Women Talk: P.R.O.M.: When your water breaks early

Jenny, a 21-year-old first-time mother-to-be, was in her 9th month of pregnancy (39 weeks, to be exact). She was in the supermarket when suddenly, while reaching out for a bottle of ketchup, she felt something warm and liquid gush out from her vagina and flow down her inner thighs and legs and onto the floor. She had been warned by her obstetrician, and had also read about, pregnant women having their bags of water break in the strangest of places, but since it was her first pregnancy, she felt a twinge of panic.

She was alone, too, planning to just do a quick purchase and then go home. These past few days she had always felt so tired, what with the baby kicking and moving so often. The contractions, although not yet regular, would come and go, and at times they were quite painful.  

Concerned supermarket staff helped her get a cab. Luckily for her, the hospital she planned to deliver in was just two blocks away. At the emergency room she was found to be 2 cm. dilated (the baby comes out at full dilatation, which is 10 cm.), and yes, her amniotic sac had broken, or in medical parlance, ruptured. Since she was not yet in labor (there were no strong, regular contractions) she was labeled as PROM, or Premature Rupture of Membranes.

Many patients ask how would they know if it was the bag of waters and not just urine or vaginal discharge. The amniotic fluid is mainly water, so it will come out of the vagina, and spill out, unlike discharges.

If this happens, the woman is advised to go immediately to the hospital. If she is in doubt she should see her obstetrician the soonest. Do not wait for labor to start. Because the membranes that surround the baby are no longer present in PROM, to wait longer for labor to occur spontaneously would give bacteria a chance to enter the uterus through the cervix, leading to an infection called chorioamnionitis. Antibiotics are usually given to prevent this, especially when women come in with a history of their waters breaking so many hours (sometimes, many days!) before admission.

Rupture of membranes before labor occurs in about 5%-10% of pregnancies. When this occurs during term, that means the baby is mature enough to be delivered, and there is not much cause to worry because the decision will be for delivery.

There is, however, a worrisome situation when the waters break when the baby is still premature (before the 37th week) in about 3% of pregnancies. This is called PPROM (Preterm Premature Rupture of Membranes). Also, although rarely, PROM can happen during the second trimester (midpregnancy).

In PPROM, there is a need to balance the benefit gained from keeping the pregnancy intact, which are: giving the baby’s lungs more time to mature (so it can adapt to lung breathing easily after delivery); and for the baby to grow some more, and gain more weight inside the mother’s womb. The risk of intrapartum infection is high. As mentioned, once the membranes rupture, bacteria are given an almost open door to come in and infect the pregnancy. Would it be wiser to keep the baby inside, or deliver? This is a dilemma that the obstetrician would want to discuss with the parents.

Sometimes the water comes from a small leak high up in the membranes, and the hole reseals by itself (this occurs only in less than 10% of all PPROMs). The woman is observed, and when no more water comes out, ultrasound is done to quantify the volume of the amniotic fluid. If other fetal parameters are normal, and the mother has no fever, some obstetricians do expectant management. This, however, is the exception rather than the rule.

Injectable steroids are given to mothers for preterm rupture of membranes to hasten fetal lung maturity. Many obstetricians also give prophylactic injectable antibiotics specifically against Group B streptococcus infection.

Some neonatologists (newborn specialists) are not too worried even if the babies are 32 weeks, as the facilities in their hospitals are capable of caring for small premature infants. The newborn facilities in a hospital are important, to determine whether or not they are capable of caring for premature babies.

Rupture of the membranes could also occur far from term, that is, mid-pregnancy. In some, as mentioned, the leak reseals itself, and the passing out of clear liquid stops. These women may continue to have a normal course during the rest of their pregnancies, go into labor normally, and deliver healthy infants. Some however, miscarry, and many infants in this population were found to have congenital anomalies, which were incompatible with life. In many women too, because of lack of amniotic fluid where there is almost no room to grow, fetal contractures and pulmonary hypoplasia (underdeveloped lungs) occur.

Why does PROM occur? Studies show that it is highly associated with women who smoke, who are very thin and poorly nourished, or who have urinary tract infection. Women who have a history too, of a previous preterm labor, vaginal bleeding anytime in pregnancy, and some procedures done on them like cerclage and amniocentesis have higher incidence of PROM. Cerclage is a procedure where sutures are placed around the cervix to keep the pregnancy in the uterus longer; amniocentesis is a procedure where amniotic fluid is obtained from a pregnant uterus using an ultrasound-guided long needle to aspirate the fluid, mainly for diagnostic reasons.

Indeed there is no room for waiting once membranes have ruptured. Seeking help immediately would spell a really big difference. There was not much of a problem with the rupture of the membranes like Jenny’s, because the pregnancy was already full term and she was seen at once. After admission, the obstetrician did a CTG (cardiotocography) or a tracing of the fetal heartbeats. Since there were no other problems, infusion of drugs through an IV fluid to induce uterine contractions were started. Labor ensued, and progress was monitored, until the baby was delivered normally eight hours after admission. — BM, GMA News