Preterm Premature Rupture of Membrane

Preterm Premature Rupture of Membrane Research Paper

Abstract

 Preterm premature rupture of membranes s the rupture of the fetal placenta before the commencement of labor. Preterm premature rupture of membranes complicates around 2-4% percent of singleton pregnancies and 7-20% of twin pregnancies (Caughey, Robinson, & Norwitz, 2008). Preterm premature rupture of membranes stands to me the leading cause for preterm births and around 18-20% of all perinatal mortalities. The medical team caring for expecting mothers should be well versed in the clinical management of preterm premature rupture of membranes because every minute is needed to diagnose, prescribe and treat these women to have the most promising outcome possible.

Preterm Premature Rupture of Membranes

It is commonly thought that with the rupture of membrane or a woman’s water breaking is the start of labor especially with the help of Hollywood it is made out to be this huge dramatic event. In real life it is usually calm with a trickle or gush of fluid that cannot be stopped. When a woman is at full term gestation there is not much to worry about, she knows her delivery is imminent, and she will get to meet her bundle of joy soon. But for a woman who is preterm and has a rupture of membrane, she knows that this is not typical of an average birth and the fear for the safety of her and her unborn baby are at risk. This paper will define preterm premature rupture of membranes, the labs and diagnostic tests to confirm rupture, how this process is clinically treated, the prognosis for those affected by preterm premature rupture of membrane, and a nursing care plan to give a visualization of the care given to a patient with preterm premature rupture of membrane.

Condition Description

Preterm premature rupture of the membrane is defined by the premature rupture of the placenta before 37 0/7 weeks of gestation (Perry, Hockenberry, Lowdermilk, & Wilson, 2018) and while the percentages of incidence differ depending on sources, preterm premature rupture of membrane is one of the biggest reasons for preterm birth (Caughey, Robinson, & Norwitz, 2008). The fetal membrane comes from the union of the amnion and chorion, this union fuses to the decidua capsularis, that turns into the decidua perietalis throughout the length of gestation. The rupture of membrane usually occurs near the internal cervical os but has the possibility of occurring at other sites (Mercer, 2008). 

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While there is no definitive reason for why preterm premature rupture of membrane occurs, there are many risk factors that make preterm premature rupture of membranes more likely to occur. These risk factors can occur from maternal influences, the placenta itself and its surrounding anatomy, and the fetus. The maternal influences include that of having had preterm premature rupture of membranes with a previous pregnancy, vaginal bleeding during the pregnancy, chronic steroid therapy, direct abdominal trauma, preterm labor, cigarette smoking, illicit drug use such as cocaine, anemia, low body weight, nutritional deficiencies, and low socioeconomic status. The uteroplacental factors include uterine anomalies, placental abruption, advanced cervical dilation, prior cervical conization (cone biopsy is a treatment used to identify and remove abnormal tissue from the cervix (Cooper & Menefee, 2019).), cervical shortening in the second trimester, uterine overdistention related to polyhydramnios or multiple fetal pregnancy, intra-amniotic infection known as chorioamnionitis, and multiple bimanual vaginal examinations. The fetus(es) itself can affect the nature of the placenta by the quantity of fetuses in utero and premature rupture of membranes has proven to complicate 7-10% of multi fetus pregnancies (Caughey, Robinson, & Norwitz, 2008). Since the rupture of membrane can not be reversed it is imperative to be aware of these risk factors and assess pregnant patients for any warning signs.

Signs and symptoms of preterm premature rupture of membranes are varied such as a gush or trickle of fluid that can not be stopped, change in vaginal discharge and pelvic pressure; because these could besymptoms of other complications or disorders, diagnostics are performed to accurately diagnose a patient with preterm premature rupture of membranes.

