Premature Rupture of the Membranes (PROM) and Birth Injury
Premature Rupture of Membranes (PROM) occurs when the membranes of the amniotic sac and chorionic rupture before labor begins (when a mother’s “water breaks” before labor starts). This places the baby at risk for numerous health issues, including periventricular leukomalacia (PVL), hypoxic-ischemic encephalopathy (HIE), neonatal encephalopathy, cerebral palsy, developmental disabilities, microcephaly, sepsis, meningitis, and more. When PROM occurs in conjunction with premature birth (delivery before 37 weeks), it is known as preterm premature rupture of membranes, or PPROM. When PROM or PPROM occur, the mother must receive antibiotics to prevent infection-related complications in the baby because amniotic fluid (which protects the baby against infection) is no longer present. C-Sections are often necessary in cases of PROM and PPROM.
What Is Premature Rupture of the Membranes (PROM)?
Premature rupture of membranes (PROM) occurs during pregnancy when there is a rupture of the membrane of the amniotic sac and chorion more than one hour before labor begins. In other words, this is when a woman’s water breaks prior to the start of labor. Physicians should make every effort to prevent PROM; this includes promptly diagnosing and treating infections such as chorioamnionitis and group B strep (GBS). If PROM occurs, proper medical management must take place to prevent birth injuries in the baby. Birth injuries that can be caused by PROM include the following:
- Periventricular leukomalacia. Although PVL can occur in term infants, it is most frequently found in premature babies.
- Hypoxic-ischemic encephalopathy (HIE). HIE usually occurs in term infants, but sometimes premature babies can develop it. HIE usually involves damage to the basal ganglia, cerebral cortex, and watershed regions of the brain, but sometimes also includes PVL.
- Neonatal encephalopathy
- Permanent brain damage
- Seizure disorders
- Cerebral palsy (CP)
- Developmental delays
- Motor disorders
- Intraventricular hemorrhages (IVH – brain bleeds)
Premature Rupture of the Membranes (PROM), Birth Injury, and Hypoxic-Ischemic Encephalopathy (HIE)
PROM is prolonged when it occurs more than 18 hours before labor. PPROM (preterm PROM) occurs before 37 weeks gestation. This is a problem because labor often begins soon after the membranes rupture (usually within 48 hours) and babies born before 37 weeks are at a high risk of experiencing birth injuries such as periventricular leukomalacia and hypoxic-ischemic encephalopathy. Approximately 11% of babies in the U.S. are born prematurely, and 3 – 4% of these births are due to PPROM.
When PROM and PPROM occur, it is necessary for the mother to receive treatment (antibiotics) to avoid possible infection in the newborn, which can lead to premature birth, sepsis, meningitis, hypoxic-ischemic encephalopathy, periventricular leukomalacia, cerebral palsy, and intraventricular hemorrhages (IVH).
PROM and PPROM are crucial factors leading to fetal distress and other complications before labor or the end of the third trimester. Without the sterile, protective amniotic fluid, an unborn baby is prone to bacterial infections, loss of nutrients, preterm birth, and other complications:
- Umbilical cord prolapse, which can cause birth asphyxia, periventricular leukomalacia (PVL), and hypoxic-ischemic encephalopathy (HIE)
- Chorioamnionitis, which is inflammation of the fetal membrane
- Premature birth, which can lead to periventricular leukomalacia and hypoxic-ischemic encephalopathy in the newborn
While PROM/PPROM can occur naturally, they also can be triggered by frequent, and often unnecessary, cervical exams late in pregnancy. Infections can result from examinations after a rupture or during restricted bed rest in the hospital, which also may contribute to fetal distress and C-sections.
What Causes Premature Rupture of the Membranes (PROM; PPROM)?
The causes of PROM are unclear. But PROM/PPROM is more likely to happen in women who:
- Had prior PPROM
- Had prior preterm labor and delivery
- Have an infection in the vagina or uterus (chorioamnionitis, Group B strep, bacterial vaginosis, urinary tract infections)
- Have bleeding from the vagina
- Have poor nutrition
- Have had previous cervical surgery, including cone biopsies or cerclage
- Have had overstretching of the uterus and amniotic sac, which sometimes occurs with multiple fetuses or too much amniotic fluid (hydramnios)
Risk Factors for PROM and PPROM
- Maternal sepsis
- Umbilical cord prolapse
- Malpresentation of the baby
Signs and Symptoms of PROM and PPROM
The most important symptom of PROM/PPROM is fluid leaking from the vagina. When a woman’s water breaks, it may feel like a sudden gush or a slow trickle of fluid from the vagina. The fluid is clear or pale yellow.
Infection and PROM/PPROM can occur together. Thus, it is important to recognize the signs of infection. Signs of infection include the following:
- Contractions of the uterus
- Increased temperature and heart rate (in the mother)
- Tenderness of the uterus
- Foul-smelling vaginal discharge
- Increased white blood cell count or a change in the pattern of white blood cell type
- An increase in the baby’s heart rate
Prompt Diagnosis of PROM and PPROM Is Critical
Physicians diagnose PROM by using a speculum to determine if fluid is leaking from the cervix. A sample of fluid from the vagina is examined under a microscope and tested with special paper to verify that the fluid is amniotic. An ultrasound may also be used to determine the amount of amniotic fluid around the baby.
