History

Fact Explanation
History of sudden onset gush of fluid leaking from the vagina/ recurrent dampness/ constant leak[1] This is the typical presentation of rupture of membranes. Here history should cover the amount of leak, duration of leak, any suspected incidence( eg: uterine blunt trauma) prior to leak and any bleeding per vaginally.
Period of gestation[1][3] This is useful in further management as, premature rupture of membranes refers to rupture of membranes beyond 37 weeks of gestation. Preterm premature rupture of membranes is rupture of membranes before 37 weeks gestation. Rupture of membranes after or with the onset of labor is termed as spontaneous premature rupture of the membranes is
Features of normal labour like increasing intensity and frequency of contractions, pain As majority of patient(60%) with premature rupture of membranes will spontaneously go into labor within 24 hrs[1]. Prolonged rupture of the membranes is termed when the onset of labor doesn't occur within this period.
Present obstetric history History of previously diagnosed( in this pregnancy) multiple pregnancy, polyhydramnios, malpresentation and any congenital abnormality of the foetus[1].
Surgical history of cervical cerclage and invasive procedures like amniocentesis in this pregnancy. Cervical cerclage and amniocentesis can induce preterm rupture of membranes[1].
Past obstetric history of premature rupture of membranes, pre term labours and vaginal bleeding[1] These can be associated with recurrences.
Social history of socioeconomical status and tobacco/ drugs use[1] Social factors associated with Premature Rupture of Membranes include low socioeconomic status and tobacco/ cocaine(increased tone) use.
Past history of urinary tract infection or symptoms suggestive of UTI like- pain during passing urine(dysuria), lower abdominal pain, red colour urine( haematurea) Urinary tract infections are known to cause premature rupture of membranes[1].
Past medical history of complicated pregnancy by pregnancy induced hypertension, gestational diabetes mellitus[2]. Several complications of pregnancy like pregnancy induced hypertension and gestational diabetes mellitus can associated with premature rupture of membranes.
Age[2] More common in teenagers
History of fever, malaise, smelly discharge or bleeding from vagina following rupture of membranes[1][2][4]. Following rupture of membranes infections can introduce causing systemic illness and sepsis if goes for long time. if the patient is having polyhydramnios following rupture of membranes placental abruption can take place.
References
  1. CAUGHEY AB, ROBINSON JN, NORWITZ ER. Contemporary Diagnosis and Management of Preterm Premature Rupture of Membranes Rev Obstet Gynecol [online] 2008, 1(1):11-22 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492588
  2. POMA PA. Premature rupture of membranes. J Natl Med Assoc [online] 1996 Jan, 88(1):27-32 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607991
  3. MILLER HC, JEKEL JF. Epidemiology of spontaneous premature rupture of membranes: factors in pre-term births. Yale J Biol Med [online] 1989, 62(3):241-251 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2589108
  4. TITA AT, ANDREWS WW. Diagnosis and Management of Clinical Chorioamnionitis Clin Perinatol [online] 2010 Jun, 37(2):339-354 [viewed 24 August 2014] Available from: doi:10.1016/j.clp.2010.02.003

