Introduction
Premature rupture of membranes (PROM) appears to be the spontaneous rupture of the amniotic sac before the beginning of the labor activity and before the 37th week of pregnancy. At term, PROM complicates approximately 8% of pregnancies. Preterm PROM (pPROM) complicates about 1% of deliveries overall.
Several risk factors of the premature rupture of membranes were identified. One of them is represented by the intrauterine infectious process. Low social and economic status, harmful habits (tobacco smoking and drugs), low Body Mass Index (less than 19.8 kg/m2), as well as insufficient food consumption are predisposing factors to premature rupture of membranes. The PROM risk is significantly higher in women who experienced premature rupture of membranes during a previous pregnancy. However, in most cases, the premature rupture of membranes occur without any predisposing factors(1).
For every second pregnant woman with pregnancy complication as PROM, the risk of preterm labor in next two weeks is considerable(2). During pregnancy at 28 to 37 weeks, complicated by premature discharge of amniotic fluid, labor activity starts spontaneously in the course of the next 24-48 hours in 50% of women and within seven days in 70-90% of women. If the discharge of amniotic fluid is registered before the 28th week of pregnancy, labor activity starts significantly later(3,4). In some cases, it is possible to prolong pregnancy for a few days, weeks or even months. As of today, the tactics of the incomplete pregnancy follow-up complicated by PROM, respiratory distress syndrome (RDS) and infectious complications prevention are relatively defined. The differences could be found only in the term of delivery(2,5). When deciding how to manage pPROM, we need to consider a few factors, including gestational age, the availability of an appropriate level of neonatal care, the presence or absence of maternal/fetal infection, labor or abruptio placentae, fetal presentation, fetal biophysical profile, and cervical status. When we suspect an intrauterine infection, abruptio placentae, fetal distress or a high risk of cord prolapse, we should indicate an expeditious delivery. The expectant management is preferable for stable patients (mother and fetus) with pPROM<34 weeks who can benefit from an antenatal corticosteroid course (ACS) that decreases the incidence of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis and neonatal mortality by up to 50%(6), a course of prophylactic antibiotics and hospital admission throughout the period until birth. In case of pregnancies with more than 34 weeks of gestation, the expectant management is only recommended if the gestational parameters are suboptimal, otherwise expeditious delivery is preferred(7).
In our article, we describe a case of a successful prolongation of pregnancy with PROM at the term of 27 weeks of pregnancy under the hospital management.
Case presentation
We present the case of a 27-year-old patient who denied any somatic or gynecological diseases. She was at her first pregnancy which was spontaneous. At 27 weeks, the patient applied for a consultation to the perinatal center after experiencing liquid discharge from the vagina. In the course of the examination, the discharge of amniotic fluid was confirmed. According to the ultrasound examination, severe oligohydramnios was observed, and the fetus development corresponded to the gestational age. The blood flow Dopplerometry was within the normal range, and the weight of the fetus was 1140 g, in pelvic presentation.
The patient was hospitalized at the Department of Pregnancy Pathology of the Perinatal Center, where she was subjected to treatment aimed at the pregnancy prolongation, fetus RDS prevention controlled by the blood flow Dopplerometry and amniotic fluid amount.
The patient was monitored for 27 days in the Department of Pregnancy Pathology and Obstetric Emergencies, with daily clinical evaluation of blood pressure, pulse, thermometry every four hours, fetal heart rate, fetal weight, cardio monitoring and evaluating the nature of vaginal discharges, as well as daily paraclinical evaluation of blood, protein C, every three days and weekly. We also performed ultrasound examination, with the assessment of fetal morphology and uterine condition.
Due to the fact that negative dynamics on these parameters were not registered, the patient was further monitored.
At the term of 30-31 weeks, the patient being under supervision in the Department of Pregnancy Pathology, symptoms of profuse bloody vaginal secretion in a volume of 200 ml and contractile pain were registered. Abdomen soft to palpation, ovoid uterus in increased tone; longitudinal site, breech presentation. Fetal hart rates were 140-150 bpm, sonorous. In the valves’ examination, the cervix was centered, shortened and closed. Moderate bloody vaginal discharge (200 ml). The diagnosis was established: pregnancy at 30-31 weeks. Preterm prenatal rupture of the amniotic sac. Long alichidian period (660 h). Fetal breech presentation. Suspicion of premature detachment of the normal inserted placenta. In connection with the association of premature detachment of the normal inserted placenta in a primipara with a complicated obstetric anamnesis with preterm prenatal rupture of the amniotic sac with a long alichidian period (660 h), as well as presented fetal breech presentation, it is recommended to finish the birth by emergency caesarean section. The parturient was advised, using information conduct, and she gave her written consent.
Thus, on 06.01.2022, at 18:38, a live male fetus was extracted from the legs, weighing 1760 g, with an Apgar score of 6/6. The child was transferred to the Resuscitation and Intensive Care Department, with the primary diagnosis of congenital infection. Respiratory support was not required. Antibacterial therapy was performed with supplemental oxygen provided through a mask. On the third day, the child was transferred to the neonatal department. Total bleeding was 1000 ml. There were no complications registered during the postpartum period. Taking into consideration the prolonged alichidian period (660 h), a course of antibacterial therapy with broad-spectrum cephalosporin was carried out. The patient was discharged on the second stage of treatment, on the sixth day after delivery, in a satisfactory condition, together with the child.
Discussion
Prelabor rupture of membranes requires immediate attention. Accurate diagnosis and knowledge of gestational age are crucial to determining the management of the patient. Gestational age dictates the management, because the frequency of perinatal complications decreases with increasing gestational age at membrane rupture and, at delivery, a gestational age-based approach to the management of pPROM is useful. While there is a potential to reduce infant morbidity when conservative management of pPROM is undertaken for the immature fetus, this benefit can only occur through a reduction of gestational age dependent morbidity with extended pregnancy prolongation and/or antenatal corticosteroid administration, or through prevention of perinatal infection.
The key to reducing the adverse effects of pPROM is to make a prompt diagnosis, working with a multidisciplinary team: the obstetrician/gynecologist will evaluate the patient and dictate the management, a nurse must participate in the monitoring of the patient, and the pediatrician must be aware of the patient’s status and treatment plan. The anesthesiologist must also be informed should the patient require a caesarean section or obstetric anesthesia. It is always important to discuss the wishes of the patient regarding the care of the baby in case the newborn will be severely preterm.
Conflict of interests: The authors declare no conflict of interests.