Premature Rupture of Membranes

Overview

What is premature rupture of membranes?

Premature rupture of membranes, or PROM, is when your water breaks before labor starts. Your healthcare provider may call it “prelabor rupture of membranes.” Prelabor is the newer, preferable term because it describes membrane rupture before labor starts — prelabor rupture — without implying prematurity. Typically, your membranes rupture after labor (or contractions) begins.

Your membranes are a fluid-filled sac (also called the amniotic sac) containing amniotic fluid. It surrounds the fetus during pregnancy. Amniotic fluid protects the fetus from infection, cushions its movements and helps develop its muscles and bones. Your membranes are sometimes called “bag of waters,” which is where the term “water breaking” comes from. When the membranes break (rupture), the amniotic fluid surrounding the fetus starts to leak or gush out your vagina. This can be a problem because without amniotic fluid, your chances of infection, premature birth and other complications increase.

Contact your pregnancy care provider right away if you believe your membranes have ruptured.

What is preterm premature rupture of membranes (PPROM)?

Preterm PROM (or PPROM) is when the amniotic sac breaks before 37 weeks of pregnancy. If your pregnancy is fewer than 37 weeks and your membranes rupture, your pregnancy care provider will decide if delivery is necessary or if they can delay labor. Allowing a pregnancy to continue after the membranes rupture increases your chances of infection and other complications. However, a premature birth also comes with risks. Your provider will carefully weigh these risks before making a decision.

What happens if you have prelabor rupture of membranes?

If your membranes rupture too soon, the fetus is at risk for premature birth or infection. If your pregnancy reaches 37 weeks, complications from premature birth are lower. However, if your baby is born before 37 weeks, they’re at higher risk for complications of being born early. These complications include respiratory issues and trouble staying warm. It can also cause changes to the fetus’s position, which can affect delivery.

Additionally, without the protection of amniotic fluid and the amniotic sac, the fetus and your uterus are at risk for infection. Infections can become quite serious.

How common is premature rupture of membranes?

  • PROM occurs in up to 10% of all pregnancies. Up to 95% of all births occur within 28 hours of PROM when it happens at term (37 weeks).
  • PPROM occurs in about 3% of pregnancies. Studies show PPROM is more likely to affect twin pregnancies.

Symptoms and Causes

What is the most common cause of preterm premature rupture of membranes (PPROM) and premature rupture of membranes (PROM)?

PPROM and PROM can have different causes. If your membranes rupture at term (37 weeks of pregnancy), it’s usually from your amniotic membranes weakening from the pressure of contractions. It’s normal for the membranes to break by themselves, but this usually happens after labor starts.

It’s important to note that just because you can’t feel contractions, your body is still preparing for labor. This means your uterus may be contracting, and your cervix may be thinning (effacing) and dilating (opening) without you feeling anything. This can cause the amniotic sac to weaken and eventually rupture.

Preterm PROM typically occurs due to a medical condition or pregnancy complication, but it can result from unknown causes. Some of the most common causes include:

What are the symptoms of PROM?

The most obvious symptom of your membranes rupturing is feeling a gush of fluid from your vagina. However, it’s not always a gush. Some people feel a slow leak or trickle of fluid. Your water breaking isn’t something you can control. Unlike when you pee, you won’t be able to hold it in.

It’s sometimes hard to tell if you’re leaking amniotic fluid, vaginal discharge (which increases in pregnancy) or pee. It may be helpful to put a white paper towel on the fluid. If it’s yellow or has an odor, it’s likely urine. If it’s clear and odorless, you should contact your pregnancy care provider.

If you’re at all unsure what’s coming out of your vagina, contact your pregnancy care provider.

Diagnosis and Tests

How is prelabor rupture of membranes diagnosed?

Your pregnancy care provider diagnoses PROM with a sterile speculum exam. This involves your provider inserting a speculum into your vagina. A speculum allows your provider to separate your vaginal wall and see your cervix. They can then collect a sample of fluid for testing. Sometimes, your provider can visually confirm the rupture of membranes if they see pooling of amniotic fluid at the top of your vagina during this exam.

Your provider may also perform an ultrasound to check the fetus’s position and the amount of amniotic fluid inside of your uterus.

What tests are used to diagnose PROM?

Your pregnancy care provider may also use nitrazine paper to diagnose PROM. Nitrazine paper measures the pH (a measure of how acidic something is) of your vagina. It involves placing a drop of your vaginal fluid on the strip of paper and waiting to see if the paper turns blue. A blue result means the fluid on the paper has a pH of greater than 6.0 and is likely amniotic fluid.

There are other ways your provider can check the pH of your vaginal fluid. It also involves swabbing your vaginal fluid and testing the pH. Vaginal fluid has a lower pH than amniotic fluid.

Another method providers may use is a fern test or ferning. Ferning refers to the fern-like pattern of dry amniotic fluid. It involves collecting a fluid sample and looking at it under a microscope.

Management and Treatment

What are treatments for prelabor rupture of membranes?

Treatment depends on the gestational age of the pregnancy (a term to describe how far along your pregnancy is), the health of the fetus and how severe your condition is.

