Premature Rupture of Membranes (PROM)

Expect the urgent delivery - Nonreassuring fetal status and chorioamnionitis are both indications for delivery, and umbilical cord prolapse or fetal prolapse seen on sterile speculum exam converts this to an emergency. Vaginal bleeding raises the question of abruption. Have the cesarean plan made before the call comes.

Diagnose chorioamnionitis by temperature plus one sign - Fever of at least 39°C (102.2°F), or 38°C to 39°C confirmed within 30 minutes, together with a clinical finding: uterine tenderness, abdominal pain, foul-smelling discharge, or maternal and fetal tachycardia. WBC count does not settle it — it is nonspecific and antenatal corticosteroids cause a transient leukocytosis. Ampicillin and gentamicin are the usual antibiotics; clindamycin, cefazolin, or vancomycin for penicillin allergy.

Maternal tachycardia may be sepsis, not hypovolemia - Maternal and fetal tachycardia are part of the chorioamnionitis picture. Sort out which one you are treating before you chase it with volume alone.

Magnesium is often already running - Magnesium sulfate is given when delivery is anticipated before 32 0/7 weeks to reduce the risk of cerebral palsy. It potentiates rocuronium, vecuronium, and cisatracurium — use small doses titrated to a twitch monitor. It does not potentiate succinylcholine, so RSI is unchanged, though fasciculations may be blunted or absent.

Check for hypermagnesemia at the knee - Patellar reflexes are the bedside marker and are lost around 12 mg/dL. ECG shows a prolonged PR and widened QRS at 6 to 12 mg/dL, respiratory arrest and SA/AV node block at 15 to 20 mg/dL, and cardiac arrest at 24 mg/dL or above. Stop the infusion and give calcium gluconate 1 g IV over 10 minutes.

Know what else is on board - A single course of antenatal corticosteroids between 24 0/7 and 34 0/7 weeks when delivery is likely within 7 days, and a 7-day antibiotic course for PPROM under 34 weeks (IV ampicillin and erythromycin for 48 hours, then oral amoxicillin and erythromycin). GBS prophylaxis if the patient qualifies. Tocolytics may buy latency but carry a higher chorioamnionitis rate before 34 weeks and have shown no clear maternal or neonatal benefit.

Tocolytic contraindications overlap your concerns - Preeclampsia with severe features, intrauterine fetal demise, lethal fetal anomaly, chorioamnionitis, hemorrhage, and significant maternal cardiac disease. If tocolysis is off the table, delivery is closer than it looks.

Limit the vaginal exams - Digital exam is avoided unless delivery is imminent or the patient is in active labor, because repeated exams after rupture drive infection. Diagnosis rests on sterile speculum exam — pooling, ferning, and vaginal fluid pH of 7.1 to 7.3 against 4.5 to 6.0 for normal secretions. Blood, semen, alkaline antiseptics, and bacterial vaginosis all give false positives.

Brief the neonatal team - The pediatric team needs the gestational age, the antibiotic and steroid course, and the infection picture before delivery. For a severely preterm fetus, the family's wishes about newborn care should already be documented.

Anticipate the premature neonate - Prematurity is the main consequence of PPROM. Respiratory distress is the most common complication, with sepsis, intraventricular hemorrhage, and necrotizing enterocolitis behind it. Magnesium and maternal opioids both contribute to apnea in the newborn — tell the neonatal team what you gave.

Premature (prelabor) rupture of membranes (PROM) is rupture of the gestational membranes before labor begins; before 37 weeks it is preterm PROM (PPROM). The membranes weaken from a rise in local cytokines, an imbalance between matrix metalloproteinases and their tissue inhibitors, and increased collagenase and protease activity, often on a background of rising intrauterine pressure. Intra-amniotic infection is the association that matters most in PPROM. PROM complicates about 8% of pregnancies at term and PPROM about 1% of deliveries, and roughly half of women with PPROM deliver within a week. Perinatal morbidity and mortality with PPROM exceeds 20% and tracks gestational age at delivery. For anesthesia, PROM is rarely the case itself — it is the setup for chorioamnionitis, a premature neonate, cord prolapse, and an urgent cesarean.