Examination

Fact Explanation
In speculum examination[1] will show watery discharge from the cervical os and/or pooling in upper vagina. Coughing/ straining (valsalva manoeuvre) may help in demonstrating the fluid leak from the cervical os. Digital cervical examinations should be avoided[1] as it can introduce infections (chorioamnionitis and neonatal infection) unless patient is in labour. No need to carry out a speculum examination if the patient is in labour. Speculum examination often confirms the leakage of amniotic fluid. During the examination colour, smell[3] and volume of discharge should be observed.
Check vital paremeters like temperature, blood pressure, respiratory rate and pulse [1][2][3] As premature rupture of membranes can be a result of an infections(eg: UTI) as well as rupture of membranes can result in infections( chorioamnionitis causes maternal tachycardia, pyrexia) , measurement of vital parameters are essential.
Examine for signs of labour like presence of contractions, frequency of contractions, progressive cervical dilatation[2]. This is useful in further management of the patient.
Obstetric examination should be done including lie, no of fetuses, presentation, amount of liquor and foetal heart sounds This is useful in assessing the condition of the baby and useful in identifying the cause for rupture of membranes. Polyhydramnios, malpresentation and multiple pregnancy can result in this[2].
Lower abdominal tenderness Chorioamnionitis[2][3] can increase uterine tenderness and urinary tract infections associated with cystitis also can present with lower abdominal tenderness.
BMI and Nutritional state of the patient Low body mass index and poor nutritional status(vitamin C, Cu, Zn deficiency) can associated with premature rupture of membranes.
References
  1. POMA PA. Premature rupture of membranes. J Natl Med Assoc [online] 1996 Jan, 88(1):27-32 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607991
  2. CAUGHEY AB, ROBINSON JN, NORWITZ ER. Contemporary Diagnosis and Management of Preterm Premature Rupture of Membranes Rev Obstet Gynecol [online] 2008, 1(1):11-22 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492588
  3. TITA AT, ANDREWS WW. Diagnosis and Management of Clinical Chorioamnionitis Clin Perinatol [online] 2010 Jun, 37(2):339-354 [viewed 24 August 2014] Available from: doi:10.1016/j.clp.2010.02.003

Differential Diagnoses

Fact Explanation
Preterm premature rupture of membranes[1] Preterm premature rupture of membranes is rupture of membranes prior to 37 weeks gestation. in this condition presentation is similar but in management there are several differences as the fetus is immature. So correct gestational age is very important.
UTI causing urinary incontinence[1] Urinary tract infections can induce urinary incontinence which will mimic the feeling of vaginal discharge.
Watery vaginal discharge due to sexually transmitting infections[1] Vaginal discharge can occur due to sexually transmitted infections like bacterial vaginosis. This is usually associated with odour and vulval itchiness.
Normal labour[1] With the normal labour excessive vaginal discharge( show) can be seen.
Excessive physiological vaginal discharge[1] Excessive physiological vaginal discharge is another different diagnosis for this condition.
References
  1. CAUGHEY AB, ROBINSON JN, NORWITZ ER. Contemporary Diagnosis and Management of Preterm Premature Rupture of Membranes Rev Obstet Gynecol [online] 2008, 1(1):11-22 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492588

Investigations - for Diagnosis

Fact Explanation
Assess the pH of the discharge with litmus/ nitrazine[1] The diagnosis is mainly a retrospective clinical diagnosis. There for no investigations are needed for diagnosis unless in a case of doubt. Checking the pH of the discharge can be done either with litmus or nitrazine. Amniotic fluid is alkaline. Presence of blood, semen and trichomonas infection can interfere with the results.
Assess the content of the discharge[1] Amniotic fluid contains high concentration of proteins.
Barbarization test[1] When a sample of fluid dry on a slide, amniotic fluid produces a characteristic fern( arborization) pattern.
Microscopic examination of the fluid[1] Amniotic fluid will contain lanugo hair and squamous cells.
Cytology[1] Nile blue staining of a sample of discharge will show desquamated fetal cells.
References
  1. CAUGHEY AB, ROBINSON JN, NORWITZ ER. Contemporary Diagnosis and Management of Preterm Premature Rupture of Membranes Rev Obstet Gynecol [online] 2008, 1(1):11-22 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492588

Investigations - Fitness for Management

Fact Explanation
Ultrasonography Helpful in confirming the gestational age and the estimated fetal weight, presentation, fetal anatomy and amniotic fluid index. [1][2]
Urine Full Report and urine culture (if organisms are present) This is useful in assessing the presence of urinary tract infection[1].
Full Blood Count White blood cell will be high in presence of chorioamnionitis[1][3].
ESR, CRP These will rise in presence of any infection[3].
References
  1. CAUGHEY AB, ROBINSON JN, NORWITZ ER. Contemporary Diagnosis and Management of Preterm Premature Rupture of Membranes Rev Obstet Gynecol [online] 2008, 1(1):11-22 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492588
  2. POMA PA. Premature rupture of membranes. J Natl Med Assoc [online] 1996 Jan, 88(1):27-32 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607991
  3. TITA AT, ANDREWS WW. Diagnosis and Management of Clinical Chorioamnionitis Clin Perinatol [online] 2010 Jun, 37(2):339-354 [viewed 24 August 2014] Available from: doi:10.1016/j.clp.2010.02.003

