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]
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.
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.

Anemia is a common problem among premature babies in the NICU. Preemies are immature, so the systems their bodies use to make red blood cells are also immature. Even term babies have a normal period of anemia around 2 months of age, so you can imagine how anemic a preemie can get!

Most newborn babies have at least mild anemia. Infants' red blood cells break down faster than new red blood cells are made. Babies are usually at their most anemic around 2 to 3 months old, and gradually improve over the next two years. This normal anemia usually doesn't need any treatment other than a healthy diet with plenty of iron.

Because they are born early, preemies may develop more a more severe type of anemia called anemia of prematurity. In the last weeks of pregnancy, two changes occur that help full term babies to make red blood cells. First, a lot of the iron needed to make new red blood cells is transferred from the mother to baby in the third trimester. Also, in the last weeks of pregnancy, red blood cell production switches from the liver to the bone marrow. Because the processes that make new red blood cells are immature in preemies, preemies have a higher rate of anemia and their anemia is more severe than in term babies.

NICU care can make anemia in preterm infants worse. Doctors and nurses try to limit the amount of blood that's drawn for lab tests, but even small blood losses can affect very small preemies.
Anemia can only be diagnosed through a blood test. At our hospital, they took a few drop of blood from the foot. If your baby shows symptoms of anemia, doctors may do a blood test to count red blood cells (hemogloblin level) or to look at the percentage of red blood cells in the blood (hematocrit). These tests are often combined into one blood test, called an "H and H" for hemoglobin level and hematocrit.

Our 31 weeker (born at 2lb 3oz) had anemia. Thankfully, it didn’t require any blood transfusions (those are reserved for the severe cases of anemia), but upon discharge, we were instructed to give 1ml of Poly-vi-sol with iron each day (you can get this over the counter). At her one year appointment, her anemia blood test came back clean, and we were able to stop the Poly-vi-sol with iron.

The medicine tastes pretty bad (and smells worse). Therefore, I recommend mixing it with a bit of formula or breastmilk to mask the taste. You may also find that constipation is a side effect or the iron.

Group B Streptococcal

Group B Streptococcal, other wise known as Group B Strep or GBS, is a bacteria carried by 30 percent of adults in their intestines and 25 percent of women vaginally.  GBS can cause life threatening infections such as sepsis (blood disease), Meningitis (infection of fluid and lining around the brain) and also pneumonia in a newborn or premature baby.  Babies typically get GBS after it is passed from their mother, to them during birth. 

Diagnosing GBS:

• Every woman is tested for GBS during her pregnancy between weeks 35 and 37.  It is a simple test that just requires a sterile swab (Q Tip) to collect a sample from a woman's vagina and rectum. 
• If a woman goes into labor before 35 weeks, then her doctor can still perform the swab test when she comes into the hospital. 
• 25% of pregnant women carry Group B Strep and are considered GBS positive or Group B Strep positive. 
• Women who test positive for GBS usually show no signs of the bacteria infection, however they are at risk for passing the bacteria on to their baby. 
• Group B Strep is NOT a sexually transmitted disease

Preventive ways to keep a baby from getting GBS positive:

• Women who are considered GBS positive will receive antibiotics through an IV during labor.
• Women who go into labor before week 37 will usually receive antibiotics during labor
• Women who's water has broke 18hrs or more before delivery will typically receive antibiotics during delivery
• Women who have fevers during labor will be given antibiotics during delivery.  \
• Women who have already had a baby with GBS does not need to be tested again, she will automatically be put on antibiotics during delivery.
• If you are having a scheduled C section and your water has not broke, then you most likely will not need antibiotics. 
• Women who get antibiotics during labor have a 1 and 4,000 chance of delivering a baby with Group B Strep.  If a Women who is GBS positive does not receive antibiotics during delivery, her baby has a 1and 200 chance of developing Group B Strep positive. 

Signs of GBS Positive in a newborn and premature babies:

• Difficulty feeding
• Irritability
• Hard to wake baby up
• Difficulty breathing
• Blue-ish color to skin
• High/low Temperature
• low blood pressure
• high/low heart rate

How it is diagnosed in newborn and premature babies:

• The only sure way to diagnose Group B Strep in babies is to do a spinal tap to test the spinal fluid for the bacteria. 

Treatment for newborn or premature baby with Group B Strep positive:

• They are treated with antibiotics through an IV for several days, and sometimes weeks. 

Early onset disease:

• Early onset disease means that a newborn or premature baby will show signs of having GBS positive within the first week of life, and it is usually within the first day. 
• For early onset disease Group B Strep usually causes sepsis (infection of the blood), pneumonia and sometimes meningitis. 

