Brief Report Premature Rupture of Membranes in the Second Trimester Lawrence M. Leem an, M D , M PH Zuni, New Mexico Spontaneous rupture of membranes during the second tri­ a patient with premature rupture of membranes at 21 mester presents difficult medical and ethical questions for weeks’ gestation who gave birth at 35 weeks. the patient and physician. Such pregnancies are at high risk for preterm birth, chorioamnionitis, and neonatal compli­ Key words. Fetal membranes, premature rupture; labor, cations. Treatment can range from expectant management premature; pregnancy complications; gestational age. to pregnancy termination. This case presentation describes (] Fam Prnct 1996; 42:293-299) Premature rupture of membranes (PROM) in the second 3 years earlier, followed by negative Papanicolaou smears. trimester results in a high incidence of pregnancy loss, She denied use of alcohol, tobacco, or illicit drugs. Her premature birth, and chorioamnionitis. The family physi­ previous childbirth 5 years earlier was a spontaneous vag­ cian involved in maternity care should be aware of the inal delivery of a term 3850-g female infant with Apgar relative risks and benefits of both expectant management scores of 5 and 7, complicated by preeclampsia and a and pregnancy termination. The family physician should postpartum hemorrhage. Her first spontaneous abortion counsel the patient during the stressful time, and consul­ occurred at 4 to 6 weeks estimated gestational age (HC!A) tation with a perinatologist is usually beneficial. Optimal and did not require dilation and curettage. Her second care may be ensured by having the family physician either spontaneous abortion occurred at 4 to 5 months EGA continue as primary care provider or develop a plan of and required a dilation and curettage. co-management. Recent developments in the manage­ At the initial visit, fundal height measured 18 cm; ment of second trimester PROM have led to the consen­ fetal heartbeat was auscultated by Doppler but not by sus that expectant management should be offered, includ­ fetoscope. The date of her last menstrual period was un ing the use of corticosteroids to promote pulmonary known. An ultrasound examination performed 4 days maturity and home management in selected cases. later demonstrated an intrauterine pregnancy of 17.9 weeks EGA. Amniotic fluid volume was normal, and no fetal or placental anomalies were noted. Routine prenatal Case Presentation laboratory test results were unremarkable. Three weeks later, the patient called her family physician to report that A 32-year-old woman, G4P1SAB2, was receiving prena­ she had a “ gush” of clear fluid from her vagina. She was tal care at the university family practice clinic in a moder­ instructed to come to the antepartum evaluation clinic at ate-sized southwestern city. Fler pregnancy was un­ the university hospital (Table 1). planned but mutually desired by the patient and her A diagnosis of premature rupture of membranes was fiance, who was in the armed services and stationed across made by means of a sterile speculum examination, which the country. Her past medical history' was notable for revealed a pool of fluid in the vagina. The fluid was iden­ cryotherapy for cervical intraepithelial neoplasia (CIN 1) tified as amniotic fluid based on a ferning pattern revealed by microscopic examination and nitrazine pH paper. An Submitted, revised, September 11, 1095. ultrasonogram obtained by a perinatologist demonstrated Prom the Department of Family and Community Medicine, University of New a 474-g fetus at 21 5/7 weeks EGA with decreased am­ Mexico, Albuquerque, and Zuni 1’HS Hospital, Zuni, New Mexico. Requests for niotic fluid volume and without apparent fetal or placental reprints should be addressed to Lawrence M. Leeman, MD, MPH, Zuni PHS Hospi­ tal, PO Box 467, Zuni, NM S7327. anomalies. The patient did not have a fever, abdominal © 1996 Appleton & Lange ISSN 0094-3509 The Journal of Family Practice, Vol. 42, No. 3(Mar), 1996 293 Second Trimester PROM Leem an Table 1. Evaluation of Possible Midtrimester Premature At 26 weeks into the pregnancy, she began daily Rupture of Membranes clinic visits for antepartum testing, which included non­ stress tests and biophysical profiles. She continued to leak • Diagnose preterm premature rupture of membranes with criteria of pooling, nitrazine positivity, and ferning pattern. Do not perform clear amniotic fluid throughout the pregnancy, and ultra­ digital cervical examination unless active labor has begun. sonography continued to show decreased amniotic fluid volume. Her nonstress tests were all reactive with no ev­ • Obtain cervical, vaginal, and urine cultures. idence of fetal tachycardia or abnormal decelerations. Her • Perform ultrasound examination to estimate gestational age and biophysical profile scores were all 8 /1 0 or higher, the assess fetal weight, amniotic fluid volume, presentation, and fetal only deficit being low amniotic fluid volume. (Corticoste­ or placental anomalies. roids to promote lung maturity and