European Journal of Cardiovascular Medicine

Prelabour rupture of the membranes (PROM) is the term used to describe the breaking of the amniotic sac before the start of labor, leading to the leakage of amniotic fluid and the connection between the amniotic cavity, endocervical canal, and vagina.[1]Term PROM (tPROM) occurs after 37 weeks, while preterm prelabour rupture of fetal membranes (PPROM) occurs before 37 weeks.[2]

In Western countries such as the United States and the United Kingdom, the incidence of term PROM is around 8% and PPROM is 2-3%.[3]According to Indian studies, the prevalence of tPROM is roughly 5-10% and PPROM is approximately 2-3% of all pregnancies.[4.5]

Risk factors for premature rupture of membranes (PROM) include a history of previous PROM, lower socioeconomic status, insufficient prenatal care and nutrition, sexually transmitted infections, vaginal bleeding, and urinary tract infections.[6]

Maternal complications encompass chorioamnionitis, dry labor, dysfunctional and prolonged labor, elevated cesarean section rates, postpartum hemorrhage, puerperal sepsis, placental abruption, retained placenta, cord compression, and maternal mortality.[7]  Premature rupture of membranes (PROM) results in substantial perinatal complications, with morbidity rates of 21.4% and mortality rates ranging from 18-20%.[8]Premature rupture of membranes (PROM) can lead to fetal death due to sepsis, asphyxia, and pulmonary hypoplasia.

Neonatal complications, in addition to prematurity, encompass sepsis, fetal distress, intraventricular hemorrhage (IVH), respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), jaundice, and cord compression resulting from oligohydramnios.[9]

Accurate determination of gestational age, diagnosis, and the presence or absence of sepsis are crucial in managing PROM.[4] Usually, the rupture of amniotic fluid from the cervix or tests such as the fern pattern/litmus paper test indicate the situation.  A longer interval between membrane rupture and labor onset increases the risk of chorioamnionitis.[10]Evidence suggests that inducing labor in cases of term premature rupture of membranes reduces the risk of chorioamnionitis without raising the rate of cesarean deliveries compared to expectant management.[11]  PPROM presents a debate between expectant management and immediate delivery. Antibiotics, steroids to promote lung maturity, and monitoring for chorioamnionitis are important in expectant management.[12]

This study aimed to determine the prevalence of prelabour rupture of membranes and analyze maternal and perinatal morbidity and mortality to identify potential preventive factors and interventions.

The current prospective study was carried out at the Department of Obstetrics and Gynaecologyof tertiary care hospital of central India, on patients who had been diagnosed with premature rupture of membranes and who presented to the antenatal outpatient department and antenatal word with complaints of leaking. Each of the 120 patients who presented with a history of premature rupture of membranes prior to the onset of labour pains was evaluated.

Criteria for inclusion: In every confirmed case, prom occurred after 28 weeks:

Criteria for exclusion: intact, bleeding P/V Any complications beyond prom that have an impact on foetal and neonatal outcomes, as well as parathyroid and adrenal diseases, hepatic and renal failure, and malabsorption, that are not present at least 28 weeks into the pregnancy. All patients presenting with a history of premature membrane rupture prior to the onset of labour pains were admitted to the labour room. An exhaustive history was gathered. Age, parity, obstetrical and menstrual health, a comprehensive medical history focusing on the precise moment of rupture, duration, quantity of leakage, and correlation with pain, as well as a record of comparable episodes in previous pregnancies, were assessed. Vaginal examinations and a comprehensive medical history including recent coitus, severe physical exertion, chronic coughing, and trauma. Systemic examination ensued after monitoring the patient's pulse, blood pressure, and temperature. Obstetric examination findings included the amount of alcohol, fundal height, presentation, position, and lie of the foetus. All facets of the health of the mother and foetus were documented.

An examination of a sterile speculum revealed the existence of liquor amnii. In the presence of frank leaking, the liquor was analysed to determine whether or not it contained meconium. Upon the absence of amniotic fluid in the vagina, the patient was instructed to cough, and a per speculum examination was performed to observe any amnionic fluid drainage or pooling in the posterior fornix. Fluid from the avagina was collected on a slide and examined under a microscope for ferning in the event of uncertainty. In addition to performing a pelvic assessment and noting the presence or absence of membranes, the presenting part, and its station, a single pelvic examination was performed to determine the bishop's score. Twelve-hour prophylactic antibiotics in the form of 1 g Ceftriaxone were administered to all patients with leaking. Monitoring for signs of infection, such as maternal or foetal distress, subsequently commenced on the patient. Pulse, blood pressure, body temperature, and the presence or absence of contractions were assessed every hour. The heart rate of the foetus was monitored every half-hour.

