Premature Rupture of Membranes

Definition Premature rupture of membranes (PROM) is an event that occurs during pregnancy when the sac containing the developing baby (fetus) and the amniotic fluid bursts or develops a hole prior to the start of labor. Description During pregnancy, the unborn baby (fetus) is surrounded and cushioned by a li uid called amniotic fluid. !his fluid, along with the fetus and the placenta, is enclosed within a sac called the amniotic membrane. !he amniotic fluid is important for several reasons. "t cushions and protects the fetus, allowing the fetus to move freely. !he amniotic fluid also allows the umbilical cord to float, preventing it from being compressed and cutting off the fetus#s supply of o$ygen and nutrients. !he amniotic membrane contains the amniotic fluid and protects the fetal environment from the outside world. !his barrier protects the fetus from organisms (li%e bacteria or viruses) that could travel up the vagina and potentially cause infection. &lthough the fetus is almost always mature at between '()*+ wee%s and can be born without complication, a normal pregnancy lasts an average of *+ wee%s. &t the end of *+ wee%s, the pregnancy is referred to as being ,term., &t term, labor usually begins. During labor, the muscles of the uterus contract repeatedly. !his allows the cervi$ to begin to grow thinner (called effacement) and more open (dilatation). -ventually, the cervi$ will become completely effaced and dilated. "n the most common se uence of events (about .+/ of all deliveries), the amniotic membrane brea%s (ruptures) around this time. !he baby then leaves the uterus and enters the birth canal. 0ltimately, the baby will be delivered out of the mother#s vagina. "n the '+ minutes after the birth of the baby, the placenta should separate from the wall of the uterus and be delivered out of the vagina. 1ometimes the membranes burst before the start of labor, and this is called premature rupture of membranes (PROM). !here are two types of PROM. One occurs at a point in pregnancy before normal labor and delivery should ta%e place. !his is called preterm PROM. !he other type of PROM occurs at '()*+ wee%s of pregnancy. PROM occurs in about 2+/ of all pregnancies. Only about 3+/ of these cases are preterm PROM. Preterm PROM is responsible for about '*/ of all premature births. Causes and symptoms !he causes of PROM have not been clearly identified. 1ome ris% factors include smo%ing, multiple pregnancies (twins, triplets, etc.), and e$cess amniotic fluid (polyhydramnios). 4ertain procedures carry an increased ris% of PROM, including amniocentesis (a diagnostic test involving e$traction and e$amination of amniotic fluid) and cervical cerclage (a procedure in which the uterus is sewn shut to avoid premature labor). & condition called placental abruption is also associated with PROM, although it is not %nown which condition occurs first. "n some cases of preterm PROM, it is believed that bacterial infection of the amniotic membrane causes it to wea%en and then brea%. 5owever, most cases of PROM and infection occur in the opposite order, with PROM occurring first followed by an infection. !he main symptom of PROM is fluid lea%ing from the vagina. "t may be a sudden, large gush of fluid, or it may be a slow, constant tric%le of fluid. !he complications that may follow PROM include premature labor and delivery of the fetus, infections of the mother and6or the fetus, and compression of the umbilical cord (leading to o$ygen deprivation in the fetus). 7abor almost always follows PROM, although the delay between PROM and the onset of labor varies. 8hen PROM occurs at term, labor almost always begins within 3* hours. -arlier in pregnancy, labor can be delayed up to a wee% or more after PROM. !he chance of infection increases as the time between PROM and labor increases. 