Generally, there are two options: delivery or expectant management. Expectant management is a treatment that delays labor. This includes precautions like bed rest, medications and frequent monitoring for infection or fetal distress.

Treatment for PROM after 37 weeks

Approximately 90% of people will go into spontaneous labor within 24 hours if they’re between 37 and 40 weeks pregnant when their water breaks. Your provider may induce labor with medications or allow your labor to progress on its own. Delivering within 24 hours is usually the safest option.

Treatment for PROM between 34 to 37 weeks

Your pregnancy care provider will weigh the risks of premature birth with the risks of infection and other complications associated with letting the pregnancy continue. If your provider wants to deliver your baby, they may arrange for specialized care (like care from a NICU) to treat your baby when they’re born.

Treatment for preterm PROM (less than 34 weeks pregnant)

The complications from prematurity are high when the fetus is fewer than 34 weeks gestation. Your provider will keep you in the hospital on bed rest and attempt to prolong the pregnancy.

They may also give you:

  • Corticosteroids to help develop the fetus’s lungs.
  • Antibiotics to prevent infection and prolong the pregnancy.
  • Tocolytics (medication to stop labor).
  • Magnesium sulfate to help the fetus’s brain.

Your provider will monitor you closely for signs of infection. They’ll also monitor the fetus’s heart rate and movement to make sure it isn’t in distress. Ideally, these treatments allow your pregnancy to progress to at least 34 weeks.

It’s important to note that if you already have an infection at the time of rupture or develop one afterward, delivery is necessary.

Prevention

How can I prevent PROM?

There isn’t a way to prevent PROM. The best thing you can do is avoid smoking cigarettes, maintain a healthy pregnancy and attend all of your prenatal exams. Using tobacco is a risk factor for developing PROM (as well as other pregnancy complications).

Risk factors for PROM and preterm PROM

You may be at higher risk for PPROM or PROM if you have or develop any conditions that weaken the chorioamniotic membrane (the outer layer of the amniotic sac). These include:

What are the most common risks associated with ruptured membranes?

The biggest concern with PROM is premature birth. Premature birth is when your baby is born before 37 weeks of pregnancy. Complications from premature birth include breathing difficulties, low body temperature and poor growth. Some premature infants also have developmental delays later in life.

Without the protection of amniotic fluid, the pregnancy is at risk for other complications, including:

Your pregnancy care provider weighs the risks of premature birth against the risks of infection and other complications before deciding when it’s best to deliver.

Outlook / Prognosis

How long after rupture of membranes should you deliver?

Studies show that people who deliver within 24 hours of membrane rupture have a lower risk of infection than those who deliver after 24 hours. This risk is compared with the risks of prematurity. Your doctor will be able to help you make the best decisions for you and your baby.

How long can you stay pregnant with ruptured membranes?

This depends on your condition and how many weeks pregnant you are at the time of rupture. If your water breaks before 37 weeks, your provider will help you make the safest choice. In some cases, the risk of infection and complications is too high, and delivery is necessary.

Can a baby survive premature rupture of membranes?

Yes, the fetus can survive if your water breaks too soon. It depends on factors like the age of the pregnancy and how much amniotic fluid is left. Your pregnancy care provider will watch for signs of fetal distress and infection to determine when they should deliver your baby.

A note from Cleveland Clinic

During pregnancy, a fluid-filled sac called the amniotic sac surrounds and protects the fetus. Ideally, the sac breaks during labor. However, sometimes it breaks before labor begins — or several weeks before labor begins. This is premature or prelabor rupture of membranes (PROM). If this happens after 37 weeks of pregnancy, your pregnancy care provider will deliver your baby. If it occurs before 37 weeks of pregnancy (preterm PROM), your provider must weigh the risks of premature birth with the risk of complications such as infection and umbilical cord compression. Your water breaking early may be a shock to you. Try to take comfort in that your provider is doing everything they can to make sure you and your baby are safe and healthy.

Last reviewed by a Cleveland Clinic medical professional on 12/22/2022.

References

  • American College of Nurse Midwives. Prelabor Rupture of Membranes at Term. (https://www.midwife.org/acnm/files/ACNMLibraryData/UPLOADFILENAME/000000000233/PS-Prelabor-rupture-of-membranes-FINAL-22-MAR-18.pdf) Accessed 12/22/2022.
  • American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 217: Prelabor Rupture of Membranes. Obstet Gynecol. 2020 Mar;135(3):e80-e97. Accessed 12/22/2022.
  • Dayal S, Hong PL. Premature Rupture Of Membranes. (https://www.ncbi.nlm.nih.gov/books/NBK532888/) [Updated 2022 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Accessed 12/22/2022.
  • LeMoine F, Moore RC, Chapple A, Moore FA, Sutton E. Neonatal Survivability following Previable PPROM after Hospital Readmission for Intervention. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714616/) AJP Rep. 2020 Oct;10(4):e395-e402. Accessed 12/22/2022.
  • Merck Manual. Prelabor Rupture of Membranes (PROM). (https://www.merckmanuals.com/home/women-s-health-issues/complications-of-labor-and-delivery/prelabor-rupture-of-the-membranes-prom) Accessed 12/22/2022.

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