Preterm PROM

Contributor: Misty McDowell, MD 
Last Update: 02/04/2016
​
BACKGROUND

PPROM occurs in approximately 3% of pregnancies and is responsible for over 1/3 of all preterm births.  Previable PPROM occurs in <1% of pregnancies. PPROM is associated with a significant increase in maternal, fetal, and neonatal morbidity and mortality that results from infection, abruption placenta, umbilical cord compression, and prematurity. The probability of neonatal death and morbidity associated with PPROM decreases with longer latency and advancing gestational age.

INITIAL ASSESSMENT

• Confirm the diagnosis of PPROM by assessing the patient’s history and documenting pooling of amniotic fluid in the vagina or a positive nitrazine or fern test.
• Perform AmniSure if diagnosis is uncertain.

 
PPROM DIAGNOSED

• Perform ultrasound examination to assess fetal presentation, gestational age, placental location, and amniotic fluid volume.
• Perform GBS swab, if unknown
• If < 37 weeks perform STI testing and infection workup
  • Gonorrhea/chlamydia (if not done within 4 weeks)
  • Wet prep for BV
  • Urine culture
  • CBC w/ diff
• If 32-34 weeks, consider obtaining a sample of amniotic fluid from the vagina for assessment of fetal lung maturity. PG may be reliably run if no blood or urine contaminates the specimen.
  • Deliver if lung maturity confirmed
• Initiate continuous monitoring to identify uterine contractions and/or non-reassuring FHR pattern for at least 24 hours.

 
SUBSEQUENT MANAGEMENT

1) PPROM >34 wks

• Induction of labor vs. cesarean section as clinically indicated
• GBS prophylaxis (see OBTS GBS Guideline)

 
2) PPROM 23-34 wks

• Patients at 23 weeks will need detailed discussion with MFM and NICU physicians regarding desires for management.
• At 24 weeks gestation or greater, inpatient management with modified bed rest and serial evaluation for evolving infection, abruption, or labor is recommended.
• NICU consult
• Antenatal Testing
  • Daily NST’s (may be more frequent in individualized cases based on AFV or FHR tracing)
  • MFM growth scans q 3-4 weeks
  • If contractions noted, continuous FHR monitoring and tocometry
  • Weekly ultrasound to assess AFI
• Administer antenatal corticosteroids, if time allows.
• Magnesium sulfate should be administered for neuroprotection if <32 weeks gestation.
• Antibiotic Therapy
  • Begin latency antibiotics, if delivery not planned
    • Ampicillin 2g IV Q6h x 48h followed by oral amoxicillin, 500mg TID x5 days AND
    • Azithromycin 500mg IV once, then 250 mg PO daily x 6 days.
  • Give GBS prophylaxis (see OBTS GBS Guideline) if allowing to labor or if delivery planned.
  • Treat chorioamnionitis (see OBTS Chorioamnionitis Guideline)
    • Ampicillin 2g IV Q6h AND
    • Gentamicin 2mg/kg loading dose, then 1.5mg/kg Q8h
  • Treat for BV, UTI, Gonorrhea, Chlamydia as necessary
• Deliver for non-reassuring fetal status or clinical evidence of infection/abruption

 
​3) Previable PPROM <23 wks

• Offer 24 hour inpatient observation to evaluate for signs/symptoms of labor, abruption, or infection
  • 40-50% of patients with previable PPROM will give birth in the first week after membrane rupture and 70-80% in 2-5 weeks.
• MFM consult for patient counseling regarding:
  • Expectant management can allow for discharge home if clinically stable.  Close follow up needed including:
    • Office visits to assess for signs/symptoms of labor, abruption, or infection
    • Serial ultrasounds to evaluate amniotic fluid volume and growth
    • Readmission when viability is reached
    • Frequent temperature checks (patient can do at home), after counseling about symptoms of fever and definition of fever.
  • Induction of labor
    • See OBTS Pregnancy Loss Guideline.

---

References

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin  No. 160; January 2016: Premature Rupture of Membranes. 

Blackwell S, O.deRegnier R, et al. Periviable Birth. Obstetrics and Gynecology 2015; 126:e82-94.

Brumbaugh J, Colaizy T, et al. Neonatal Survival After Prolonged Preterm Premature Rupture of Membranes Before 24 Weeks of Gestation. Obstetrics and Gynecology 2014; 124: 992-998.

Mercer BM. Preterm premature rupture of the membranes. Obstetrics and Gynecology 2003; 101: 178-193

Mercer BM, Crocker LG, Boe NM, Sabia BM.  Induction versus expectant management in premature rupture of the membranes with mature amniotic fluid at 32 to 36 weeks:  a randomized trial.  Am J Obstet Gynecol 1993;169:775-82

Mercer BM, Miodovnik M, Thurnau GR, et al.  Antibiotic therapy for reduction of infant morbidity after preterm premature rupture of the membranes.  JAMA 1997;278:989-95

Naef RW, Albert JR, Ross EL, et al.  Premature rupture of membranes at 34 to 37 weeks’ gestation:  aggressive versus conservative management.  Am J Obstet Gynecol  1998;178:126-30.  1997;278:989-96

Schucker JL, Mercer BM. Midtrimester premature rupture of the membranes. Semin Perinatol 1996;20:389-400

Waters TP, Mercer BM. The management of preterm premature rupture of the membranes near the limit of fetal viability. Am J Obstet Gynecol 2009;201:230-40.