8hile this may cause doctors to encourage labor in the patient who has reached term, the ris% of complications in a premature infant may cause doctors to try delaying labor and delivery in the case of preterm PROM. !he types of infections that can complicate PROM include amnionitis and endometritis. &mnionitis is an infection of the amniotic membrane. -ndometritis is an infection of the innermost lining of the uterus. &mnionitis occurs in +.9)2/ of all pregnancies. "n the case of PROM at term, amnionitis complicates about ')29/ of pregnancies. &bout 29)3'/ of all cases of preterm PROM will be complicated by amnionitis. !he presence of amnionitis puts the fetus at great ris% of developing an overwhelming infection (sepsis) circulating throughout its bloodstream. Preterm babies are the most susceptible to this life)threatening infection. One type of bacteria responsible for overwhelming infections in newborn babies is called group : streptococci. Diagnosis Depending on the amount of amniotic fluid lea%ing from the vagina, diagnosing PROM may be easy. 1ome doctors note that amniotic fluid has a very characteristic musty smell. & pelvic e$am using a sterile medical instrument (speculum) may reveal a tric%le of amniotic fluid leaving the cervi$, or a pool of amniotic fluid collected behind the cervi$. One of two easy tests can be performed to confirm that the li uid is amniotic fluid. & drop of the fluid can be placed on nitra;ine paper. <itra;ine paper is made so that it turns from yellowish green to dar% blue when it comes in contact with amniotic fluid. &nother test involves smearing a little of the fluid on a slide, allowing it to dry, and then viewing it under a microscope. 8hen viewed under the microscope, dried amniotic fluid will be easy to identify because it will loo% ,feathery, li%e a fern. Once PROM has been diagnosed, efforts are made to accurately determine the age of the fetus and the maturity of its lungs. Premature babies are at great ris% if they have immature lungs. !hese evaluations can be made using amniocentesis and ultrasound measurements of the fetus# si;e. &mniocentesis also allows the practitioner to chec% for infection. Other indications of infection include a fever in the mother, increased heart rate of the mother and6or the fetus, high white blood cell count in the mother, foul smelling or pus)filled discharge from the vagina, and a tender uterus. Treatment !reatment of PROM depends on the stage of the patient#s pregnancy. "n PROM occurring at term, the mother and baby will be watched closely for the first 3* hours to see if labor will begin naturally. "f no labor begins after 3* hours, most doctors will use medications to start labor. !his is called inducing labor. 7abor is induced to avoid a prolonged gap between PROM and delivery because of the increased ris% of infection.

Preterm PROM presents more difficult treatment decisions. !he younger the fetus, the more li%ely it may die or suffer serious permanent damage if delivered prematurely. =et the ris% of infection to the mother and6or the fetus increases as the length of time from PROM to delivery increases. Depending on the age of the fetus and signs of infection, the doctor must decide either to try to prevent labor and delivery until the fetus is more mature, or to induce labor and prepare to treat the complications of prematurity. 5owever, the baby will need to be delivered to avoid serious ris%s to both it and the mother if infection is present, regardless of the ris%s of prematurity. & variety of medications may be used in PROM> Medication to induce labor (o$ytocin) may be used, either in the case of PROM occurring at term or in the case of preterm PROM and infection. !ocolytics may be given to halt or prevent the start of labor. !hese may be used in the case of preterm PROM, when there are no signs of infection. Delaying the start of labor may give the fetus time to develop more mature lungs. 1teroids may be used to help the fetus# lungs mature early. 1teroids may be given in preterm PROM if the fetus must be delivered early because of infection or labor that cannot be stopped. &ntibiotics can be given to fight infections. Research is being done to determine whether antibiotics should be given prior to any symptoms of infection to avoid the development of infection. Prognosis !he prognosis in PROM varies. "t depends in large part on the maturity of the fetus and the development of infection. Prevention !he only controllable factor associated with PROM is smo%ing. 4igarette smo%ing should always be discontinued during a pregnancy.

