Before a baby is born, the water bag needs to break at some point. Maybe this happens at the very last second, in which case the doctor who is positioned to deliver the baby gets hit with a huge gush of water (as has happened to this author more than once!). Or more often the water breaks during early labor or perhaps during active labor, or maybe the ob doctor breaks the water bag on purpose during labor (this is called amniotomy).
But, sometimes the water breaks without any sign of labor. This is called premature rupture of membranes (PROM), or sometimes spontaneous premature rupture of membranes (SPROM). If the patient’s pregnancy has progressed beyond its 37th week, they are full term, so this situation is normally not a cause for concern.
But if the water breaks without any signs of labor and the gestational age is less than 37 weeks, this is called preterm premature rupture of membranes (PPROM). Depending on how far along the pregnancy is, this can be a minor concern or a potentially devastating and tragic situation.
The Difference Between PROM and PPROM
After the 37th week of pregnancy begins, a woman is generally considered ready to deliver, meaning the baby is fully developed and should do well after it is born. If her water breaks at this point, even if labor has not yet begun, the baby should be on its way soon, even if labor needs to be induced medically. PROM is not a particularly dangerous situation—in fact, it occurs in 8 to 10 percent of all pregnancies.
PPROM, on the other hand, occurs in far fewer pregnancies, but it is a complication of at least 25 percent of all preterm births, and possibly as many as a third of them. In 3–4 percent of preterm births, PPROM is the cause of premature labor.
Symptoms and Diagnosis
The most easily recognizable symptom of PROM or PPROM is leakage of amniotic fluid from the vagina. This fluid may gush in a heavy flow, or it may be only a very small leakage—in fact, many women mistake this leakage for urine. Amniotic fluid can easily be distinguished from urine by its smell, which is much sweeter and less offensive than the smell of urine. If you experience fluid leakage and are unsure what it is, capture it in a pad and sniff it. If you have any doubt, call your doctor.
PPROM dramatically increases the likelihood of infection in the uterus. Or sometimes an infection occurs first and this causes the water to break. If your leakage is followed by the development of a fever of 100° F or higher, call your doctor and go to the emergency room immediately!
If you or your doctor suspects PROM, your doctor will examine you to determine exactly what is going on. The typical exam is called a sterile speculum exam (SSE). A sterile instrument is used to minimize the chances of introducing bacteria during the exam itself. Your doctor will examine your cervix for leakage of fluid from the cervical opening, and he or she may order an ultrasound examination. Your doctor will also take a sample of the fluid that is leaking from you in order to examine a dried sample under a microscope and to test the pH level (acidity) with what is called a nitrazine paper test. If the pH of the fluid is higher than 7.0, it is probably amniotic fluid, and PROM has most likely occurred.
Treatment—What to Expect
Once your doctor confirms that PROM has occurred, you will probably be hospitalized immediately and kept there until the baby is born. If you have already started the 37th week, your baby is safe to be born and you are apt to go into labor at any time. If you do not go into labor within a few hours after being admitted to the hospital, your doctor may want to induce labor in order to prevent complications such as uterine infection.
In fact, most doctors prefer to induce labor in such cases even if the patient is only 34 to 36 weeks along, as the risk of infection is thought to be more serious than the risks involved with preterm labor and preterm birth. It is safer to deliver a healthy preterm baby that is only a few weeks too early than to try to delay delivery, which can lead to the baby being born with a bacterial infection.
For pregnancies that have not reached the 34th week, the situation is more problematic. If infection does not seem to be present, the doctor may attempt to delay labor in order to give the baby’s lungs more time to mature (amniocentesis can help to determine how well developed the baby’s lungs are, if the amount of fluid loss does not prohibit it). Steroids may be used to speed the maturation of the lungs, and the mother will be given antibiotics during this time in order to stave off infection. Once the lungs have matured sufficiently, the doctor will induce labor. In some cases a C-section delivery may be necessary.
For very early PPROM, such as from 16 to 24 weeks, the fetus is not yet considered viable. Management is complicated due to the risks to the developing fetus not only of infection, but of developing inside a womb that has very little fluid. The fetus needs the fluid for optimal development: it allows for fetal movement, swallowing, breathing, and urination—all normal bodily functions that occur during fetal development and depend on the presence of amniotic fluid, a precious substance!
Causes of PROM and PPROM
The cause of this event can be hard to determine in a given case. In some cases it may happen due to overstretching of the amniotic sac by twins or multiples, or by one exceptionally big baby. The amniotic sac can also be overstretched by an excess of amniotic fluid, a condition known as polyhydramnios. There is a strong statistical link between PROM and cigarette smoking during pregnancy, although the exact reason for this link has not been determined.
A very important cause to identify is incompetent cervix. This is when the cervix dilates painlessly and without labor, often in the second trimester, leading to pregnancy loss. If this is the cause, the next time the patient becomes pregnant she may need a stitch in her cervix called a cerclage.
Other risk factors for PPROM include:
- Prior surgery of the cervix such as a cone biopsy or a LEEP procedure
- Previous pregnancy in which this occurred
- 2nd or 3rd trimester bleeding
- Underweight mother
- Untreated vaginal bacterial infection
- A sexually transmitted disease such as gonorrhea
- Poor prenatal care
One serious risk of PPROM is chorioamnionitis, an infection of the placenta that can be extremely dangerous to both mother and baby.
Other possible complications of PPROM include:
- Higher incidence of C-section delivery
- Premature birth
- Newborn infections such as pneumonia or septicemia
- Placental abruption (premature separation of the placenta)
If you experience PPROM before your 34th week of pregnancy, your doctor may try to postpone delivery for as long as possible, but most women deliver within a week of membrane rupture regardless of treatment. In cases like this, the prognosis depends on how mature the fetus was at the time of membrane rupture, how mature its lungs are when labor finally begins, whether or not infection has developed and whether or not the birth process introduced any excessive stress or trauma to the baby.
In less severe cases, however, the prognosis is generally excellent: preterm babies born in this day and age have a far higher rate of survival than they did even a generation ago—and it is worth noting that James Elgin Gill, the baby who set the record for preterm birth survival, was born in May of 1987 after just 21 weeks and five days in utero. That makes him 27 years old as of this writing, and he is quite healthy today.