Keywords
PPROM - dye test - fluorescein - tampon
Introduction
The diagnosis of membrane rupture is typically made using nitrazine paper, visualization
of fluid within the vagina or “pooling” on speculum exam, and examination of vaginal
fluid for ferning under a microscope. The preterm period is arguably the most imperative
time frame to confirm preterm prelabor rupture of membranes (PPROM), as it increases
the risk of intra-amniotic infection (IAI), preterm labor, and neonatal sepsis.[1]
[2] In cases where the diagnosis is unclear based on an inconclusive work-up, the instillation
of intra-amniotic dye can be used for confirmation of membrane rupture. This test
is usually performed with indigo carmine, but a shortage of this drug has led to the
identification of alternatives.[3] Reference images of results are lacking in those cases.[4] We present two cases of confirmed PPROM using fluorescein dye.
Patient 1
Patient 1 is a 41-year-old G3P1011 female, presented to a regional hospital at 216/7 weeks with loss of fluid and persistent leaking. Her pregnancy was otherwise complicated
by GERD, anxiety/depression, asthma, AMA, and two first-degree relatives with malignant
hyperthermia. At presentation, she denied fevers, chills, contractions, or vaginal
bleeding. Her vital signs were unremarkable.
Nitrazine test and amnisure were positive, so betamethasone and antibiotics were administered
for PPROM, and the patient was transferred to a tertiary care facility. Upon arrival,
she began experiencing vaginal bleeding. Speculum exam was notable for bright red
blood with no clear source, cervix was closed, and a nonbleeding cervical polyp was
observed. There was no ferning visualized on microscopic examination. Interpretation
of a positive nitrazine test was confounded in the setting of bleeding. Ultrasound
showed amniotic fluid pockets smaller than expected for gestational age (2.1 × 2.4
and 5.7 × 2.6 cm), but no amniotic fluid leak was confirmed. The patient was admitted
for presumed PPROM, continued ampicillin and azithromycin, given a second dose of
betamethasone, and given magnesium, anticipating a prolonged admission to the antepartum
service. Given the discordant findings since transferring from the outside hospital
and gestational age, instillation of intra-amniotic dye was recommended.
Patient 2
The patient, a 22-year-old G2P1001 female, presented to a regional hospital at 315/7 weeks with loss of fluid without persistent leaking. Her pregnancy was otherwise
complicated by a prior cesarean delivery. At presentation, she denied fevers or chills
and endorsed mild lower back pain. Her vital signs were unremarkable.
Her speculum exam was negative for pooling, but microscopic examination of her vaginal
swab demonstrated “copious ferning.” Nitrazine paper was unavailable. The patient
was admitted with PPROM, started on ampicillin and azithromycin, given betamethasone
given magnesium, and transferred to a tertiary center, anticipating a prolonged admission.
On arrival, she lacked evidence of labor or intra-amniotic IAI and continued to deny
any vaginal leakage. Subsequent ultrasound revealed a normal AFI of 10 cm, and an
additional sterile speculum exam was negative the following day. Given discordant
exams and the patient's desire to leave the hospital, the patient opted for the instillation
of intra-amniotic dye.
Methods
In both cases, due to a shortage of indigo carmine, 5 cc of sodium fluorescein was
injected into the amniotic cavity under ultrasound guidance. The patients were instructed
to wear a tampon for 30 minutes while ambulating. The tampon appeared normal on direct
visualization ([Figs. 1] and [2]). However, under UV light, the tampon exhibited photoluminescence, confirming the
presence of fluorescein and the diagnosis of PPROM ([Figs. 1] and [2]).
Fig. 1 Tampons by naked eye (right) and under fluorescent light (left), dye test tampon
on right, unused tampon on right from patient case 1.
Fig. 2 Tampons by naked eye (right) and under fluorescent light (left), dye test tampon
on right, unused tampon on right from patient case 2.
Discussion
Patient 1
The patient remained on the antepartum service until hospital day 49, at which point
she developed contractions, abdominal pain, and malaise, concerning for IAI. She underwent
cesarean delivery at 286/7 weeks and was treated with ampicillin and gentamycin. Ultimately, the patient's postpartum
course was uncomplicated, and she was discharged postpartum day 3. The neonate was
admitted to the intensive care nursery (ICN) and was discharged home after 67 days.
Patient 2
The patient remained on the antepartum service until hospital day 5, at which point
she developed fevers and fetal tachycardia, concerning for IAI. She underwent repeat
cesarean delivery and was treated for presumed endometritis due to continued fevers
after delivery. Ultimately, the patient did well and was discharged postpartum day
3. The neonate was admitted to the ICN and was discharged home after 48 days.
Conclusion
In an intraamniotic indigo-carmine dye test, the tampon is visibly blue. In contrast,
fluorescein requires the use of a UV light (in our case, a Wood's lamp) and displays
a bright yellow appearance ([Fig. 2]). Though the technique is well described in the literature, images of positive results
are limited. These images may provide guidance in confirming PPROM diagnoses in similar
cases.