Treating PROM and PPROM
PROM at Term
In a term pregnancy where PROM has occurred, spontaneous labor usually is permitted. Current standard of practice includes an induction of labor at approximately 12 hours if it has not already begun (although many physicians induce labor immediately) and consideration of group B strep prophylaxis at 18 hours. Research suggests that a woman who has labor induced is less likely to develop an infection in her uterus than a woman who waits for labor to start naturally. Antibiotics usually are given prophylactically to ensure that no infection is spread to the baby.
When PROM occurs between 34 and 37 weeks, labor usually will be induced. It is thought that the risk of infection is greater than the risk of the baby being born a few weeks early.
If PROM occurs before 34 weeks, the situation is more complex. If there are no signs of infection, the physician may try to delay labor with medication (tocolytics) until the baby’s lungs are more mature. Antibiotics are usually administered, and steroids are often given to help the baby’s lungs develop more quickly. The physician may collect a sample of fluid for analysis to determine if the baby’s lungs are mature, and if they are, labor will be induced.
When PPROM occurs between 32 and 34 weeks, the standard recommendation is less clear. These cases require careful evaluation and frequent reevaluation. The use of corticosteroids (drugs to mature a preterm baby’s lungs) after 32 weeks in women with PPROM is somewhat controversial, as treatment at this gestational age has not consistently resulted in benefit. However, corticosteroids generally are administered in such cases when there is documented fetal lung immaturity and no evidence of chorioamnionitis.
The Use of Antenatal Steroids in the Treatment of PROM and PPROM
When PPROM occurs before 32 weeks of pregnancy, it is best to delay delivery. A course of corticosteroids should be given. Research shows that neonatal death, respiratory distress syndrome (RDS), intraventricular hemorrhages (IVH) or brain bleeds, necrotizing enterocolitis (tissue death in portions of the bowel), and the duration of respiratory support were significantly reduced by steroid treatment, without an increase in either maternal or neonatal infection. Babies delivered this early often have RDS, IVH, and intestinal problems (NEC).
The key to understanding PPROM is that a premature baby with an infection is much more worrisome than a premature baby without an infection. Ideally, the baby should be delivered the hour before the uterus and baby would get infected. This is difficult to predict, so close monitoring is essential, and signs of infection or changes in the baby’s testing (even subtle ones) should be relied on.
Antibiotics for Prevention of Infection
The rationale for administering antibiotics as a precautionary measure is that infection appears to be both a cause and consequence of PPROM, and is related to preterm delivery. The goal of antibiotic therapy is to decrease the frequency of maternal and fetal infection and delay the onset of preterm labor and to minimize the risk of chorioamnionitis, cerebral palsy, and other known complications associated with infection.
C-Section for PROM and PPROM
The longer the time between the rupture of membranes and delivery of the baby, the more likely the chance of infection occurring. The risk significantly increases if labor does not occur within 12 hours of the membranes rupturing. The main goal is to keep the baby safe. It is crucial to protect a baby from infection. It also is important to prevent the dangers that can happen when physicians wait for a natural delivery, which may not occur within a safe time frame. This could lead to using forceps and vacuum extractors, which carry the risk of traumatic birth injuries to the delicate baby, or administering potentially dangerous drugs like Cytotec and Pitocin to speed up delivery.
Umbilical Cord Compression and PROM
Cord compression is a serious complication associated with PROM and PPROM. If the baby’s heart rate drops below 100 for 60 seconds or more, there is a significant chance the cord is compressed. Extremely close monitoring is crucial at this point, and if the cord is compressed, delivery usually must occur right away to prevent birth asphyxia, hypoxic-ischemic encephalopathy (HIE), cerebral palsy, and other birth injuries.
Medical Malpractice, PROM, and PPROM
There are many complications that can occur with premature rupture of membranes. It is crucial for physicians to closely monitor the mother and baby when PROM/PPROM takes place. Timing is very important in these instances. Guidelines must be followed to prevent infection and to ensure that the baby’s lungs are mature at birth. These factors take careful consideration and skill. If a physician or medical team fails to follow medical guidelines and standards of care, properly monitor the infant, or perform a timely C-section when necessary, it is negligence. If this negligence leads to injury of the mother or baby, it is medical malpractice.
Legal Help for PROM and PPROM
If you or a loved one were injured as the result of PROM or PPROM, we encourage you to call the award-winning birth injury attorneys at Reiter & Walsh ABC Law Centers. With over 100 years of joint legal experience, our legal team has the education, qualifications, results, and accomplishments necessary to succeed. We’ve handled cases involving dozens of different complications, injuries, and instances of medical malpractice related to obstetrics and neonatal care, many of which directly involve PROM and PPROM. From our main location in Detroit, Michigan, our team handles cases all over the United States. We’re able to help clients and their families in Michigan, Ohio, Arkansas, Mississippi, Wisconsin, Pennsylvania, Washington D.C., Tennessee, Texas, and other parts of the United States.
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Video: Premature Birth
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