Preterm prelabour rupture of the membranes (PPROM)

1. Preterm prelabour rupture of the membranes (PPROM)

2. Preterm prelabour rupture of the membranes (PPROM) occurs before 37 completed weeks' gestation, where the fetal membranes rupture without the onset of spontaneous uterine activity and the consequential cervical dilatation. • It affects 2% of pregnancies and placental abruption is evident in 4–7% of women who present with PPROM. The condition has a 17–32% recurrence rate in subsequent pregnancies of affected women

3. There is a strong association between PPROM and maternal colonization (Bacterial vaginosis [BV]), with potentially pathogenic micro-organisms, with a 30% incidence of subclinical chorioamnionitis • Infection may both precede (and cause) or follow PPROM. • It is also more common in smokers and recreational drug users, for example cocaine users. • Preterm prelabour rupture of the membranes is associated with 40% of preterm births

4. Risks of PPROM • Risks associated with PPROM include: • imminent labour resulting in a preterm birth • chorioamnionitis, which may be followed by fetal and maternal systemic infection if not treated promptly • oligohydramnios if prolonged PPROM occurs • cord prolapse • malpresentation associated with prematurity • antepartum haemorrhage • neonatal sepsis • psychosocial problems resulting from uncertain fetal and neonatal outcome and long- term hospitalization; increased incidence of impaired mother and baby bonding after birth

5. Management • If PPROM is suspected, the woman will be admitted to the maternity unit. • A careful history is taken and rupture of the membranes confirmed by a sterile speculum examination of any pooling of liquor in the posterior fornix of the vagina. • Saturated sanitary towels over a 6-hour period will also offer a reasonably conclusive diagnosis if urine leakage has been excluded. • A Nitrazine test may be useful to confirm this. • A fetal fibronectin immunoenzyme test is useful in confirming rupture of the membranes • ,and ultrasound scanning also has some value.

6. Digital vaginal examination should be avoided to reduce the risk of introducing infection. • Observations are made of the fetal condition from the fetal heart rate, as an infected fetus may have a tachycardia, and also a maternal infection screen, temperature and pulse, uterine tenderness and any purulent or offensively smelling vaginal discharge. • A decision on future management will then be made. • If the pregnancy is less than 32 weeks, the fetus appears to be uncompromised and APH and labour have been excluded • it will be managed expectantly.

7. The woman is admitted to hospital. • Frequent ultrasound scans are undertaken to assess the growth of the fetus and the extent and complications of any oligohydramnios. • Corticosteroids are administered to mature the fetal lungs as soon as PPROM is confirmed, should the baby be born early. • If labour intervenes the administration of a tocolytic drug (such as atosiban acetate) should be considered to prolong the pregnancy. In practice these are usually discontinued after the corticosteroids have had time to take effect.

8. Known vaginal infections are treated with antibiotics. Prophylactic antibiotics may also be offered to women without symptoms of infection. • If membranes rupture before 24 weeks of gestation the outlook is poor and the woman may be offered termination of the pregnancy. • If the woman is more than 32 weeks pregnant, the fetus appears to be compromised and APH or intervening labour is suspected or confirmed, active management will ensue. The mode of birth will need to be decided and induction of labour or caesarean section performed. • Hindwater leakage of amniotic fluid, and resealing of the amniotic sac are currently poorly understood phenomena.

9. Conclusion • Midwives have an important role to play when women experience pathological problems in their pregnancy. The woman is likely to report symptoms firstly to a midwife, who will then make basic observations that confirm or exclude the likelihood of a deviation from normal. While explaining her findings to the woman and her partner, the midwife must make a decision about possible diagnoses, whether to transfer her to a high-risk obstetric unit and if this warrants transportation by ambulance. The midwife may be required to start managing the woman's condition prior to admission to hospital. In hospital the midwife is required to ensure the

10. woman's care is coordinated with other healthcare professionals, who must be supplied with appropriate background information, that the woman and her partner receive psychological support and that contemporaneous records are kept • The midwife must report any deterioration in a woman's condition immediately to an appropriate healthcare professional. The midwife is responsible for maintaining continual updating of her professional knowledge and skills in all areas of practice to ensure that every woman receives optimal maternity care throughout her pregnancy.

11. Finishing chapter 12