Definition

Premature rupture of membranes (PROM) is the rupture of gestational membranes before the onset of labor.

PROM can occur at or after 37 weeks of gestation and is called full-term PROM. When membrane rupture occurs before 37 weeks of gestation, it is referred to as preterm premature rupture of membranes (PPROM).

In Indonesia, the problem of preterm rupture of membranes (PPROM) is quite common and has a high incidence. The incidence of PROM is around 6.46-15.6% in full-term pregnancies.

It is a major cause of increased infant mortality and morbidity. In addition, the maternal mortality rate (MMR) and infant mortality rate (IMR) in Indonesia are still health problems and are among the highest in Southeast Asian countries.

Premature rupture of the membranes can result in both immediate and long-term medical complications, as well as economic difficulties. As a result, it is one of the cases that demands extra attention.

In the meanwhile, 8% of all pregnancies globally may have PROM. Additionally, African Americans are more likely to have it.

Causes

The amniotic membrane's natural tendency to rupture toward the end of pregnancy could be caused by uterine contractions or by the membrane itself.

Nevertheless, other researchers hypothesize that the development of PROM is connected to an upsurge in inflammatory cells and their interactions with the amniotic membrane, which may raise intrauterine pressure and result in an early rupture of the membranes.

Risk factor

In most cases, the cause of PROM is unknown. Some cause or risk factors may be:

• Patients with low socioeconomic status
• Smokers
• History of sexually transmitted infections
• History of preterm labor
• History of PROM in a previous pregnancy
• History of vaginal bleeding or bleeding through the vagina
• History of uterine overstretching e.g. because of multiple pregnancies 
• Multiple or twin pregnancies
• Polyhydramnios or excessive amniotic fluid levels
• A decreased amount of collagen in the amniotic membrane
• Nutritional deficiencies in zinc and copper
• Low body mass index
• Short cervix or cervix

Symptoms

The symptoms of PROM may vary from case to case, including:

• Sudden vaginal discharge that cannot be contained
• Wetness in the vagina or underwear
• There is fluid seeping or leaking in the vagina

Many people occasionally have trouble telling the difference between pee and amniotic fluid. Amniotic fluid should, in short, be odorless, transparent, and non-foaming.

Diagnosis

Upon arrival, the doctor will conduct an assessment of the pregnant woman with PROM. The assessment includes confirmation of diagnosis, confirmation of gestational age and fetal position, and assessment of maternal and fetal conditions.

Medical Interview and Physical Examination

The diagnosis of PROM can be made through anamnesis or medical interview and physical examination by looking at the amniotic fluid that comes out. The doctor will ask about the patient's main complaints, accompanying complaints if any, confirmation and gestational age, and the presence of risk factors experienced by the patient as described above.

On physical examination, the doctor can use litmus paper to see the pH level or acidity level in the fluid that comes out of the vagina. If the red litmus paper changes color to blue when exposed to the fluid, then it is most likely amniotic fluid.

The doctor can also perform a direct examination using a speculum inserted into the vagina that has been lubricated. In this examination, the doctor will see if there is an opening of the uterine mouth, and whether there is an umbilical cord or the bottom of the fetus that has descended into the vagina.

Ultrasound (Ultrasonography)

Ultrasound examination is used to assess amniotic fluid. If it is found that the amount of amniotic fluid is reduced without any abnormalities in the fetal kidneys or no other problems with the fetus, the suspicion of rupture of the membranes is very large. 

Laboratory examination

Blood tests may be required to confirm the diagnosis of PROM. The doctor may recommend blood tests if there is a suspicion of infection because of PROM. The doctor may also take a sample of vaginal fluid to rule out other diagnoses.

Management

Management of patients with prelabor rupture of membranes is determined by gestational age.

• Early term and term patients (37 0/7 weeks of gestation or more): proceed to delivery and Group B Streptococcus prophylaxis should be administered as indicated
• Late Preterm (34 0/7- 36 6/7 weeks of gestation): same for early term and term
• Preterm (24 0/7–33 6/7 weeks of gestation): expectant management, latency antibiotics, single course of corticosteroids, GBS prophylaxis as indicated
• Less than 24 weeks of gestation: patient counseling, expectant management or induction of labor, antibiotics can be considered as early as 20 0/7 weeks of gestation, GBS prophylaxis/corticosteroids/tocolysis/magnesium sulfate are not recommended before viability

Furthermore, physicians may administer corticosteroid medication to aid in the fetus's lung growth. Depending on the health of the mother and fetus or the treatment provided by the doctor, each pregnant woman will receive different care.

Complications

PROM can cause several complications. Both complications to the mother and the fetus. Among them are the following:

• Maternal Complications

Intrauterine infection, often known as uterine infection, is the most frequent problem among mothers. Sepsis may result from an infection that manifests as either chorioamnionitis (infection of the amniotic membrane) or endomyometritis (infection of the uterine wall).

When an infection spreads to every organ in the body, it is called sepsis. Sepsis has the potential to raise maternal mortality if left untreated.

Furthermore, there is an increased chance of a cesarean section. Following surgery, complications may include bleeding, infection, or injury to organs.

Read more about membrane infections: The Disease Of Korioamnionitis - Definition, Cause, Symptom, And Laksana AI Care (ai-care.id)

• Fetal Complications

The most common complication is premature labor. Furthermore, a living fetus may suffer from diseases like cord compression, respiratory difficulty, neurological distress, and brain hemorrhage if premature rupture of the membranes happens extremely early.

Prevention

There is no known method to stop membranes from rupturing too soon. To help the doctor treat you appropriately if you have a condition that puts you at risk for PROM, you can take regular birth control during your pregnancy.

It is advantageous for pregnant women to gain knowledge about PROM to be ready and respond appropriately when it takes place.

Pregnant women should also make sure they are getting enough fluids by drinking at least two liters of water daily, minimizing their intake of sugar and caffeine, abstaining from alcohol and tobacco, maintaining a healthy body mass index, and taking any vitamins or supplements that their doctor prescribes.

When to see a doctor?

If you are pregnant and there is a vaginal discharge that cannot be restrained like urination, especially if you have risk factors for PROM, immediately go to the nearest doctor for further treatment.

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