Premature Rupture of Membranes (PROM)

Overview: 

Premature rupture of membranes (PROM), or pre-labor rupture of membranes, is a condition that can occur in pregnancy. It is defined as rupture of membranes (breakage of the amniotic sac), commonly called breaking of the mother's water(s), more than 1 hour before the onset of labor. The sac (consisting of membranes, the chorion and amnion) contains amniotic fluid, which surrounds and protects the fetus in the uterus (womb). After rupture, the amniotic fluid leaks out of the uterus through the vagina. 

1. Risk Factors: 

The cause of premature rupture of membranes (PROM) is not clearly understood, but the following are risk factors that have been shown to increase the chance of it happening. In many cases, however, no risk factor is identified.  

• Infections: urinary tract infection, sexually transmitted diseases, lower genital infections (ex: Bacterial Vaginosis)  

• Cigarette smoking during pregnancy 

• Illicit drug use during pregnancy 

• Having had PROM or preterm delivery in previous pregnancies 

• Hydramnios: too much amniotic fluid 

• Multiple gestation: being pregnant with two or more fetuses at one time 

• Having had episodes of bleeding anytime during the pregnancy 

• Invasive procedures (ex: amniocentesis)  

• Nutritional deficits 

• Cervical insufficiency: having a short or prematurely dilated cervix during pregnancy  

• Low socioeconomic status 

When premature rupture of membranes occurs at or after 37 weeks completed gestational age (at term), there is minimal risk to the fetus and labor typically starts soon after. If rupture occurs before 37 weeks, called preterm premature rupture of membranes (PPROM), the fetus and mother are at greater risk for complications. PPROM causes one-third of all preterm births, and babies born preterm (before 37 weeks) can suffer from the complications of prematurity, including death. Open membranes provide a path for bacteria to enter the womb and puts both the mother and fetus at risk for life-threatening infection. Low levels of fluid around the fetus also increase the risk of the umbilical cord compression and can interfere with lung and body formation in early pregnancy.  

2. PROM at Term: 

If labor does not begin soon after the rupture of membranes, an induction of labor is recommended because it reduces rates of infections, decreases the chances that the baby will require a stay in the neonatal intensive care unit (NICU), and does not increase the rate of cesarean sections.  

3. PPROM Greater than 34 Weeks: 

When the fetus is premature (< 37 weeks), the risk of being born prematurely must be weighed against the risk of prolonged membrane rupture. As long as the fetus is 34 weeks or greater, delivery is recommended as if the baby was term.  

4. PPROM Less than 34 Weeks: 

Before 34 weeks, the fetus is at a much higher risk of the complications of prematurity. Therefore, as long as the fetus is doing well, and there is no signs of infection or placental abruption, watchful waiting (expectant management) is recommended. The younger the fetus, the longer it takes for labor to start on its own, but most women will deliver within a week. Waiting usually requires a woman to stay in the hospital so that health care providers can watch her carefully for infection, placental abruption, umbilical cord compression, or any other fetal emergency that would require quick delivery by induction of labor. 

5. Chorioamnionitis: 

Chorioamnionitis is a bacterial infection of the fetal membranes, which can be life-threatening to both

mother and fetus. Women with PROM at any age are at high risk of infection because the membranes

are open and allow bacteria to enter. Women are checked often (usually every 4 hours) for signs of

infection: fever (> 38 °C/100.5 °F), uterine pain, fast maternal heart rate (>100 beats per minute), fast fetal

heart rate (>160 beats per minute), or foul smelling amniotic fluid. If infection is suspected, artificial

induction of labor is started at any gestational age and broad antibiotics are given. Cesarean section

should not be automatically done in cases of infection, and should only be reserved for the usual fetal emergencies. 

6. Pre-Term Birth (Before 37 weeks): 

PROM occurring before 37 weeks (PPROM) is one of the leading causes of preterm birth. 30-35% of all preterm births are caused by PPROM. This puts the fetus at risk for the many complications associated with prematurity such as respiratory distress, brain bleeds, infection, necrotizing enterocolitis (death of the fetal bowels), brain injury, muscle dysfunction, and death. Prematurity from any cause leads to 75% of perinatal mortality and about 50% of all long-term morbidity. PROM is responsible for 20% of all fetal deaths between 24 and 34 weeks gestation.  

7. Fetal Development (before 24 weeks): 

 Before 24 weeks the fetus is still developing its organs, and the amniotic fluid is important for protecting the fetus against infection, physical impact, and for preventing the umbilical cord from becoming compressed. It also allows for fetal movement and breathing that is necessary for the development of the lungs, chest, and bones. Low levels of amniotic fluid due to mid-trimester or pre-viable PPROM (before 24 weeks) can result in fetal deformity (ex: Potter-like facies), limb contractures, pulmonary hypoplasia (underdeveloped lungs), infection (especially if the mother is colonized by group B streptococcus or bacterial vaginosis), prolapsed umbilical cord or compression, and placental abruption.  

Why is PROM Important to the NICU RT? 

PROM (Premature Rupture of Membranes) is important for a Neonatal Intensive Care Unit Respiratory Therapist (NICU RT) to know for several reasons: 

• Respiratory Distress Risk: PPROM increases the risk of premature birth. Preterm infants often face respiratory distress syndrome (RDS) due to underdeveloped lungs. As a NICU RT, understanding this risk helps in anticipating and managing respiratory complications in these infants.  

• Assessment and Monitoring: Infants born after PPROM may have respiratory issues requiring immediate assessment and monitoring. NICU RTs play a crucial role in evaluating respiratory status, providing respiratory support, and monitoring oxygen levels. 

• Surfactant Administration: Preterm infants born after PPROM may lack sufficient surfactant, a substance necessary for lung function. NICU RTs may be involved in administering surfactant therapy to improve lung compliance and prevent or treat RDS. 

• Ventilation Support: Infants born prematurely due to PPROM may need mechanical ventilation or non-invasive respiratory support. NICU RTs are responsible for managing ventilators, providing respiratory care, and ensuring adequate oxygenation. 

• Neonatal Resuscitation: In cases of very premature births resulting from PPROM, neonatal resuscitation skills become crucial. NICU RTs are trained to assist in resuscitation efforts, including providing respiratory support and managing airway issues. 

• Infection Control: PPROM increases the risk of infection for both the mother and the newborn. NICU RTs need to be vigilant about infection control practices to prevent the transmission of infections to vulnerable preterm infants.