Table 1 illustrates the distribution of cases based on booking status in the ANC, where 46 patients (38.3%) are recorded as booked while 74 patients (61.6%) are unbooked out of a total of 120 cases.

Table 2 presents the distribution of cases categorized by age groups in years. The age groups include <20, 21-25, 26-30, and >30. Among these groups, 8 patients (6.6%) fall under the age group <20, while the majority, comprising 54 patients (45%), are in the 21-25 age range. Additionally, 46 patients (38.3%) belong to the 26-30 age bracket, and 12 patients (10%) are above 30 years old. The total number of cases accounted for in the table is 120.

Table 3 displays the distribution of cases categorized by gestational age in years. The gestational age groups include 28-31+6, 32-36+6, and >37. Among these groups, 58 patients (48.3%) are within the gestational age range of 28-31+6, while 48 patients (40%) fall between 32-36+6 weeks. Additionally, 14 patients (11.6%) have a gestational age greater than 37 weeks. The total number of cases considered in the table is 120.

Table 4 outlines the distribution of cases based on amniotic fluid volume in relation to premature rupture of membranes (PROM). The categories include Adequate (>8), Just Adequate (6-7), Increased (>25), Reduced (<6), and Practically Nil (1-2) amniotic fluid volume. Out of 120 cases, 36 (30%) exhibit adequate amniotic fluid volume (>8), 8 (6.6%) fall under just adequate (6-7), 2 (1.6%) show increased amniotic fluid volume (>25), while 62 (51.6%) present reduced amniotic fluid volume (<6). Furthermore, 12 cases (10%) have practically nil amniotic fluid volume (1-2).

Table 5 presents the distribution of cases categorized by risk factors in relation to premature rupture of membranes (PROM). The listed risk factors include previous history of PROM, idiopathic, tobacco chewing, hypertensive disorders, history of acute or chronic infections, hypothyroidism, multiple pregnancy, polyhydramnios, smoking, drugs, history of trauma, and diabetes mellitus. Among these, the most prevalent risk factor is a previous history of PROM, accounting for 30 patients (25%), followed by idiopathic cases at 26 patients (21.6%). Other notable risk factors include tobacco chewing with 22 cases (18.3%), hypertensive disorders and history of acute or chronic infections with 10 cases each (8.3% each), and drugs with 6 cases (5%). Additionally, there are 4 cases each (3.3%) of hypothyroidism, multiple pregnancy, smoking, and 2 cases (1.6%) each of polyhydramnios and diabetes mellitus.

The aim of this study was to examine the incidence and management of preterm premature rupture of membranes (PROM) and to compare the outcomes for both the fetus and mother in cases of term and preterm PROM at LTH. The incidence of premature rupture of membranes (PROM) was determined to be 4.1%, which corresponds to the findings of a study carried out in Egypt.[13]. Nevertheless, it is important to acknowledge that this statistic surpasses the rates documented in specific previous research conducted in Nigeria and other nations. [14-18]. The mentioned incident, however, displayed a lower frequency in comparison to the documented prevalence rates of 7.4%, 10.3%, 12.5%, and 17.6% previously reported in Borno and Osun states in Nigeria, East China, and Ethiopia, respectively.[19-22] The observed variation can be ascribed to the discrepancy in the gestational age at which a fetus is considered viable in different countries. Moreover, the low occurrence documented by Eleje et al., Emechebe et al., and Adeniji et al. may possibly be ascribed to disparities in the frequency of deliveries among various centers.[14,15,17]

However, the occurrence rate of premature rupture of membranes (PROM) varies from 2-18% in all pregnancies, a figure that aligns with the results of multiple studies, including our own investigation.[23,24] The lack of a statistically significant correlation between socio-demographic factors and the incidence of PROM aligns with the results reported by Assefa et al. in their study conducted in Ethiopia.The user's text is a reference to a source or citation. However, a higher proportion of the female participants were in the advanced stages of their reproductive years (above the age of 35), had completed tertiary education, and were employed in skilled professions. The study found that most women in the sample experienced premature rupture of membranes (PROM) at term, which is consistent with the findings reported in previous studies. The given sequence is [16, 14, 18, 25, 26, 27]. However, Mohan et al. (year) discovered that the occurrence of preterm premature rupture of membranes (PROM) was more frequent in women during the late preterm gestational period, specifically between 34 and 36 weeks.[18]

