PROM

PROM occurs when the fetal membranes rupture prior to the onset of labor, regardless of gestational age. When this occurs before 37 weeks, it is specifically termed PPROM. Risk factors include prior PROM/PPROM, intra-amniotic infection, smoking, short cervical length, low socioeconomic status, connective tissue disorders (e.g., Ehlers-Danlos syndrome), polyhydramnios, multiple gestation, and vaginal bleeding during pregnancy.

Pathophysiology involves weakening of the membranes due to inflammation, infection (subclinical chorioamnionitis is a major cause of PPROM), oxidative stress, and mechanical factors, leading to collagen degradation via matrix metalloproteinases.

Diagnosis is clinical: sterile speculum exam showing pooling of fluid in the vaginal vault, a positive nitrazine test (pH >6.5, turns blue), and ferning pattern on microscopy. Ultrasound may show oligohydramnios. Avoid digital cervical exams to reduce infection risk until labor is imminent or induction planned.

Management depends on gestational age: - Term PROM (≥37 weeks): Induce labor if not spontaneous within a reasonable time to reduce infection risk. - Preterm PPROM (24-34 weeks): Expectant management with antibiotics (typically ampicillin and azithromycin/erythromycin) to prolong latency and reduce infection, corticosteroids for fetal lung maturity, and magnesium sulfate for neuroprotection if <32 weeks. Tocolytics are generally avoided or used cautiously. - Previable PPROM (<24 weeks): Counseling regarding poor prognosis, risks of pulmonary hypoplasia, and expectant management vs. termination.

Complications include chorioamnionitis, umbilical cord prolapse or compression, placental abruption, fetal pulmonary hypoplasia (especially if oligohydramnios occurs early and is prolonged), and neonatal sepsis. Monitoring for signs of infection (maternal fever, tachycardia, uterine tenderness, fetal tachycardia) is critical during expectant management.