Snapshot A 30-year-old G2P1 female at 33 weeks gestation presents to the emergency department saying that her "water broke." She reports that the fluid is a pale yellow color and denies the presence of mucus or blood. External fetal monitoring reveals a reactive fetal heart tracing and no uterine contractions. Speculum exam reveals a closed cervical os with a pool of fluid in the vaginal vault. The fluid is fern and nitrite positive. Bedside sonogram shows oligohydramnios and a fetus with cephalic presentation. Introduction Clinical definition rupture of membranes at ≥ 37 weeks gestation prior to the start of uterine contractions note that preterm premature rupture of membranes (PPROM) describes PROM < 37 weeks gestation Epidemiology incidence ~8% of all pregnancies risk factors most patients do not have identifiable risk factors previous rupture of membranes genital tract infection antepartum bleeding cigarette smoking Pathogenesis not completely understood; however, the integrity of fetal membranes is compromised due to proinflammatory cytokines imbalance btw matrix metalloproteases and their tissue inhibitor Prognosis usually results in delivery within a week of onset Presentation Symptoms gush or slow leak of fluid from the vagina Physical exam amniotic fluid exiting the cervical os amniotic fluid pooling in the vaginal fornix Studies Labs Nitrazine paper tests the pH of the vaginal fluid note that vaginal fluid is acidic (pH ~4) and amniotic fluid has a pH ~7 fern test fluid is swabbed and placed on a glass swab a ferning pattern is seen with amniotic fluid Differential Urinary incontinence Genital tract infection increased cervical discharge Treatment Conservative expectant management indication if there is no evidence of chorioamnionitis or fetal compromise in a fetus that is 22-34 weeks gestation administer betamethasone if < 34 weeks gestation if the Lecithin/Sphingomyelin < 2.0, can administer betamethasone up to < 36 weeks gestation delivery indications if > 34 weeks gestation unless the genstational age of the fetus is uncertain and fetal maturity cannot be confirmed Complications Complications chorioamnionitis umbilical cord prolapse