Early water loss: a secret sign of infection

p wloss - Host and Care Medical Journal

Dropping water is usually a happy sign: it’s time to give birth, and you need to go to the delivery room. But early water loss, that is, rupture of the amniotic sac outside of active labor, can sometimes indicate an infection in the uterus that could endanger the fetus. Who is in the risk group, how is it identified and what can be done?

Water loss is part of the birth process and usually happens during its active phase. When detecting water loss – no matter when – it is important to immediately go to the maternity ward.

Premature water loss is the rupture of the amniotic sac before the start of active labor. Pollution is assumed to be one of the main causes of this.

The most obvious sign of an intrauterine infection is a fever of more than 37.8 degrees accompanied by rupture of the membranes and sometimes pain in the lower abdomen.

One of the clearest signs that it’s time to give birth is when spontaneous water falls or in other words: when the amniotic sac ruptures spontaneously.

Water loss is part of the birth process, and it usually occurs during its active phase. Therefore, when you detect a drop in water – and it doesn’t matter what time – you should immediately go to the maternity ward.

In some cases, which fortunately are rare, water loss may indicate an infection in the uterus, especially when it occurs in the early stages of pregnancy

water loss

What is the importance of amniotic fluid?

Amniotic fluid is a liquid that surrounds the fetus while it is in the womb. They allow the fetus to move freely (thus developing the lungs, joints and muscles), protect it from physical harm and help it maintain a constant temperature. 

The membranes that surround the amniotic sac protect against the entry of polluting factors coming from the vagina and cervix.

Where does the amniotic fluid come from?

in the first half of pregnancy . There are different estimates regarding the source of the amniotic fluid: according to one of them, the source is from the maternal plasma (a transparent liquid with a yellowish tint that flows in the blood vessels); According to another estimate, the source of the water is the membrane of the amniotic fluid. 

In the second half of pregnancy  the main contributor to the amniotic fluid is the urine of the fetus. Fluid regulation at this stage depends on the balance between the production of amniotic fluid in the urinary and respiratory tracts of the fetus and their absorption by the fetus (through swallowing) and through the membranes of the gestational sac.

How do you estimate the amount of amniotic fluid?

The accepted method is to estimate the amount of water using ultrasound. The index is called AFI (abbreviation of Amniotic fluid index): the abdomen is divided imaginary into four quarters, the largest fluid pocket in each of the quarters is measured by ultrasound and the four measurements are added together.

Another method is a vertical measurement of the largest water pocket identified by ultrasound examination.

In general, a result of 25 centimeters or more or a maximum pocket of 8 centimeters or more indicates polyamniotic fluid. The definition of amniotic fluid deficiency is less uniform, and in the past it was common to determine the definition according to the week of pregnancy. In general, it was customary to say that a result of less than 9 centimeters indicates a relative lack of amniotic fluid. Today it is customary to determine that the woman suffers from a lack of amniotic fluid when the AFI is 5 centimeters or less or when the maximum pocket depth is less than 2 centimeters.

What is early water drop?

This means that rupture of the amniotic sac occurred before active labor began. The early water break can be on time (ie after 37 weeks of pregnancy) or before the time (before 37 full weeks of pregnancy are completed).

What are the reasons for early water loss before the due date?

Early water loss before the due date is called in the medical language PPROM (preterm prelabor rupture of membranes).

One of the more significant causes of premature water breaking is infection. Its prevalence is inversely proportional to the gestational age: the younger the gestational age, the higher the chance that the water loss is due to infection.

The infection can be in the amniotic fluid itself, but it is also possible that it is an infection that comes from the vagina and the cervix.

Other possible reasons for early water loss:

  • Recurrent bleeding during pregnancy or hematomas (accumulation of blood at the edges of the gestational sac).
  • Local defects in membranes.
  • Anatomical defects such as birth defects.
  • Insufficiency of the cervix.
  • Previous surgeries or abortions.
  • Overstretching of the membranes due to excess amniotic fluid or multiple pregnancy.
  • Nutritional factors.
  • Smoking.
  • Fetal defects.
  • An invasive operation such as amniocentesis .

What are the signs of uterine infection?

The most obvious sign that indicates an intrauterine infection is a fever of 38 degrees or more of the mother accompanied by the rupture of the amniotic membranes. This may be accompanied by pain in the lower abdomen, sensitivity on the surface of the uterus and a rapid heartbeat of the mother (more than 100 beats per minute) and of the fetus (more than 160 beats per minute).

What are the dangers of uterine infection?

Studies show that babies born to women who developed an intrauterine infection had higher morbidity and mortality rates and a 3 times higher incidence of respiratory distress, sepsis and intracerebral bleeding compared to babies of the same age born to mothers who did not suffer from the infection.

An increase – of almost 4 times – in the incidence of cerebral palsy in children exposed to intrauterine infection was also reported.