decrease the rate of • Perform maternal examination to include assessment for fever, intraventricular hemorrhage were not given because at blood pressure, and abdominal tenderness. that time rupture of membranes was a contraindication • Monitor for fetal tachycardia or bradycardia, heart rate variability, for corticosteroid use. Current National Institutes of and decelerations. Health [NIH] recommendations would favor corticoste­ • Use tocodynamometry to detect uterine contractions. roid use in this scenario.) The patient presented to labor and deliver)' at 35 weeks EGA with signs and symptoms of an upper respi­ tenderness, or clinical signs or symptoms of infection. All ratory tract infection, a 38°C oral temperature, abdominal routine cervical cultures were negative. The family prac­ tenderness, and uterine contractions occurring 3 to 5 tice service obtained a consultation from the maternal- minutes apart. A cervical examination revealed 1 -cm dila­ fetal medicine service, and the patient was admitted to the tion with a breech presentation. She declined a trial of university hospital. labor for a vaginal breech delivery, and a cesarean section The potential risks of premature birth, intrauterine was performed. A 2600-g male infant of 37 weeks EGA infection, and neonatal complications were discussed and was born, with Apgar scores of 5 and 8. The amniotic fluid the options of termination or expectant management was foul-smelling, and uterine atony was noted. Umbili­ were reviewed. The patient was given a tour of the new­ cal cord blood gases revealed an arterial pH of 7.23 and born intensive care unit to observe the realities of prema­ venous pH of 7.33. ture birth and the potential complications. During this The baby was brought to the newborn intensive care process, she became increasingly confused about what she unit because of decreased neuromuscular tone and poor should do, and explained to one of the nurses that she felt respiratory efforts. He required endotracheal intubation the physicians wanted her to terminate her pregnancy. for less than 48 hours and his condition was diagnosed as She reported that she had been counseled that this would neonatal pneumonia, for which he received a 10-day not be viewed as an abortion because the baby would not course of antibiotics. He was discharged home after a be able to live on its own and was unlikely to reach a viable 16-day hospital stay. At a 6-week developmental assess­ age without serious complications. ment, he was felt to have age-appropriate motor skills, and The patient stated that she could not end the preg­ at his 4-month well-child visit, he was growing well and nancy despite all the risks because she could feel the baby had no medical problems. The family subsequently move. In response to discussions about the inability of a moved out of state, and when the infant was approxi­ baby to live when born before 25 weeks’ gestation, she mately 9 months old, they mailed photos and a letter said that she felt the baby was “ strong” because of her describing a healthy boy and mother. perception that it kicked hard. She explained that al­ though in her Pueblo Indian culture the baby is not truly considered an individual or given a name until taken to the village and held up to the light of the morning sun, Discussion her religious and cultural beliefs prohibited terminating a Premature rupture of membranes is not an uncommon pregnancy that felt “ strong.” problem. A retrospective study at one hospital reported a She agreed to a discharge plan for bedrest at home rate of 1.75% before 34 weeks.1 Management issues are with frequent visits by a home health aide and the involve­ very' different in women with second-trimester PROM, as ment of a social worker. She was to monitor her temper­ their fetuses may not be of viable age (Table 2). To coun­ ature at home and come to the hospital for immediate sel patients with PROM, family physicians should be fa­ evaluation if she developed a fever, abdominal pain, con­ miliar with the risks for neonatal morbidity and mortality tractions, or a change in color or smell of the leaking Although there are no large studies of second-trimester amniotic fluid. PROM, the small studies demonstrate a high rate of neo- 294 The Journal of Family Practice, Vol. 42, No. 3(Mar), 1996 Second Trimester PROM Lee man Table 2. Management of Premature Rupture of Membranes survival for PROM at 22 weeks EGA or earlier, compared During the Second Trimester with 53.9% at 23 weeks or more. Thus, most patients with Therapeutic decisions PROM before 23 weeks will not give birth to a viable • Discuss options for expectant and interventive management with fetus. patient and family. If the fetus is not yet viable, pregnancy The above studies of the natural history' of the ex­ termination can be presented as an option. • Initiate course of corticosteroids (intramuscular betamethasone or pectant management of PROM all understate the mor­ dexamethasone) if less than 30 to 32 weeks’ gestation and bidity and mortality' of this condition.