Premature rupture of membranes resident survival guide
Synonyms and keywords:Approach to premature rupture of membranes; PROM; Preterm prelabor rupture of membrane; Preterm premature rupture of membranes; pPROM

# Overview
Premature rupture of membranes (PROM) is a condition that occurs in pregnancy when the amniotic sac ruptures before the onset of labor irrespective of gestational age. The term pPROM stands for preterm premature rupture of the membranes which occurs when the rupture happens before 37 weeks of gestation. Risk factors include maternal vaginal infections which ascend to the amniotic membrane, vaginal bleeding during pregnancy and maternal stature among others. Rupture of the membranes typically presents as a large gush of clear vaginal fluid or as a steady trickle. The differential diagnosis includes leakage of urine, excessive vaginal discharge for example physiologic discharge or bacterial vaginosis and cervical mucus (show) as a sign of impending labor.The diagnosis of PROM is done by careful complete history and physical examination, ultrasound is done to confirm oligohydramnios. Once the membranes rupture, delivery is recommended when the risk of ascending infection outweighs the risk of prematurity. When PROM occurs at term, labor typically takes place spontaneously or is induced within 12 to 24 hours.

# Causes
Common risk factors in the development of PROM include :
- Maternal risk factors:
Sepsis
Previous history of PROM, recurrence risk is 16%32% as compared with 4% in women with a prior uncomplicated term delivery.
Chronic steroid therapy
Abnormal bleeding during the second trimester or late in the pregnancy.
Low body mass index (BMI < 19.8 kg/m2)
Smoking and drug abuse
Low socioeconomic status
Deficiency of copper or vitamin C, along with connective tissue disorders such as  Ehlers-Danlos syndrome, Systemic Lupus Erythematosus are also linked to increased risk of PROM.
Direct abdominal trauma
Preterm labor
Anemia
- Sepsis
- Previous history of PROM, recurrence risk is 16%32% as compared with 4% in women with a prior uncomplicated term delivery.
- Chronic steroid therapy
- Abnormal bleeding during the second trimester or late in the pregnancy.
- Low body mass index (BMI < 19.8 kg/m2)
- Smoking and drug abuse
- Low socioeconomic status
- Deficiency of copper or vitamin C, along with connective tissue disorders such as  Ehlers-Danlos syndrome, Systemic Lupus Erythematosus are also linked to increased risk of PROM.
- Direct abdominal trauma
- Preterm labor
- Anemia
- Uteroplacental Factors:
Uterine anomalies (such as uterine septum)
Placental abruption
Advanced cervical dilation (cervical insufficiency)
Prior cervical conization
Cervical shortening in the 2nd trimester (< 2.5 cm)
Uterine overdistention (Polyhydramnios, Multiple pregnancy)
Intra-amniotic infection (Chorioamnionitis)
Multiple bimanual vaginal examinations (but not sterile speculum or transvaginal ultrasound examinations)
- Uterine anomalies (such as uterine septum)
- Placental abruption
- Advanced cervical dilation (cervical insufficiency)
- Prior cervical conization
- Cervical shortening in the 2nd trimester (< 2.5 cm)
- Uterine overdistention (Polyhydramnios, Multiple pregnancy)
- Intra-amniotic infection (Chorioamnionitis)
- Multiple bimanual vaginal examinations (but not sterile speculum or transvaginal ultrasound examinations)
- Fetal factors include :
Multiple pregnancy ( preterm PROM complicates 7%10% of twin pregnancies)
Prematurity
Infection
Cord prolapse
Malpresentation. 
- Multiple pregnancy ( preterm PROM complicates 7%10% of twin pregnancies)
- Prematurity
- Infection
- Cord prolapse
- Malpresentation. 

# Diagnosis
Shown below is an algorithm summarizing the diagnosis of Premature rupture of membranes:
Abbreviations: BP: Blood pressure; RR=Respiratory rate;
HR=Heart Rate, PROM= Premature rupture of membranes; AFV=  Amniotic fluid volume

# Treatment
Shown below is an algorithm summarizing the treatment of premature rupture of membranes.
Abbreviations: PROM: Premature rupture of membranes; ECG=Electrocardiogram ;
GBS= Group B Streptococcus, IV= Intravenous; HSV=  Herpes Simplex Virus volume; HIV=Human Immunodeficiency Viruse

# Dos
- GBS prophylaxis should be given based on prior culture results or intrapartum risk factors if cultures not performed or unavailable.
- Patient should be monitored regularly with ultrasound and counsel patients to watch for signs of infection, bleeding or miscarriage.
- Cervical cerclage should be considered for women with the following:
Current singleton pregnancy.
Prior spontaneous preterm birth < 34 weeks.
Cervical length < 25 mm prior to 24 weeks.
- Current singleton pregnancy.
- Prior spontaneous preterm birth < 34 weeks.
- Cervical length < 25 mm prior to 24 weeks.
- Pregnant women should avoid smoking.

# Don'ts
- Tocolytic therapy is not recommended at 34w0d to 36w7d gestation.