIMMPs) bind to MMPs and shut down proteolysis, thereby helping to

    maintain membrane integrity [2,3]. A variety of pathologic events can disrupt this homeostasis and initiate a

    cascade of biochemical changes that culminate in PROM. Although the pathway varies depending on the initiating

    event, it is likely that all pathways lead to a final common pathway ending in membrane rupture. (See

    "Pathogenesis of spontaneous preterm birth".)

    CLINICAL FINDINGS

    Risk factors — Mater nal physiologic, genetic, and environmental factors likely predispose to development of 

    preterm premature rupture of membranes (PPROM) in many cases. These risk factors are similar to those for 

    preterm labor (table 1), but most patients have no identifiable risk factors. (See "Risk factors for preterm labor and

    delivery".)

     A history of PPROM in a previous pregnancy, genital tract infection, antepartum bleeding, and cigarette smoking

    have a particularly strong association with PPROM [4].

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    Expectant management versus intervention●

    Use of tocolytics●

    Duration of administration of antibiotic prophylaxis●

    Timing of administration of antenatal corticosteroids●

    Methods of testing for maternal/fetal infection●

    Timing of delivery●

    Previous PPROM — Studies have consistently reported that a history of PPROM is a strong risk factor for 

    recurrence. As an example, the Preterm Prediction Study, a large prospective study conducted by the

    National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU)

    http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/abstract/4 http://www.uptodate.com/contents/risk-factors-for-preterm-labor-and-delivery?source=see_link http://www.uptodate.com/contents/risk-factors-for-preterm-labor-and-delivery?source=see_link http://www.uptodate.com/contents/risk-factors-for-preterm-labor-and-delivery?source=see_link http://www.uptodate.com/contents/pathogenesis-of-spontaneous-preterm-birth?source=see_link http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/contributors http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/contributors http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/contributors http://www.uptodate.com/ http://www.uptodate.com/contents/pathogenesis-of-spontaneous-preterm-birth?source=see_link http://www.uptodate.com/contents/management-of-premature-rupture-of-the-fetal-membranes-at-term?source=see_link http://www.uptodate.com/contents/management-of-premature-rupture-of-the-fetal-membranes-at-term?source=see_link http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/abstract/4 http://www.uptodate.com/contents/risk-factors-for-preterm-labor-and-delivery?source=see_link http://www.uptodate.com/contents/image?imageKey=OBGYN%2F68992&topicKey=OBGYN%2F6754&rank=1%7E134&source=see_link http://www.uptodate.com/contents/pathogenesis-of-spontaneous-preterm-birth?source=see_link http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/abstract/2,3 http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/abstract/2 http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/abstract/1 http://www.uptodate.com/contents/management-of-premature-rupture-of-the-fetal-membranes-at-term?source=see_link http://www.uptodate.com/contents/midtrimester-preterm-premature-rupture-of-membranes?source=see_link http://www.uptodate.com/home/editorial-policy http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/contributors http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/contributors http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/contributors http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/contributors http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/contributors http://www.uptodate.com/contents/preterm-premature-prelabor-rupture-of-membranes/contributors http://www.uptodate.com/

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    1/11/2016 Preterm premature (prelabor) rupture of membranes

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    In addition, several genetic polymorphisms of genes related to infection, inflammation, and collagen degradation

    have been identified as potential risk factors for PPROM.

    Patient presentation — The classic clinical presentation of PPROM is a sudden "gush" of clear or pale yellow

    fluid from the vagina. However, many women describe intermittent or constant leaking of small amounts of fluid or 

     just a sensation of wetness within the vagina or on the perineum.

    Findings on physical examination — Direct observation of amniotic fluid coming out of the cervical canal or 

    pooling in the vaginal fornix is pathognomonic of PPROM. If amniotic fluid is not immediately visible, the woman can

    be asked to push on her fundus, Valsalva, or cough to provoke leakage of amniotic fluid from the cervical os.

    For patients who are not in active labor, examination of the cervix and vagina is performed using a sterile speculum.

    Digital examination should be avoided because it may decrease the latency period (ie, time from rupture of 

    membranes to delivery) and increase the risk of intrauterine infection [12-14]. The cervix may appear dilated and/or  effaced and, rarely, prolapse of a fetal part or the umbilical cord may be detected.

    Findings on ultrasonography — Fifty to 70 percent of women with PPROM have low amniotic fluid volume on

    initial sonography [15].

    Clinical course — The majority of pregnancies with PPROM deliver within one week of membrane rupture. In a

    randomized trial of PPROM at 24 to 32 weeks, the median time to delivery of 239 group B streptococcal (GBS)

    negative patients managed expectantly with prophylactic antibiotics was 6.1 days; 27 percent delivered within 48

    hours, 56 percent delivered within 7 days, 76 percent delivered within 14 days, and 86 percent delivered within 21

    days [16]. However, the duration of the latency period inversely correlates with gestational age at membrane rupture

    Network, observed that women with a history of PPROM had a 13.5 percent rate of PPROM in a subsequent

    pregnancy compared to 4.1 percent in women with no such history (RR 3.3, 95% CI 2.1-5.2) [5]. Others have

    reported recurrence rates at high as 32 percent [6]. Women with a history of PPROM are at risk for recurrent

    PPROM or preterm birth without PPROM [7,8].

    Genital tract infection — Genital tract infection is the single most common identifiable risk factor for 

    PPROM. Three lines of epidemiologic evidence strongly support this association: (1) women with PPROM are

    significantly more likely than women with intact membranes to have pathogenic microorganisms in the

    amniotic fluid, (2) women with PPROM have a significantly higher rate of histologic chorioamnionitis than

    those who deliver preterm without PPROM, and (3) the frequency of PPROM is significantly higher in women

    with certain lower genital tract infections (particularly b

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