Differential diagnosis
1) Pre labour rupture of membrane
- Establish that the fluid is truly amniotic fluid and not urine.
- Contraction pain
- Liquor color
2) In labour
- Contraction pain that become shorten in intervals
3) Bacterial vaginosis
- Foul smelling discharge
- Itchiness of vagina
- Yellow or cream color discharge
- Any systemic sign for infection.
Complication to look for
1) Chorioamnionitis
Notes: chorioamnionitis must be anticipated in patient presented with PPROM or PROM as it can cause death to the mother and fetus.
Beware sign and symptoms of chorioamnionitis
a) Fever
b) Maternal tachycardia
c) Tender uterus
d) Fetal tachycardia
Management
1) Close observation of vital sign
2) Review patient regularly especially palpation of uterus.
a) Elicit uterine tenderness
b) Lie and presentation of the fetus
c) Estimated fetal weight.
3) Assessment of fetal well being (CTG and ultrasound )
4) Rehydrate the patient
5) IV ampicillin as prophylaxis against GBS (rate of infection rise after 12 hour rupture of membrane)
6) Corticosteroid is not indicated.
7) Notify the pediatric team regarding the possibility to admit the baby because of infection.
8) This patient should not be discharged and induction of labour should be discussed with patient if not deliver after >24 hour. Usually 90% of patient with PROM will deliver within 24 hour.
Notes:
Student must be able to differentiate between the PPROM and PROM.
PPROM is premature rupture of membrane. i.e; membrane rupture during the period of fetal viability (>24 W) but not reach term yet.
Meanwhile, Prelabour rupture of membrane, PROM is the ruptured membrane before labour. The patient already at term.
In PPROM, the focus is 1) to prolong the pregnancy so that the chances for fetus to survive remain high and 2) to prepare the baby for possibility to be delivered prematurely.
In PROM, a focus should be stress on possible infection to the mother and also to the fetus. Lung complication to the fetus is unlikely as lung maturation already completed.