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History A 22 year old Hispanic female (first pregnancy) at 36 weeks gestation presents to the obstetric triage unit on 5/7/2011 with suspected leakage of clear fluid described as a constant trickle since 2:00 am. She has a history of systemic lupus erythematosus (SLE) and is maintained on prednisone 20mg daily. Additionally, she report having experienced scant vaginal bleeding throughout the first trimester only. Currently the fetal well being is reassuring and the patient has no contractions noted in tocometry. Physical Assessment Upon examination, patient vital signs were BP 108/70, P-99, R-20, and T- 37.10 C. On a a scale of 1- 10, patient indicated that her pain was a 4. There was evidence of fluid pooling in the vagina, or leaking from the cervical os when the patient coughed or when fundal pressure was applied. Her abdomen is soft and she is a febrile. When the fluid was placed on the nitrazine paper, it was positive and confirmed that presence of PROM. In addition a DNA probe or cervical culture for chlamydia and gonorrhea should be performed, those results were negative. Her labs were normal. Date 5/7/2011 5/7/2011 5/7/2011 5/7/2011 5/7/2011 5/7/2011 Type of Test Glucose Urea Nitrogen Sodium Potassium Chloride Calcium Patient Value 96 10 140 4.4 103 9.4 Normal Value 74- 106 7- 20 137-145 3.5-5.1 98- 107 8.4- 10.2 Findings Normal range Normal range Normal range Normal range Normal range Normal range

Definition

2 Premature rupture of membranes (PROM) is an event that occurs during pregnancy when the sac containing the developing babies (fetus) and the amniotic fluid bursts or develops a hole prior to the start of labor. During pregnancy, the unborn baby (fetus) is surrounded and cushioned by a liquid called amniotic fluid. This fluid, along with the fetus and the placenta, is enclosed within a sac called the amniotic membrane. The amniotic fluid is important for several reasons. It cushions and protects the fetus, allowing the fetus to move freely. The amniotic fluid also allows the umbilical cord to float, preventing it from being compressed and cutting off the fetuss supply of oxygen and nutrients. The amniotic membrane contains the amniotic fluid and protects the fetal environment from the outside world. This barrier protects the fetus from organisms (like bacteria or viruses) that could travel up the vagina and potentially cause infection. Although the fetus is almost always mature at between 36-40 weeks and can be born without complication, a normal pregnancy lasts an average of 40 weeks. At the end of 40 weeks, the pregnancy is referred to as being term. At term, labor usually begins. During labor, the muscles of the uterus contract repeatedly. This allows the cervix to begin to grow thinner (called effacement) and more open (dilatation). Eventually, the cervix will become completely effaced and dilated. In the most common sequence of events (about 90% of all deliveries), the amniotic membrane breaks (ruptures) around this time. The baby then leaves the uterus and enters the birth canal. Ultimately, the baby will be delivered out of the mothers vagina. In the 30 minutes after the birth of the baby, the placenta should separate from the wall of the uterus and be delivered out of the vagina. Sometimes the membranes burst before the start of labor, and this is called premature rupture of membranes (PROM). There are two types of PROM. One occurs at a point in pregnancy

3 before normal labor and delivery should take place. This is called preterm PROM. The other type of PROM occurs at 36-40 weeks of pregnancy. PROM occurs in about 10% of all pregnancies. Only about 20% of these cases are preterm PROM. Preterm PROM is responsible for about 34% of all premature births.

Etiology Although the precise cause and specific predisposing factors are unknown, there is a higher incidence of PROM in women who smoke, have had a sexually transmitted disease, intrauterine infection, or have had PROM in a previous pregnancy. African American women are twice as likely as white women to have PROM. Having a multiple pregnancy can increase the risk of PROM. Additionally, procedures such as cervical cerclage and amniocentesis can increase the risks of PROM. Pathophysiology PROM is associated with malpresentation, possible weak areas in the amnion and chorion, subclinical infection, and, possibly, incompetent cervix. Basic and effective defense against the fetus contracting an infection is lost and the risk of ascending intrauterine infection, known as chorioamnionitis, is increased. The leading cause of death associated with PROM is infection. When the latent period (time between rupture of membranes and onset of labor) is less than 24 hours, the risk of infection is low.

Clinical Manifestation

4 The main symptom of PROM is fluid leaking from the vagina. It may be a sudden, large gush of fluid, or it may be a slow, constant trickle of fluid. The complications that may follow PROM include premature labor and delivery of the fetus, infections of the mother and/or the fetus, compression of the umbilical cord (leading to oxygen deprivation in the fetus), maternal fever, fetal tachycardia, and malodorous discharge may indicate infection.
Labor almost always follows PROM, although the delay between PROM and the onset of labor varies. When PROM occurs at term, labor almost always begins within 24 hours. Earlier in pregnancy, labor can be delayed up to a week or more after PROM. The chance of infection increases as the time between PROM and labor increases. While this may cause doctors to encourage labor in the patient who has reached term, the risk of complications in a premature infant may cause doctors to try delaying labor and delivery in the case of preterm PROM.

