Premature Rupture of the Membranes (PROM) and Birth Injury

Physicians should make every effort to prevent PROM; this includes promptly diagnosing and treating infections such as chorioamnionitis and group B strep (GBS).

While PROM/PPROM can occur naturally, they also can be triggered by frequent, and often unnecessary, cervical exams late in pregnancy. Infections can result from examinations after a rupture or during restricted bed rest in the hospital, which also may contribute to fetal distress and a possible C-section.

The causes of PROM/PPROM are sometimes unclear. But it is more likely to happen in women who have experienced (1,4):

• Prior PPROM: Women with a history of PPROM leading to preterm delivery have a 13.5% rate of recurrence in subsequent pregnancies.
• Prior preterm labor and delivery
• Genital tract infection: Genital tract infection is the most common risk factor for PPROM. Common infections include bacterial vaginosis, urinary tract infections, chorioamnionitis, and Group B strep.
• Antepartum bleeding: Bleeding in the first trimester is associated with an increased risk of PPROM.
• Cigarette smoking: smokers have a two to fourfold increased risk of developing PPROM compared to nonsmokers.
• Polyhydramnios: an excess of amniotic fluid
• Placental abruption
• Poor nutrition
• Previous cervical surgery, including cone biopsies or cerclage
• Overstretching of the uterus and amniotic sac, which sometimes occurs with multiple fetuses or too much amniotic fluid (hydramnios)

PROM and PPROM are associated with the following complications (1,2,3):

• Premature birth: The main risk of PPROM is premature birth, or birth before 37 weeks. This can lead to many serious neonatal complications.
• Fetal distress
• Respiratory distress syndrome (RSD)
• Infections: The fetus is at a higher risk of infection after the leaking of the amniotic fluid that surrounds and protects it.
• Loss of nutrients
• Sepsis
• Umbilical cord prolapse: a complication in which the umbilical cord comes out before or alongside of the fetus and can be compressed. This can cause birth asphyxia, periventricular leukomalacia (PVL), and hypoxic-ischemic encephalopathy (HIE). Umbilical cord compression usually requires emergency c-section.
• Placental abruption
• Chorioamnionitis: the inflammation of the fetal membrane
• Malpresentation
• Oligohydramnios
• Necrotizing enterocolitis (NEC)
• Intraventricular hemorrhage (IVH – brain bleeds)
• Periventricular leukomalacia. Although PVL can occur in term infants, it is most frequently found in premature babies.
• Hypoxic-ischemic encephalopathy (HIE). HIE usually occurs in term infants, but sometimes premature babies can develop it. HIE usually involves damage to the basal ganglia, cerebral cortex, and watershed regions of the brain and can sometimes also include PVL.
• Neonatal encephalopathy
• Permanent brain damage
• Seizure disorders
• Cerebral palsy (CP)
• Motor disorders
• Microcephaly
• Meningitis
• Fetal death

Water breaking

The most important symptom of PROM/PPROM is fluid leaking from the vagina (1). This is what is often referred to as “water breaking,” and it usually feels like a sudden gush or a slow trickle of fluid from the vagina. The fluid is clear or pale yellow. Many women describe the “water breaking” as a constant or intermittent leaking of smaller amounts of fluid, and others have observed it as a sensation of wetness. If you think your water has broken, whether prematurely or during labor contractions, call your doctor immediately.

Signs of infection

Infection and PROM/PPROM can occur together. Thus, it is important to recognize the signs of infection. Signs of infection include the following:

• Contractions of the uterus
• Increased temperature and heart rate (in the mother)
• Tenderness of the uterus
• Foul-smelling vaginal discharge
• Increased white blood cell count or a change in the pattern of white blood cell type
• An increase in the baby’s heart rate

Physicians can diagnose PROM using a thorough history, a physical examination, and lab testing. They can observe amniotic fluid that has pooled or is coming out of the cervical canal (1). They can also use a speculum to determine if fluid is leaking from the cervix. If the fluid isn’t immediately present, the patient may be asked to cough or push gently on the fundus to push some of it out (4). A sample of fluid from the vagina is examined under a microscope and tested with special paper to verify that the fluid is amniotic. An ultrasound may also be used to determine the amount of amniotic fluid around the baby. Roughly 50-70% of women with PPROM have low amniotic fluid volume in the first sonography.