Ruptured Uterus
Overview of Ruptured Uterus During labor there are spasmodic contractions of the uterus. Rarely, there may be a sharp, ripping sensation in the upper and lower abdomen during these contractions. !he uterus becomes ruptures. :leeding into the abdomen may occur and the fetus may be e$truded from the uterus. Causes of Ruptured Uterus Rupture of the uterus may be caused by cephalopelvic disproportions, instrumentation used during delivery, trauma and fetal malposition. Previous cesarean section is a ris% factor. Signs and Symptoms of Ruptured Uterus Rupture of the uterus is heralded by sudden, severe, ripping pain in the upper and lower abdomen. !his occurs during the course of labor. 4ontractions of the uterus suddenly stop. Diffuse abdominal pain and swelling may occur as bleeding into the abdominal cavity occurs. :lood irritating the diaphragms may produce shoulder pain. 1hoc% and anemia may occur leading to shortness of breath, wea%ness, rapid heart rate and pallor. What are the signs of uterine rupture What your caregiver wi!! do "motiona! consideration and S#$DS support & rupturing of the uterus occurs very rarely (2 in about 2,9++ births, or +.+?/), but can cause devastating complications for the woman, and her baby, if it does. "t is a situation where the wall of the woman#s uterus splits open, causing internal haemorrhaging. &s you can imagine this can be life threatening for both the woman and her baby. "f the uterus is at ris% of rupturing, it will usually happen during the labour, but in some circumstances, it can also happen in the last few wee%s of the pregnancy. "t must be remembered, that the following situations will in most cases $OT lead to a rupture of the uterus, but have been lin%ed with it#s occurrence. 0terine rupture can be associated with> %eing given drugs to stimu!ate the contractions& 0sing drugs such as prostag!andins, or an o'ytocin drip, for induction and 6 or augmentation, can carry the ris% of overstimulating the woman#s uterus to contract too vigorously, and therefore increase the ris% of uterine rupture. !his is especially so if this is not the woman#s first baby, as her uterus can be more sensitive to these medications, and therefore more prone to rupturing. !his is e$plained in detail in 4lass *, induction and augmentation. The opening of a scar from a previous Caesarean birth& !his rare complication can occur in about +.' to +.?/ of cases, with a lower segment uterine scar (where the incision was made low and hori;ontal, or across). "t is more li%ely (up to 2+/) if the scar in the uterus is vertical (up and down). !he ris% is also increased if the subse uent labour after a 4aesarean birth is induced or augmented with prostag!andins, or an o'ytocin drip. =ou may wish to read more about vaginal birth after 4aesarean (@:&4) in C!ass ( . The !abour being obstructed& !his is more li%ely if it is the woman#s second or subse uent labour and the baby is not progressing down the birth canal, despite good, strong contractions. !he uterus contracts harder and harder to try and allow the baby to be born. "f this goes on for too long, then the uterus could rupture. "t is more li%ely if the baby is in an unusual position (such as a brow presentation) or is unusually large due to an abnormality or diabetes.

)our caregiver performing a mid to high forceps de!ivery& "f the baby#s head is still relatively high after the woman#s cervi$ has fully dilated, and the woman recommends a forceps delivery, then the forceps may have to be inserted part of the way into the uterus to allow them to be properly placed on the baby#s head (as opposed to #low a forceps delivery# that only needs the forceps to go in as far as the woman#s vagina). !his increases the ris% of damage to the woman#s uterus and possibly uterine rupture. 5igh forceps are rarely done these days, with caregivers opting more for a 4aesarean instead. =ou may wish to read more on this in forceps. )our caregiver needing to manipu!ate the baby interna!!y& 1ometimes the caregiver needs to try and manipulate a baby#s position, by placing their hand inside the woman#s uterus through an internal vaginal e$amination. !his may be necessary to deliver a second twin, who is lying in a transverse position, or across ways in the uterus (after the first baby is born). !his procedure is referred to as an #internal podalic version# (or "P@). !he caregiver usually grabs the feet of the baby to deliver them in a breech position. =ou may wish to read more about this in twins or more. What #re Treatments for the Rupturing of the Uterus "f one has a ruptured uterus a common treatment is a hysterectomy, which is the removal of the uterus. "f the rupture is not as severe, the uterus can be sutured and repaired. & ruptured uterus in pregnancy can lead to fetal death and premature labor.