The types of infections that can complicate PROM include amnionitis and endometritis. Amnionitis is an infection of the amniotic membrane. Endometritis is an infection of the innermost lining of the uterus. Amnionitis occurs in 0.5-1% of all pregnancies. In the case of PROM at term, amnionitis complicates about 3-15% of pregnancies. About 15-23% of all cases of preterm PROM will be complicated by amnionitis. The presence of amnionitis puts the fetus at great risk of developing an overwhelming infection (sepsis) circulating throughout its bloodstream. Preterm babies are the most susceptible to this life-threatening infection. One type of bacteria responsible for overwhelming infections in newborn babies is called group B streptococci. Diagnostic Tests Depending on the amount of amniotic fluid leaking from the vagina, diagnosing PROM may be easy. Some doctors note that amniotic fluid has a very characteristic musty smell. A pelvic exam using a sterile medical instrument (speculum) may reveal a trickle of amniotic fluid leaving

5 the cervix, or a pool of amniotic fluid collected behind the cervix. One of two easy tests can be performed to confirm that the liquid is amniotic fluid. A drop of the fluid can be placed on nitrazine paper. Nitrazine paper is made so that it turns from yellowish green to dark blue when it comes in contact with amniotic fluid. Another test involves smearing a little of the fluid on a slide, allowing it to dry, and then viewing it under a microscope. When viewed under the microscope, dried amniotic fluid will be easy to identify because it will look feathery like a fern. Once PROM has been diagnosed, efforts are made to accurately determine the age of the fetus and the maturity of its lungs. Premature babies are at great risk if they have immature lungs. These evaluations can be made using amniocentesis and ultrasound measurements of the fetus size. Amniocentesis also allows the practitioner to check for infection. Other indications of infection include a fever in the mother, increased heart rate of the mother and/or the fetus, high white blood cell count in the mother, foul smelling or pus-filled discharge from the vagina, and a tender uterus. Medications Corticosteroids decrease perinatal morbidity and mortality after preterm PROM. Because corticosteroids are effective at decreasing perinatal morbidity and mortality, all physicians caring for pregnant women should understand the dosing and indications for corticosteroid administration during pregnancy. The National Institutes of Health recommends administration of corticosteroids before 30 to 32 weeks gestation, assuming fetal viability and no evidence of intra-amniotic infection. Use of corticosteroids between 32 and 34 weeks is controversial. Administration of corticosteroids after 34 weeks gestation is not recommended unless there is evidence of fetal lung immaturity by amniocentesis. ANTIBIOTICS

6 Giving antibiotics to patients with preterm PROM can reduce neonatal infections and prolong the latent period. A meta-analysis showed that patients receiving antibiotics after preterm PROM, compared with those not receiving antibiotics experienced reduced postpartum endometritis, chorioamnionitis, neonatal sepsis, neonatal pneumonia, and intraventricular hemorrhage. It is advisable to administer appropriate antibiotics for intrapartum group B streptococcus prophylaxis to women who are carriers, even if these patients have previously received a course of antibiotics after preterm PROM. TOCOLYTIC THERAPY Limited data are available to help determine whether tocolytic therapy is indicated after preterm PROM. As described above, corticosteroids and antibiotics are beneficial when administered to patients with preterm PROM, but no studies of these therapies combined with tocolysis are available. Tocolytic therapy may prolong the latent period for a short time but do not appear to improve neonatal outcomes. In the absence of data, it is not unreasonable to administer a short course of tocolysis after preterm PROM to allow initiation of antibiotics, corticosteroid administration, and maternal transport, although this is controversial. Long-term tocolytic therapy in patients with PROM is not recommended.

Complications of PROM One of the most common complications of preterm PROM is early delivery. The latent period, which is the time from membrane rupture until delivery, generally is inversely proportional to the gestational age at which PROM occurs. For example, one large study revealed patients at term revealed that 95 percent of patients delivered within approximately one day of PROM, whereas an analysis of studies evaluating patients with preterm PROM between 16 and 26 weeks

7 gestation determined that 57 percent of patients delivered within one week, and 22 percent had a latent period of four weeks. When PROM occurs too early, surviving neonates may develop malpresentation, cord compression, oligohydramnios, necrotizing enter colitis, neurologic impairment, intraventricular hemorrhage, and respiratory distress syndrome. Nursing Management Based on Patients Gestational Age 34 O 36 WEEKS Management is based on gestational age because the patient is 36 weeks gestation, evidence based studies has proved that labor induction clearly is beneficial at or after 34 weeks gestation and pregnancy should not be prolonged more than 24hrs. The physician explained to patient the fetus appears to be unharmed for the moment and she has two options. First option is to start on tocolysis therapy (magnesium sulfate) which will delay preterm delivery within 48 hours from the initiation of steroid prophylaxis with a gain of an additional 3-4 days and this therapy has a high risk of toxicity to both mother and fetus. Option 2 will be to start on antibiotics which will reduce neonatal infections and prolong the latent period and have a greater chance of prolonging labor until 3 weeks, this will bring this patient to 39 weeks. The patient is fully aware of both options and both her and her husband agreed to option 2. The patient was started on 2 grams of ampicillin and 250 mg of erythromycin every six hours for 48 hours, followed by 250 mg of amoxicillin and 333 mg of erythromycin every eight hours for five days. Women given this combination are more likely to stay pregnant for three weeks despite discontinuation of the antibiotics after seven days. It is vital for the nurse to prevent infection and other potential complications. This can be done by making an early and accurate evaluation of membrane status, using sterile speculum examination and determination of ferning. Thereafter, keep vaginal examinations to a minimum to

8 prevent infection, obtain smear specimens from vagina and rectum as prescribed to test for betahemolytic streptococci (an organism that increases the risk to the fetus), determine maternal and fetal status, including estimated gestational age, continually assess for signs of infection, and maintain the client on bed rest if the fetal head is not engaged. This method may prevent cord prolapse if additional rupture and loss of fluid occur. Once the fetal head is engaged, ambulation can be encouraged.

References:

9 Mercer BM, Arheart KL. Antimicrobial Therapy in Expectant Management of Preterm Premature Rupture of the Membranes. Lancet. 1995; 346: 12719. Davidson, Susan. Diseases Causes & Diagnosis Current Therapy Nursing Management Patient Education (Educational Publishing House. 1990)