Diagnostics and Lab Tests

The diagnosis of preterm premature rupture of membranes can be performed multiple ways, once the patient states the presence of a gush or trickle of fluid from their vagina, the confirmation can possibly be seen through visual examination of the perineum with a slight musty odor present or through a sterile speculum examination considered minimally invasive. During this examination the examiner will be able to document the three signs of rupture of membranes considered the gold standard of diagnosing: visual pooling of clear fluid in the vaginal canal, an alkaline pH test with nitrazine paper to test an area that should be more acidic in nature, and microscopic ferning which is the crystallization of the amniotic discharge once dried. This gold standard is not without fault, generally after an hour of the rupture of membranes the pH starts to change back to more acidic and there is a possibility of having a false negative due to cervicitis, vaginitis, or contamination with blood, urine, semen or diagnostic tools such as lubricant, ranging from a 16%-70% accuracy (Caughey, Robinson, & Norwitz, 2008). The visual element may be hindered as well if the patient suffered from oligohydramnios in which there may not be a gush of fluid felt or visualized (Mercer, 2008). The ferning test can show a false positive result by human error of a fingerprint being present or other contaminants such as semen or cervical mucus present on the slide, resulting in a 51%-70% accuracy (Caughey, Robinson, & Norwitz, 2008).

There is a new test that is being used widely throughout the United States, approved by the Food and Drug Administration (FDA) for the diagnosis of premature rupture of membranes called Amnisure. This test recognizes trace amounts of PAMG-1, a glycoprotein that is found abundantly in amniotic fluid. A swab is inserted vaginally for one minute then the swab is placed in a vial of solvent for one minute, a test strip is placed in the same vial, after 5-10 minutes the strip will show a control line and the presence of a line or lack thereof, this new test has yielded approximately 99% accuracy in its results, thereby moving the technology of the rupture of membranes testing and diagnosing into a whole new realm of assurance (Caughey, Robinson, & Norwitz, 2008). With this new state of the art test pregnant women seen with a possible preterm premature rupture of membrane will have a more definite and less invasive way to diagnose this condition.

Clinical Management of Condition

 The clinical management of preterm premature rupture of membranes has many spokes to its wheel, because there are so many facets to worry about, treatment must come from many different avenues. With this concept in mind, the longer the baby can stay in utero results in the best outcome, the clinical management takes the approach of modifying its care by gestational age and individually with ongoing assessments of both mom, baby and risks of complications (Mercer, 2008). A priority of care for this situation is ensuring fetal well-being, therefore applying a fetal monitor to the mom to see how the baby is handling the circumstances. Once fetal well-being is assessed and ensured, a plan of action can be determined. The nurses will be performing a biophysical profile test through admission to delivery comprised of a non-stress test (fetal heart monitoring), fetal ultrasound to assess movement, breathing, muscle tone, amniotic fluid level and the baby’s heart rate along with daily kick counts conducted by the mom. The ultrasound that will be performed will assess the amount of amniotic fluid in utero, this fluid is the very life force of the fetus, it is measured and assessed through the amniotic fluid index shown in Table 1.

The loss of too much amniotic fluid (oligohydramnios) can lead to cord compression resulting in unfavorable late decelerations of the baby, hypoxia and intrauterine growth restriction. After well-being of the fetus is assured, the next step if not already done is to initiate IV fluids to hydrate both mom and baby and also increasing the amount of liquids ingested orally is recommended to replace some of the fluid lost. Most often women with preterm premature rupture of membranes are admitted to the hospital until delivery because there are so many risks and complications that could occur when not under the watchful eyes of medical professionals (Caughey, Robinson, & Norwitz, 2008). Along with IV fluids, bed rest and pelvic rest are indicated, including no use of tampons, sexual intercourse, douching or tub baths. Bed rest is used to try and reaccumulate amniotic fluid back into the placenta creating a more stable environment for the fetus (Caughey, Robinson, & Norwitz, 2008).

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In these scenarios, the medical team will be preparing for an early delivery, therefore they will try to make the outcome as favorable as possible. This is the reason for administering corticosteroids usually either betamethasone or dexamethasone to mature the lungs of the fetus by increasing the surfactant in the baby’s lung thus stimulating them to work on their own out of utero as soon as a diagnosis has been made. The dosage for betamethasone is 12 mg IM q24hr x 2 doses or dexamethasone 6 mg IM q12hr x 4 doses, with seeing these doses the medical team would prefer to have at least 1-2 days for the steroid to take affect before delivery, if possible (Caughey, Robinson, & Norwitz, 2008).