Late onset disease:

• Late onset disease can occur from the first week through three months of life.
• Late onset disease can have the same infections as early onset disease, however meningitis is more common with late onset disease. 

Long term effects Group B Strep can cause:

• 25% of babies who have meningitis caused by GBS develop Cerebral Palsy, Hearing problems, Learning problems, and seizures
• Care for sick babies has drastically improved in the U.S., however 4-6% of babies with group B strep die from their infections.  And premature babies are more likely to die from GBS than full-term babies. 

While researching GBS positive to write this article, I could not find very much information on Group B Strep and premature babies so I will share my daughter Nora's story with you.

Nora was born at 25w5 days.  When I went into labor with Nora I was tested for Group B Strep and I tested positive so they put me on antibiotics during my labor.  I also had a sever infection of my uterus called Chorio, so I had almost every symptom listed above to be put on antibiotics to prevent Nora from getting GBS positive.  I had high fever, UTI, premature labor, infection, and I tested positive for it, so on the antibiotics I went. 

Nora was born with an infection but it was not GBS, it was chorio so she was automatically put on antibiotics at birth for the first 2 weeks of life.  After her birth all we heard about was chorio, so I did not think we had to worry about Group B Strep at all.  3 weeks after Nora was born she came down with another infection, again not GBS.  She was re-intubated and treated with antibiotics for a few days and then we continued on our NICU journey. 

It was not until Nora was 2 months old and 34weeks gestation, that she became extremely sick.  We got a phone call in the middle of the night telling us that Nora had stopped breathing (she was on nasal cannula at .5L and 21% oxygen) and that they were having to constantly stimulate her to breath.  We had been down this road a few weeks earlier when she had gotten the infection, and I never wanted to go down this road again.  My husband and I went up to the hospital, where I held my almost 4lb baby girl and had to pat her back, rub her head and beg her to breath every 2 or 3 minutes.  Nora turned every shade of blue, white and grey and those are colors I never want to see on my child again.  Nora stopped breathing several times in 2 hours and the Neonatologists decided it was time to give her poor body a break and put her back on the ventilator,  run some blood cultures, and put her on antibiotics right away.  They were pretty sure it was an infection, they just had to figure out which one it was.  It was not until about 12hrs later that her blood culture came back showing signs of GBS, so they then did a spinal tap on Nora (her 2nd one in the NICU) and that is when they discovered she had GBS positive. 

My pregnancy was going perfect. Had nothing wrong with anything, baby was growing great, I wasn't gaining too much weight. Just had normal aches and pains, nothing more. That all changed on April 30, 2012. I was 34 weeks exactly. I woke up swollen. My feet hurt if you touched them. This had never happened before. The swelling had always gone down overnight and my blood pressure has always been fine. Well, I took my blood pressure. 154/80. WHAT?! I called the doc to see if he wanted to see me earlier than my 11am appointment. They had me come in at 10. My BP at the office was 165/90. There was a little protein in my urine. My nurse, Linda, had me lie on my left side. She came back and my BP had dropped to 120/85. When my OB came in, he checked my cervix and I was slightly dialted and a little effaced. He put me on strict bed rest. Before I left we did an NST and ultrasound, both came back perfect. I had to do a 24 hour urine and was given BP medicine. I was to monitor my BP twice a day and if it got over 160 then I was to go straight to L&D. Our goal was to make it 3 more weeks to 37 weeks. I ended up in the hospital the next night and was observed overnight just to be discharged with a diagnosis of pre-e. I wasn't to move off the couch except to go to the bathroom or to my bed. Just great, I'm going to go crazy. When I went back to my OB's office on Friday of that week, he sent me directly to L&D because my BP wasn't getting better. I was going to be in the hospital until I delivered this baby. I felt perfectly fine but couldn't do anything. It was very frustrating. On May 7th I told my nurse that I thought my mucus plug had come out and they didn't seem concerned. The goal was now to get to 36 weeks which was Sunday May 13th. We can do this I thought. Well, 4am on May 8th rolled around and my LO had a different idea. My water broke. I didn't start feeling labor until around 1pm, 3 hours after they started pitocin. I didn't have to have mag because as soon as my water broke my BP went down. It was strangly good. At 3pm I was dialated to 4 so I got my epidural. By 530pm I was pushing! Mind you, this is my first, they never expected me to move that quick. At 7:17pm Evelyn Marie was born at 4lb 11oz and 18in long. She was perfect. Absolutley nothing wrong. She spent one week in the special care nursery as a feeder/grower. What a blessing she is!