Investigations - Followup

Fact Explanation
Ultra sound scan and Doppler scan[1] This is useful in assessing the fetus's well being.
Cardiotocography (CTG) This is also useful in assessing the condition of the fetus[1]. Foetal heart rate will be high in presence of chorioamnionitis.
References
  1. CAUGHEY AB, ROBINSON JN, NORWITZ ER. Contemporary Diagnosis and Management of Preterm Premature Rupture of Membranes Rev Obstet Gynecol [online] 2008, 1(1):11-22 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492588

Investigations - Screening/Staging

Fact Explanation
Full Blood Count This useful in screening for the presence of any ongoing infection[2].
Amniotic fluid culture and ABST This is also helpful in assessing the presence of chorioamnionitis[1][2].
References
  1. CAUGHEY AB, ROBINSON JN, NORWITZ ER. Contemporary Diagnosis and Management of Preterm Premature Rupture of Membranes Rev Obstet Gynecol [online] 2008, 1(1):11-22 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492588
  2. TITA AT, ANDREWS WW. Diagnosis and Management of Clinical Chorioamnionitis Clin Perinatol [online] 2010 Jun, 37(2):339-354 [viewed 24 August 2014] Available from: doi:10.1016/j.clp.2010.02.003

Management - General Measures

Fact Explanation
Monitor for maternal well being[1] Monitor vital parameters of the mother. Record temperature, blood pressure, respiratory rate and pulse on admission and monitor temperature every 4 hourly during waking hours.
Monitor for foetal well being[1] Ultrasonographic evaluation of Amniotic fluid index and growth and well being of the fetus. CTG is useful in assessing the foetal well being.
Look for evidence of labour [1] Progressive uterine contractions, cervical dilatation, descend of the foetus will give evidence of going in to labour.
References
  1. CAUGHEY AB, ROBINSON JN, NORWITZ ER. Contemporary Diagnosis and Management of Preterm Premature Rupture of Membranes Rev Obstet Gynecol [online] 2008, 1(1):11-22 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492588

Management - Specific Treatments

Fact Explanation
Educate mother about the condition[1] Mother should be offer the choice between immediate induction and expectant management. Advantages and disadvantages of both methods should be explained to the mother.[1]
Conservative management until going into labour[1][2] Advice the patient to rest after assessing the signs and symptoms of labour and cord proplapse need to be excluded. Educate mother to report any change/ offensive smell of the discharge or reduction of foetal movements. Advice to avoid sexual intercourse as it can introduce infections but showering and bathing will be okay.
Induction of labour[1][2][3] This should be consider if no spontaneous labour for 24 hours.
Antibiotic therapy[1][3] The use of antibiotics is controversial. Some guidelines are not recommend prophylactic antibiotics even the rupture of membrane is more than 24 hours. But regular maternal observations should be done to pick up signs of infections early and to go for early antibiotic treatments. If clinically evident infection is present broad spectrum IV antibiotics should be given after sending blood and high vaginal swab for culture and immediate induction should be done.
References
  1. CAUGHEY AB, ROBINSON JN, NORWITZ ER. Contemporary Diagnosis and Management of Preterm Premature Rupture of Membranes Rev Obstet Gynecol [online] 2008, 1(1):11-22 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492588
  2. POMA PA. Premature rupture of membranes. J Natl Med Assoc [online] 1996 Jan, 88(1):27-32 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607991
  3. TITA AT, ANDREWS WW. Diagnosis and Management of Clinical Chorioamnionitis Clin Perinatol [online] 2010 Jun, 37(2):339-354 [viewed 24 August 2014] Available from: doi:10.1016/j.clp.2010.02.003