As the water drops, pressure may be caused on the umbilical cord and/or prolapse of the umbilical cord or  separation of the placenta may occur .

How can water loss be diagnosed?

The diagnosis is not always simple.

Sometimes the loss of water is clear – watery fluid comes out of the vagina uncontrollably – but sometimes there is only a feeling of wetness or of light non-continuous dripping. For the purpose of the diagnosis, the doctor uses a speculum to detect a drop of water from the cervix or vagina. Even these actions are not always enough to confirm or rule out a water drop.

There are additional auxiliary tests based on the identification of the acidity/alkalinity index of the vagina or on the identification of proteins in the vagina (the proteins are usually only found in the amniotic fluid). However, even these methods are not completely reliable.

Ultrasound can also be used to diagnose the amount of water.

What do you do when there is a water drop on time (after 37 weeks of pregnancy) and there are no signs of impending birth? 

Usually, when a woman comes to the emergency room with water loss, she is already in labor or will go into labor within a few hours. This is true both with regard to water falling on time and with regard to early water falling. 60% of women who have early water loss will go into spontaneous labor within 24 hours.

If a woman had her water break on time, but she is not in the labor stage, she is usually sent to the hospital to wait for the development of spontaneous labor within about 24 hours. The length of the wait  depends on the protocol in place at that hospital and other factors that do not require a newborn to be born soon, such as carrying the GBS bacteria, fever, inadequate fetal monitor or the loss of meconial water (brown, thin or thick water that indicates that the fetus has passed its first exit – meconium – already being in the womb).

If by the appointed time the woman goes into spontaneous labor, the doctors – usually – recommend that the birth be delayed to avoid complications of prolonged water loss. These complications include, among other things, an increase in the incidence of developing an infection in the uterus.   

And if the water falls before the time?

When the water breaks before the due date (before 37 full weeks), the procedure depends on the gestational age at which the water broke.

Water loss before the 23rd-24th week of pregnancy . In such a case, there is a high risk of developing an infection in the mother and developmental injuries in the fetus (impaired lung development and limb deformities). Therefore, in most of these cases, doctors recommend terminating the pregnancy, especially if the woman has not completed 23 full weeks.

Water loss between the 24th and 34th week of pregnancy . During the admission of the woman to the emergency department, a careful assessment is done, during which they look for signs of intrauterine infection. If these signs do not exist, the aim will be to “pull out” the pregnancy.

The woman giving birth will be hospitalized, will receive a course of steroids to ripen the fetal lungs and will receive prophylactic antibiotic treatment for a week (usually this is two days of intravenous infusion and five days of oral medication).

As long as no signs of infection develop, the goal will be to “pull out” the pregnancy until at least the 34th week, and then the need to proceed to delivery will be considered.

Until a few years ago, there was an unequivocal recommendation for the child upon reaching 34 full weeks of pregnancy. Today, it is customary in many medical centers in Israel to evaluate and weigh the advantages and disadvantages of continuing the pregnancy and the newborn baby in more advanced weeks – even in the 36th or 37th week. 

If fever or other signs of infection appear during the hospitalization (such as a fast heartbeat of the mother, a fast heartbeat of the fetus, contractions or pain), the delivery will be hastened regardless of the gestational age since the continuation of the pregnancy carries a significant danger for the mother and the fetus.

Water loss after the 34th week of pregnancy . In the past, it was customary to wait a few hours, and if labor did not develop on its own, the recommendation was – usually – to start a procedure to  induce labor . Today, each case is evaluated individually, considering the need to administer steroids to mature the lungs of the fetus and in some cases, after a conversation with the birth mother regarding the advantages (reduction of complications of prematurity) and disadvantages (increase in the risk of infection) it is possible to continue the follow-up (usually as part of hospitalization) even up to the 37th week .  

When do you give birth immediately, without waiting?

In the following cases, give birth immediately :

  • Infection or suspected infection of the amniotic fluid (chorioamnionitis).
  • Suspicion of fetal distress – suspected fetal monitoring.
  • Decreased meconial water.

When is antibiotic treatment necessary?

Antibiotic treatment is given in the following cases:

  • It is known that the woman giving birth is a carrier of the GBS bacteria after taking a culture from the vagina and rectum or following a positive urine culture during pregnancy.
  • Water loss that lasts more than 18 hours in a situation where it is not known if there is a GBS infection.
  • Premature water loss (before 37 full weeks) in a situation where it is not known if GBS infection exists.
  • If the mother has a fever of 38 degrees or more.
  • If the amniotic fluid loss is accompanied by other signs of infection.

In the absence of signs of intrauterine infection, the standard antibiotic treatment is intravenous penicillin.

In case of early water loss before the 34th week of pregnancy, and in the absence of signs of infection inside the uterus, it is customary to give prophylactic intravenous antibiotic treatment (usually a combination of two types of antibiotics) for 48 hours, after which oral treatment (administration of medication by mouth) is given for five additional days.

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