With the rupture of a placenta the worry of infection is extremely high, administering antibiotics is the first line of defense to stop the growing bacteria that could attack both mom and baby. Once the membrane has ruptured, there is a mental clock started by the medical team but with the administration of antibiotics, it can slow down said clock to allow the baby to stay in utero as long as the mothers body will allow it and the benefits outweigh the risks. Substantial evidence has shown that with the use of aggressive broad spectrum antibiotics such as IV administration of ampicillin 2g q6h and erythromycin 250mg q6h for 48 hours, followed by oral therapy with amoxicillin at 250mg q8hr and enteric-coated erythromycin base at 333mg q8hr for 5 days can show considerable prolonged potential of gestation (Caughey, Robinson, & Norwitz, 2008).

While the plan of clinical management depends on how far along the mom is in gestation, the ultimate goal is to prepare both mom and baby for a favorable delivery. Thus, prescribing bed rest, increased fluid intake, constant monitoring and assessment of mom and baby, the administration of both corticosteroids and antibiotics aids in the well-being and a higher chance of an advantageous outcome.

Prognosis

Preterm premature rupture of membrane has the definitive risk of maternal and fetal demise and morbidity, with that knowledge the medical team will be aware of the risks and complications that could occur, using their experience and judgement of what courses of action to take if this pregnancy is viable or should be terminated (Tavassoli, Ghasemi, Mohamadzade, & Sharifian, 2010). The outcome for patients with preterm premature rupture of membrane is quite dependent on when the rupture occurred in gestation. Patients with preterm premature rupture of membranes between 32-36 weeks have been studied and concluded that expedited delivery is generally the best outcome because the risk of infection outweighs letting the baby stay in utero, once the medications are administered between 1-2 days, the likelihood of survival is more favorable (Mercer, 2008). Between the weeks of viability 23- and 31-weeks’ gestation there is a dramatically higher risk for fetal demise and morbidity (Mercer, 2008). Because of these risks every precaution is taken to prolong pregnancy, thus begins the fine line of balancing between maintaining gestation versus delivery in reference to the presence of labor that is active, vaginal bleeding, infection present in utero, and fetal compromise (Mercer, 2008). Continuous evaluations and assessments are performed while the mother is in the hospital, taking in all the information and making an informed decision on the plan of care on a case by case basis is the best avenue for an optimum prognosis.

Nursing Care

 As a woman with preterm premature rupture of membranes, there are many scenarios that play out in her mind, what if the baby comes early, am I going to be able to keep the baby safe but the biggest worry in a nurse’s mind is we have to do everything in our power, so she doesn’t get an infection. The risk of infection is so great that this is thetop priority when we are caring for a preterm premature rupture of membrane patient. Her diagnosis would be risk for infection related to preterm premature rupture of membrane as evidenced by gush/trickle of amniotic fluid with possibility of bacterial transmission. Being taught in lecture as soon as the placenta ruptures, a nurse starts a clock in her mind and with every hour her risk of infection rises. On assessment of the patient after she states that she had a gush or trickle of fluid that she could not stop after ensuring the safety of the fetus by getting them put on the fetal heart monitor, the medical team performs a sterile vaginal exam and diagnostic testing such as a nitrazine test, amnisure test or a ferning test to confirm placental rupture. Prior to this the nurse would have already hooked up a fetal monitor to ensure fetal well-being and a tocodynamometer to measure if she is having any contractions and the frequency. The outcome expected of all preterm premature rupture of membranes patients is that she will be free of infection at delivery of fetus by amniotic fluid staying clear and free of foul odor, the patient’s temperature stays within normal limits of her baseline and the patient shows no sign of elevated white blood cells in her CBC for a pregnant woman. Interventions that would be performed would be a non-stress test (NST), apply the fetal monitor on the baby to ensure health and safety; also have the mom frequently do kick counts to ensure movement of the baby. The nurse would follow providers orders and administer antibiotics to hopefully circumvent the risk of infection and possibly lengthen the pregnancy to a viable due date; and administer glucocorticoid betamethasone to mature the baby’s lungs by irritating the lungs into stimulation and to produce surfactant for breathing out of utero. Also, the nurse would instruct the patient on the importance of good hygiene and peri care ensuring wiping from front to back to reduce the possibility of introducing new bacteria to the environment. 

