Genetic Considerations

PROM may occur with some of the hereditary connective tissue disorders such as Ehlers-Danlos syndrome, a class of six conditions resulting in skin fragility, skin extensibility, and joint

764 Premature Rupture of Membranes hypermobility, that can be inherited in either an autosomal dominant or an autosomal recessive pattern.

PROM occurs in 3% to 17% of all deliveries, but it is not associated with maternal age or with ethnicity or race.

HISTORY. Ask the patient the date of her last menstrual period to determine the fetus's gestational age. Ask her if she has been feeling the baby move. Review the prenatal record if it is available, or question the patient about problems with the pregnancy, such as high blood pressure, gestational diabetes, bleeding, premature labor, illnesses, and trauma. Have the patient describe the circumstances leading to PROM. Determine the time the rupture occurred, the color of the fluid and the amount, and if there was an odor to the fluid. Patients can report a sudden gush of fluid or a feeling of "always being wet." Inquire about any urinary, vaginal, or pelvic infections. Ask about cigarette, alcohol, and drug use and exposure to teratogens.

PHYSICAL EXAMINATION. The priority assessment is auscultation of the fetal heart rate (FHR). Fetal tachycardia indicates infection. FHR may be decreased or absent during early pregnancy or if the umbilical cord prolapsed. If bradycardia is noted, perform a sterile vaginal examination to check for an umbilical cord. If a cord is felt, place the patient in Trendelenburg's position, maintain manual removal of the presenting part off of the umbilical cord, and notify the physician immediately.

Note the frequency, duration, and intensity of any contractions. With PROM, contractions are absent. Perform a sterile vaginal examination if the patient is term (>37 weeks), and note the dilation and effacement of the cervix and the station and presentation of the fetus. If the patient is preterm, notify the physician before doing a vaginal examination, which is often deferred in preterm patients to decrease the likelihood of introducing infection.

It is important in the initial examination to determine if PROM actually occurred. Often, urinary incontinence, loss of the mucous plug, and increased leukorrhea, which are common occurrences during the third trimester, are mistaken for PROM. Inspect the perineum and vaginal vault for presence of fluid, noting the color, consistency, and any foul odor. Normally, amniotic fluid is clear or sometimes blood-tinged with small white particles of vernix. Meconium-stained fluid, which results from the fetus passing stool in utero, can be stained from a light tan to thick green, resembling split pea soup. Take the patient's vital signs. An elevated temperature and tachycardia are signs that infection is present as a result of PROM. Auscultate the lungs bilaterally. Palpate the uterus for tenderness, which is often present if infection is present. Check the patient's reflexes, and inspect all extremities for edema.

PSYCHOSOCIAL. If the pregnancy is term, most patients are elated with the occurrence of ROM, even though they are not having contractions. If the patient is preterm, PROM is extremely upsetting. Assess the patient's relationship with her significant other and available support.

Diagnostic Highlights

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