When PROM and PPROM occur, it is necessary for the mother to receive treatment (antibiotics) to avoid possible infection in the newborn, which can lead to premature birth, sepsis, meningitis, hypoxic-ischemic encephalopathy, periventricular leukomalacia, cerebral palsy, and intraventricular hemorrhages (IVH).

In a term pregnancy where PROM has occurred, spontaneous labor usually is permitted. Current care standards suggest that labor induction is beneficial at or after 24 weeks , although many physicians induce labor immediately.  Research suggests that a woman who has labor induced is less likely to develop an infection in her uterus than a woman who waits for labor to start naturally. Antibiotics usually are given prophylactically to ensure that no infection is spread to the baby.

When PROM occurs after 37 weeks, your doctor will likely induce labor within 24 hours (2). If you are between 34 and 37 weeks, labor will often be induced also, because it is thought that the risk of infection is greater than the risk of the baby being born a few weeks early.

If PROM occurs before 34 weeks, the situation is more complex (2). If there are no signs of infection, the physician may determine it’s too soon to deliver the baby safely and try to delay labor with medication.

Corticosteroids

Corticosteroids decrease perinatal morbidity and mortality when used to treat PROM (4). They are commonly used with babies likely to be born prematurely, to accelerate lung development within the womb. The physician may collect a sample of amniotic fluid (amniocentesis) for analysis to determine if the baby’s lungs are mature before administering corticosteroids.

When PPROM occurs before 32 weeks of pregnancy, it is best to delay delivery. A course of corticosteroids should be given. Research shows that neonatal death, respiratory distress syndrome (RDS), intraventricular hemorrhages (IVH) or brain bleeds, necrotizing enterocolitis (tissue death in portions of the bowel), and the duration of respiratory support were significantly reduced by steroid treatment, without an increase in either maternal or neonatal infection. Babies delivered this early often have RDS, IVH, and intestinal problems (NEC).

The use of corticosteroids even after 32 weeks (late preterm) in women showed a number of benefits for the infant (5). These babies had lower rates of respiratory complications and less surfactant need than babies whose mothers were not given the steroids.

Antibiotics are also used to treat PROM because they can reduce neonatal infections (4). A study found that women with PROM who were treated with antibiotics had lower rates of chorioamnionitis, neonatal sepsis, endometritis, neonatal pneumonia, and neonatal intraventricular hemorrhage (4). The rationale for administering antibiotics as a precautionary measure is that infection appears to be both a cause and consequence of PPROM, and is related to preterm delivery.  The goal of antibiotic therapy is to decrease the frequency of maternal and fetal infection, to delay the onset of preterm labor, and to minimize the risk of chorioamnionitis, cerebral palsy, and other known complications associated with infection.

The key to understanding PPROM is that a premature baby with an infection is much more worrisome than a premature baby without an infection. Ideally, the baby should be delivered before infection occurs. This is difficult to predict, so close monitoring is essential, and signs of infection or changes in the baby’s testing (even subtle ones) should be relied on.

The longer the time between the rupture of membranes and delivery of the baby, the more likely the chance of infection occurring (1). The risk significantly increases if labor does not occur within 12 hours of the membranes rupturing. The main goal is to keep the baby safe. It is crucial to protect a baby from infection. It also is important to prevent the dangers that can happen when physicians wait for a natural delivery, which may not occur within a safe time frame. This could lead to using forceps and vacuum extractors, which carry the risk of traumatic birth injuries to the delicate baby, or administering potentially dangerous drugs like Cytotec and Pitocin to speed up delivery.

There are many complications that can occur with premature rupture of membranes. It is crucial for physicians to closely monitor the mother and baby when PROM/PPROM takes place. Timing is very important in these instances. Guidelines must be followed to prevent infection and to ensure that the baby’s lungs are mature at birth. These factors take careful consideration and skill. If a physician or medical team fails to follow medical guidelines and standards of care, properly monitor the infant, or perform a timely C-section when necessary, it is negligence. If this negligence leads to injury of the mother or baby, it is medical malpractice.