Click here to view next page of this article


Premature Rupture of Membranes

Premature rupture of membranes is very common.  By definition, rupture of membranes is spontaneous rupture of the membranes before the onset of labor premature rupture of membranes, ruptured bag of waters. Premature rupture of membranes is before 37 weeks gestation and mid trimester rupture of membranes between 14 and 26 weeks and you find some text books on previable rupture of membranes.

We have to know that 3% of all pregnancies are complicated by premature rupture of membranes, 10% of all pregnancies are complicated by rupture of membranes before labor but 3% of the premature ruptures, 120 pregnancies in the United States and is a significant cause of infant morbidity as well as sometimes infant mortality. Fifty percent of patientís with ruptured membranes will deliver within two days, 48 hours and 80% will delivery within a week, 15 to 20% will develop chorioamnionitis.

Why do membranes rupture? One of the theories, itís something in the membranes, the membranes are weak, the motherís nutrition status is not great, poor maternal nutrition, mother smokes or some collagen deficiency syndrome that makes then rupture their membranes, or it could be mechanical stress, trauma or distension of the uterus in cases of multiple gestation or in the case of polyhydramnios, in case of other trauma to exposure of the membranes in case of incompetent cervix.

If itís not mechanical, then a lot of people who wrote about the biochemical data, why do membranes rupture, it is told that the total collagen content is reduced in women with preterm premature rupture of membranes, however, Ortega said there is no reduction in the collagen content in fetal content, premature rupture of membranes, but Zyde and Everson and Ortega said there is no difference and the total collagen between women with and without rupture of membranes, so one says there is, one says donít. The there is the question of the cytokines and interleukin 1 and mononucleosis factor, they stimulate collagenous activity, prostaglandin production, chorionic cells and that probably is how we get the ruptured membranes and the contractions.

If thatís the case, woman who have ruptured membranes, not all of the get infected and not all of them delivery very fast and get septic because when God created man, he put different mechanisms. I did some work at the University of Chicago, look at whatís in the amniotic fluid that causes infection and there are a lot of things, immunoglobulins, zinc phosphate ratio. Amniotic fluid itself has the ability to combat infections when the infection is actually not overwhelming.

If infection is the cause of ruptured membranes, then the way to think of it is, here is the bacteria, they will work on the membranes and weaken it, and causes ruptured membranes or you have the localized inflammation.

What are the clinical risk factors for patientís to get ruptured membranes, previous preterm delivery is one of the increased ratio of somebody getting ruptured membranes, cigarette smoking, another culprit and bleeding during pregnancy in the first trimester, second trimester, and during the third trimester. If the patient bleeds through three trimesters, then the chance that this patient will get rupture of membranes is almost seven times as much as the one who did not have bleeding at all.

Smoking, was found that smokers have a higher incidence of ruptured membranes compared to the nonsmokers between 20 and 36 weeks. Recurrent rupture of membranes, what are the chances of getting rupture of membranes again, this is the data that we have in the literature between 1982 and 1993, it was found the chance of getting 30% ruptured membranes again, he found that if the patient has ruptured membranes, once you have ruptured membranes, there is a chance at least that you will get ruptured membranes more often than her peers who did not have ruptured membranes.

C-reactive protein as a blood test is not very specific and for some reason, it was less sensitive but more specific and found it very sensitive and very specific. The biophysical profile, people look at biophysical profile and it depends, how does biophysical profile answer the question of infection, if you do it daily, you find that it correlates, the same thing with Mercer in 1991, he found that it correlates, if you do it daily itís okay, people who did it less often then it did not really correlate very well.

How do we manage patientís with ruptured membranes, letís see if you and I maybe can reach an agreement on certain issues, at term, preterm and previability and this is the work of Johnson in 1981 when they looked at patientís at term, and they looked at the issue of delay in delivering patientís, once you hit two days or more, then the morbidity goes up, so if the patient has development in the first two days, then they are okay, but once you leave them for more than eight hours.