Monday, August 20, 2012

Premature Rupture of Membranes (PROM) and Preterm Premature Rupture of Membranes (pPROM)
Premature rupture of membranes (PROM) refers to a woman who is beyond 37 weeks' gestation and has presented with rupture of membranes prior to the onset of labor. Rupture of membranes is more commonly referred to as “water broke” or “broken sac”.  Preterm premature rupture of membranes pPPROM) is a repture of membranes prior to 37 weeks' gestation. pPROM is associated with 30-40% of preterm deliveries and is the leading identifiable cause of preterm delivery.  pPROM complicates 3% of all pregnancies and occurs in approximately 150,000 pregnancies yearly in the United States.[1]


[2]
Causes
At term, programmed cell death and activation of catabolic enzymes, such as collagenase and mechanical forces, result in ruptured membranes.  Essentially, it’s the normal “water broke” process that pregnant women experience, but often prior to contractions / labor.   
pPROM is a bit more difficult to pinpoint causes, however it is likely due to the same mechanisms and premature activation of these pathways. However, pPROM appears to be linked to underlying pathologic processes as well, most likely due to inflammation and/or infection of the membranes. Clinical factors associated with pPROM include low socioeconomic status, low body mass index, tobacco use, preterm labor history, urinary tract infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis. [3]
I was laying in bed while I was 25 weeks pregnant with boy/girl twins, watching the evening news, when I felt wet “down there”.  I literally started giggling as I thought to myself, “I’m only 25 weeks pregnant and I’m already peeing my pants!”  I got out of bed, took my yoga pants off, and noticed it was a little more than the dribble I felt.  I walked to the bathroom where I sat on the toilet, stood up, and a huge WOOSH of water came out.  I knew right then and there that it wasn’t urine, it was fluid, and that my water had broke.  I called my OB and she told me to put a pad on and get to the hospital.  I told them that at this point we were beyond a pad, hung up the phone, stuck a towel between my legs, and headed to the hospital where they confirmed almost immediately via an AmnioSense strip test that it was amniotic fluid.  Looking back, I believe bleeding from a subchorionic hemorrhage or hematoma present with Baby A from weeks 9 until 17 deteriorated her sac and caused my pPROM.
Treatment and Risks
Unfortunately, there is no treatment for PROM or pPROM.  With PROM doctors feel that, in the majority of cases, it is safer for both the mother and baby to induce labor and deliver early.  However, some doctors may choose to put a mother on hospital bedrest and a non-stress test (NST) given daily to monitor the baby and ensure there is no distress.  Antibiotics are likely to be administered to ward off infection.  There remain different schools of thought, but PROM mothers are likely to face immediate delivery.
The course of action for pPROM is significantly different.  Mothers are put on strict hospital bed rest with constant monitoring unless there are other significant risks to the mother and / or baby to consider including fetal distress.  In those cases, immediate delivery is suggested.  The hope is to stop / prevent labor and stave off infection for as long as possible with the goal to keep the baby in for as long as possible until it is safer outside than inside.  Since amniotic fluid is essentially baby urine, a baby can last quite some time in a broken sac as long as infection stays away. 
Magnesium sulfate is often given to stop labor and corticosteroid shots (ex. betamethasone) to help accelerate the development of the baby’s lungs.  Magnesium sulfate is also linked to protecting the sensitive tissues of the brain in premature babies and can lessen the risk of cerebral palsy.  An antibiotic regimen is also started to work against any potential infection and NSTs are conducted at least daily.  Additional monitoring such as ultrasounds to identify size and monitor fluid levels may be prescribed as well.
An ultrasound was conducted that showed Baby A, baby girl Keltie, had a broken sac and low amniotic fluid.  Baby B, baby boy Colton, had a sac still intact and both babies were not in distress.  While in the admitting room, they also found I was contracting every 3-4 minutes and I was immediately given a steroid shot (the first in a series of two) and started on magnesium sulfate to stop the labor.  I was put on strict bed rest where I couldn’t get up to use the bathroom or shower.  But, I was willing to do anything to keep the babies inside for as long as possible.  I had three goals given to me:  1 – make it 24 hours for the second steroid shot, 2 – make it another 24 hours past that to have the steroid series considered “complete”, and 3 – make it to 26 weeks gestation where the survivability rate goes from 50% to 75% for the babies.
The vast majority of women proceed to go into active labor and deliver soon after pPROM. With appropriate therapy and conservative management, approximately 50% of all remaining pregnancies deliver within one week after pPROM. Thus, very few women remain pregnant more than 3-4 weeks after pPROM.  Spontaneous sealing of the membranes does occur occasionally (< 10% of all cases), mostly after pPROM that has occurred subsequent to amniocentesis; however, this is the exception rather than the rule. [4]  Women suffering pPROM should ensure they are at a hospital with a Level III NICU capable of dealing with babies less than 34 weeks gestation.  If not, a transfer request should be made to one able to handle complicated premature babies.
I made it 4 days before Keltie stuck her feet through my cervix and sent me into full blown labor.  I was rushed in for an emergency c-section and on January 24, 2012 at 3:19am at only 26 weeks and 1 day gestation, I gave birth to two beautiful twins.  Colton weighed 1lb, 13oz and Keltie weighed 1lb, 9oz and both were 13 inches long.  After 100 days in the NICU, Keltie joined us at home.  Six weeks later and after 142 days in the NICU, her brother Colton finally joined us – that was the happy ending we were waiting for.  Today they are growing and thriving – to learn more about our story, please visit:  Project26WeekPreemies.


[1] http://emedicine.medscape.com/article/261137-overview#a1
[2] http://www.tommys.org/page.aspx?pid=972
[3] http://emedicine.medscape.com/article/261137-overview#a1
[4] http://emedicine.medscape.com/article/261137-overview#a1

3 comments:

Rachel Beer said...

I had pProm when I was 34 weeks. Wonder how doctors will handle my next pregnancy?

Unknown said...

Loved reading this, Krista. You wrote it so well. xo Christine

jhon cena said...

You guys present there are performing an excellent job.Go to Rik Lei

Precious and priceless so lovable too, the world’s sweetest littlest miracle is, a baby like you.

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