Premature Rupture of Membranes: Understanding and Management

What is Premature Rupture of Membranes (PROM)?

PROM occurs when the amniotic sac ruptures before the onset of labor, which includes signs such as vaginal discharge, abdominal pain, bulging of the amniotic sac, cervical effacement, cervical dilation, and cervical ripening.

Valsalva Maneuver in PROM

The Valsalva maneuver helps to check for amniotic fluid leakage by forcefully coughing, increasing abdominal pressure. If fluid is released, it indicates that the amniotic sac has ruptured.

Why is a Vaginal Exam Not Recommended with PROM?

A vaginal exam can increase the risk of infection because the speculum insertion can cause the cervix to close, creating a favorable environment for bacterial invasion.

Amniotic Fluid Infection

Amniotic fluid infection can affect both the mother and the baby:

• Baby: Early-onset neonatal sepsis (NTSS)

• Mother: 9 types of postpartum infection

Fetal Ultrasound in the First Trimester

• Ultrasound at 11-13 weeks:

• Measure nuchal translucency

• Assess the risk of Down syndrome

• Detect chromosomal abnormalities

• Ultrasound at 20-22 weeks:

• Assess fetal morphology

• Ultrasound at 30-32 weeks:

• Monitor fetal growth

Determining Gestational Age Using Ultrasound

• Fetus < 13 weeks 6 days: Ultrasound is the most accurate method for determining gestational age.

• Fetus > 14 weeks: The fetus has started to move, so the accuracy of ultrasound will decrease.

Determining Gestational Age in the First Trimester Using Ultrasound

• Based on factors such as:

• Gestational sac

• Amniotic sac

• Crown-rump length

Identifying the True Gestational Sac

The true gestational sac is eccentric in the early stages, with a bright ring of trophoblasts and a bright ring…

Determining Gestational Age After 14 Weeks

• Based on parameters such as:

• Head circumference (HC)

• Abdominal circumference (AC)

• Femur length (FL)

• Biparietal diameter (BPD)

Abnormalities in the First Trimester

• Multiple gestation:

• 1 placenta: T sign

• 2 placentas: Lambda sign

• Missed miscarriage

• Threatened miscarriage

• Incomplete miscarriage

• Ectopic pregnancy

• Molar pregnancy

When is the Lambda Sign Specific?

The Lambda sign is only specific in the first trimester. In the second trimester, this sign will resemble the T sign.

What Information Does First Trimester Ultrasound Provide?

• Information about the fetus: Size, heartbeat, weight, fetal presentation, fetal movements

• Information about adnexa: Placental maturity, placental location, amniotic fluid, amniotic fluid index (AFI), placenta previa

Clinical Presentation of PROM

• Symptoms: Vaginal fluid discharge, abundant, watery or flocculent, increased cough.

Differential Diagnosis of Amniotic Fluid from Other Secretions

• Urine

• Mucus

• Vaginal discharge

Foul-Smelling Vaginal Discharge

• Considerations:

• Presence of infection?

• Gestational age

• Labor

Antibiotics in PROM

• Cephalosporin antibiotics are used for about 4 hours before the baby is born.

Distinguishing PROM from Preterm Premature Rupture of Membranes (PPROM)

• PROM: The amniotic sac ruptures before the onset of labor, PROM occurs 1 hour before labor.

• PPROM: The amniotic sac ruptures during labor, before the cervix is fully dilated.

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