Moreover, it is worth mentioning that the highest frequency of this phenomenon was observed among individuals aged 35-39 years who are capable of reproduction. This finding contradicts previous studies that reported a lower occurrence among younger individuals in the reproductive age range.[14,20] Furthermore, it was noted that PROM primarily impacted women who had experienced multiple childbirths, which is consistent with the results of prior research. Nevertheless, it is important to highlight that the occurrence of PROM was not statistically significant in relation to maternal age and parity.[14,15,28,20,17] This phenomenon may be linked to previous occurrences of childbirth, characterized by varying degrees of repetitive trauma to the cervix. The trauma can impair the cervix's ability to support a pregnancy until its completion, thus making women who have had multiple births more prone to experiencing preterm premature rupture of membranes (PROM). Regarding the management outcome, a significant difference was observed in the rates of caesarean section and operative vaginal delivery, based on the type of management administered. This difference was found to be statistically significant. Most women who were treated conservatively had a spontaneous vaginal delivery (SVD), which is consistent with the results reported by Akintayo et al.[21]

Moreover, there is empirical evidence that favors the idea that inducing labor, rather than adopting a strategy of waiting for natural labor, does not lead to a higher incidence of cesarean deliveries.[29,30] A notable correlation existed between the gestational age at which premature rupture of membranes (PROM) occurred and the length of the latency period. A higher proportion of individuals had a latency period of less than 24 hours after the rupture of membranes, especially among women who were more than 37 weeks pregnant. The aforementioned observation contradicted the findings of Ibishi et al., who discovered no association between latency period and gestational age, even among women in the term pregnancy group with a latency period of less than 24 hours[25]. The expected nature of this observation can be ascribed to the fact that premature rupture of membranes (PROM) mainly occurred at full term in the current study, which could potentially account for the relatively low incidence of negative outcomes. Emechebe et al. conducted a study in Calabar, Nigeria, where they observed a longer latency period that could be associated with an increased prevalence of infection.[15] No cases of maternal mortality were observed in our study, consistent with the findings reported in the studies conducted by Mohan et al. and Akintayo et al. However, this report revealed divergent results in comparison to recent studies conducted in low-resource settings that documented instances of maternal mortality.[18,31]

The expected nature of this observation can be attributed to the fact that premature rupture of membranes (PROM) mainly occurred at full term in the present study, which could explain the relatively lower occurrence of negative outcomes reported. Within the specified examination period, there were three instances of fetal deaths, resulting in a perinatal mortality rate of 0.18 per 1000 deliveries. The documented incidence rates were less than 0.26 per 1000 deliveries in Anambra, Nigeria, and 0.33 per 1000 deliveries in India.[13,18] The discrepancy may be ascribed to the relatively smaller number of recorded deliveries in the index study. The perinatal deaths observed in the preterm PROM group were caused by complications related to premature birth, while the perinatal death in the term PROM group was caused by neonatal sepsis. The rates of live births were 90% and 97.6% in the preterm and term pregnancy groups with premature rupture of membranes (PROM), respectively. Premature rupture of membranes (PROM) is strongly linked to several adverse outcomes in the fetus, such as lower apgar scores at 1 and 5 minutes, higher birth weight, and the need for admission to the neonatal intensive care unit (NICU).

Preterm premature rupture of membranes remains a notable obstetric issue linked to maternal well-being. The occurrence of health problems during the period surrounding childbirth, especially when they occur before the expected due date, is a matter of great concern. The outcome of the fetus was influenced by various factors, such as the duration between the onset of labor and delivery, the weight of the newborn, the Apgar score, and the need for admission to the Neonatal Intensive Care Unit (NICU). However, the way in which the management is carried out depends on different factors related to the mother and the fetus. Implementing conservative treatment strategies has been demonstrated to result in a higher gestational age at delivery, thus increasing the probability of a vaginal birth. Additional investigation should be undertaken to compare the management of premature rupture of membranes (PROM) and its occurrence across a wider range of healthcare environments.

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