The second concern nurses have for the mother and fetus is having deficient fluid volume in utero related to preterm premature rupture of membranes as evidenced by the loss of fluid volume in the placenta. The outcome that is sought out for patients in this situation is that they will maintain adequate amniotic fluid depending on how many weeks gestation the mom is according to Table 1 to sustain effective gas exchange for fetus until time of delivery. Medical professionals are able to measure this by performing an amniotic fluid index (AFI) by way of ultrasound to determine that there is enough amniotic fluid to withstand life in utero at their gestational age. Fetal heart monitoring will show reassuring signs of life with non-stress test meeting the criteria of a heart rate of 110-160 beats per minute, moderate variability of 5-25 beats per minute, and 2 qualifying accelerations in 20 minutes with no decelerations. The mom will also be given the job of performing kick counts everyday to show no change in movement pattern. The interventions that will be performed is bed rest for the mom, so that there is no unnecessary jostling or loss of fluid, the medical team will hydrate her orally and intravenously to try and aid in returning fluid back into the placenta to create buoyancy for the fetus until delivery, and for the mom to perform a daily routine of kick counts to ensure fetal movement and well-being. All of these actions performed for both the risk for infection and deficient fluid volume are to promote the health and safety of mom and baby throughout gestation and to create the most optimal outcome to an unexpected situation.

Conclusion

In summary the research has shown that while there is no absolute conclusive reason for preterm premature rupture of membranes there are risk factors that make it more likely, thus the physician and their team should closely monitor those at risk. This paper has shown that preterm premature rupture of membranes is a rare complication but one that brings great maternal and fetal risk (Linehan, et al., 2016). There are definitive tools to diagnose a rupture of membrane and various treatments for the myriad of manifestations associated with premature rupture of membranes. While the prognosis of preterm premature rupture of membranes can range from very good to imminent mortality and can be broken down into categories, it basically comes down to gestational age and the viability of the fetus. The nursing care of these patients shows a vast array of care that has to be managed for not just one patient but two. It is the hope and effort of everyone involved to produce a viable, healthy, and safe pregnancy and delivery for both mom and baby.

References

• Aris, I. M., Logan, S., Lim, C., Choolani, M., Biswas, A., & Bhattacharya, S. (2017). Preterm prelabour rupture of membranes: a retrospective cohort study of association with adverse outcome in subsequent pregnancy. BJOG, 124, 1698-1707. doi:10.1111/1471-0528.14462
• Caughey, A. B., Robinson, J. N., & Norwitz, E. R. (2008). Contemporary Diagnosis and Management of Preterm Premature Rupture of Membranes. Reviews in Obstetrics and Gynecology, 1(1), 11-22.
• Jones, O. (2016, December 24). Oligohydramnios. Teach Me ObGyn: https://teachmeobgyn.com/pregnancy/fetal-abnormality/oligohydramnios/
• Linehan, L. A., Walsh, J., Morris, A., Kenny, L., O’Donoghue, K., Dempsey, E., & Russell, N. (2016). Neonatal and maternal outcomes following midtrimester preterm rupture of the membranes: a retrospective cohort study. BMC Pregnancy and Childbirth, 25(16), 1-7. doi:10.1186/s12884-016-0813-3
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• Mercer, B. (2008, May). Preterm Premature Rupture of the Membranes. The Global Library of Women's Medicine. doi:10.3843/GLOWM.10120
• Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2018). Maternal child nursing care (6th ed.). St. Louis: Elsevier.
• Tavassoli, F., Ghasemi, M., Mohamadzade, A., & Sharifian, J. (2010, April). Survey of Pregnancy Outcome in Pretern Premature Rupture of Membranes with Amniotic Fluid Index <5 and greater than or equal to 5. Oman Medical Journal, 25(2), 118-123. doi:10.5001/omj.2010.32