Obgyn · Year 3 · from Obgyn
Case 1: Preterm Premature Rupture of Membranes (PPROM)
Patient Demographics
- Age: 29 years
- Sex: Female
- Occupation: Bank teller
Chief Complaint
"I felt a gush of fluid and I think my water broke. I'm only 31 weeks pregnant."
History of Present Illness
The patient is G2P1 at 31 weeks 2 days gestation who reports an acute gush of clear fluid from her vagina 4 hours ago while at work. She has had persistent leaking since then. She denies uterine contractions, vaginal bleeding, fever, or foul-smelling discharge. She reports normal fetal movement.
Past Medical History
- Asthma (well-controlled, uses albuterol inhaler rarely)
- No prior preterm births
Obstetric History
- G2P1001
- Prior term uncomplicated vaginal delivery at 39 weeks
Physical Examination Findings
- Vital Signs: BP 112/68 mmHg, HR 78 bpm, Temperature 98.4F
- Abdomen: Gravid, soft, non-tender, fundal height 30 cm, vertex presentation by Leopold
- Sterile Speculum Examination:
- Pooling of clear fluid in posterior vaginal fornix
- Positive nitrazine test (fluid turns paper blue, pH >6.5)
- Ferning pattern present on microscopy
- Cervix appears 1 cm dilated, no prolapsed cord
- NO digital cervical exam performed (increases infection risk with ruptured membranes)
Fetal Assessment
- Fetal Heart Rate: Baseline 140 bpm, moderate variability, accelerations present
- Ultrasound: Vertex presentation, AFI 4 cm (oligohydramnios), EFW 1,600 grams
Diagnosis
Preterm Premature Rupture of Membranes at 31 weeks 2 days
- Confirmed by pooling, positive nitrazine, positive ferning
- No evidence of chorioamnionitis
- No active labor
Management Plan
Admission and Monitoring:
- Continuous fetal monitoring initially, then daily NST
- Maternal temperature and vital signs every 4 hours
- Monitor for signs of infection or labor
Latency Antibiotics (to prolong latency and reduce infection):
- Ampicillin 2 g IV every 6 hours for 48 hours
- Azithromycin 1 g PO once
- Then Amoxicillin 500 mg PO every 8 hours for 5 days
Antenatal Corticosteroids (for fetal lung maturity):
- Betamethasone 12 mg IM x 2 doses, 24 hours apart
- Administered at 31 weeks - within recommended window (24-34 weeks)
Magnesium Sulfate for Neuroprotection:
- Indicated because <32 weeks and delivery anticipated within 24 hours is possible
- 4 g IV loading dose, then 1 g/hour maintenance
GBS Prophylaxis:
- GBS culture obtained
- Will receive intrapartum prophylaxis regardless of culture result (prolonged ROM)
Hospital Course
Day 1-2:
- Received both betamethasone doses
- Completed magnesium sulfate (24 hours)
- No contractions, afebrile
- Transitioned to oral antibiotics
Day 3-7:
- Stable, afebrile
- Minimal fluid leaking
- AFI 3 cm (persistent oligohydramnios expected)
- Daily NST reactive
- No signs of chorioamnionitis
Day 8 (32 weeks 3 days):
- Patient developed temperature 38.2C, maternal tachycardia (110 bpm), fetal tachycardia (170 bpm)
- Uterine tenderness on palpation
- WBC 18,000 with left shift
Diagnosis of Chorioamnionitis
Clinical chorioamnionitis diagnosed based on:
- Maternal fever (>38C)
- Maternal and fetal tachycardia
- Uterine tenderness
- Elevated WBC
Delivery Decision
Indication for delivery: Chorioamnionitis (infection mandates delivery regardless of gestational age)
Delivery:
- Ampicillin and gentamicin started for broader coverage
- Induction of labor initiated with oxytocin
- Vaginal delivery after 6 hours of labor
- Female infant, 1,720 grams, Apgar 7/8
- Admitted to NICU for prematurity and sepsis evaluation
Clinical Image
Image Description: Algorithm diagram showing the management of preterm premature rupture of membranes, including gestational age-based decision making, latency antibiotics protocol, and criteria for chorioamnionitis diagnosis.
Attribution: Educational illustration adapted from ACOG guidelines. Used for medical education purposes.