Preterm Premature Rupture
of Membranes

Evidence-Based Management

ACOG/SMFM Clinical Update
Maternal-Fetal Medicine

Learning Objectives

  • Recognize PPROM epidemiology and pathophysiology
  • Apply evidence-based diagnostic criteria
  • Implement GA-specific management protocols
  • Counsel on maternal and fetal risks
  • Navigate areas of clinical uncertainty

Epidemiology

3%
of all pregnancies
30-40%
of preterm births

Pathophysiology

Membrane Failure

  • Matrix metalloproteinases
  • Collagen degradation
  • Inflammatory mediators
  • Mechanical stress

Infection Link

  • Bidirectional relationship
  • Cause or consequence
  • Ascending pathway risk

Risk Factors

Strong Evidence

  • Prior PPROM (recurrence 16-32%)
  • Vaginal bleeding in pregnancy
  • Cigarette smoking
  • Short cervical length (<25mm)
  • Intraamniotic infection

Diagnosis: Clinical Triad

Sterile Speculum Exam Level A

  • Pooling: Amniotic fluid in posterior fornix
  • Nitrazine: pH >6.5 (caution: false positives)
  • Ferning: Microscopic crystallization pattern
Avoid digital cervical exam unless labor/delivery imminent

When Diagnosis Unclear

Commercial Tests

  • AmniSure (PAMG-1): Sens 98-99%, Spec 87-100%
  • ROM Plus (IGFBP-1/AFP): Moderate accuracy
  • Ultrasound: Oligohydramnios supports but not diagnostic

Management by Gestational Age

16-22⁶
Periviable
Counseling-centered
23-31⁶
Expectant
ABX + Steroids
32-33⁶
Transition
Consider delivery
34⁰-36⁶
Delivery
at 34 weeks

Periviable PPROM (16-22⁶ weeks)

Counseling-Centered Approach Consensus

  • GA-specific survival and morbidity data
  • Pulmonary hypoplasia risk (10-26%)
  • Maternal risks (infection, retained placenta)
  • Offer expectant vs. delivery options
No corticosteroids at this gestational age

Latency Antibiotics

NICHD MFMU Protocol Level A

IV ampicillin 2g Q6h + IV erythromycin 250mg Q6h × 48h
↓
PO amoxicillin 250mg Q8h + PO erythromycin 333mg Q8h × 5d
Avoid amoxicillin-clavulanate — associated with NEC

Antenatal Corticosteroids

Strong Evidence for Benefit Level A

Betamethasone 12mg IM Q24h × 2 doses
OR
Dexamethasone 6mg IM Q12h × 4 doses
  • Indication: 23-34 weeks (some use through 36⁶)
  • Reduces: RDS, IVH, NEC, neonatal mortality

Neuroprotection

Magnesium Sulfate Level A

4-6g loading dose, then 1-2g/hr maintenance
  • Indication: Delivery anticipated <32 weeks
  • Benefit: Reduces cerebral palsy risk and severity

Late Preterm PPROM (34-36⁶ weeks)

Delivery recommended at 34⁰ weeks

PPROMT Trial Evidence Level A

  • Reduces chorioamnionitis
  • Reduces neonatal infection
  • No increase in neonatal morbidity

Indications for Delivery

  • Chorioamnionitis (fever, tenderness, fetal tachycardia)
  • Non-reassuring fetal status
  • Placental abruption (bleeding, pain)
  • Advanced labor
  • ≥34 weeks gestation

Maternal Risks

Chorioamnionitis
13-60%
↑ with early GA, ↑ latency
Abruption
4-12%
Higher than baseline
Cord Prolapse
1-2%
↑ with oligohydramnios
  • Endometritis, sepsis (rare but serious)
  • Increased cesarean delivery risk
  • Recurrence risk in subsequent pregnancies

Fetal/Neonatal Risks

Immediate

  • Neonatal sepsis/pneumonia
  • Cord compression/prolapse
  • Malpresentation
  • Placental abruption

Prematurity-Related

  • RDS, BPD
  • IVH, PVL
  • NEC
  • ROP
  • Long-term neurodevelopmental

Pulmonary Hypoplasia

Periviable PPROM-Specific Risk

  • Incidence: 10-26% with PPROM <24 weeks
  • Risk factors: Rupture <20 weeks, severe prolonged oligohydramnios
  • Outcome: Often lethal or severe respiratory compromise

Initial Counseling

  • What happened: "Protective bag of water" has broken early
  • Timing: Most deliver within 1 week; some longer latency
  • Management: Hospitalization, antibiotics, steroids, monitoring
  • Risks: Infection, preterm birth complications
  • Signs to report: Fever, pain, foul discharge, bleeding, contractions

GA-Specific Counseling

Gestational Age Key Counseling Points
Periviable Full outcomes discussion; option for expectant vs. delivery; shared decision-making
23-32 weeks Each week improves outcomes; goal to reach 34 weeks; NICU course likely
34-36 weeks Excellent survival; delivery recommended at 34 weeks; may have mild respiratory issues

Areas of Controversy

Timing of Delivery (32-34 weeks)

  • Established: Delivery at 34 weeks superior to expectant management
  • Uncertain: Optimal timing between 32-34 weeks
  • Current practice: Varies by institution

Areas of Controversy

Outpatient Management

  • Traditional: Hospitalization until delivery
  • Evolving: Selected outpatient candidates after stabilization
  • Uncertain: Patient selection criteria, GA limits, safety protocols
  • Current: Most favor inpatient, especially <32 weeks

Areas of Controversy

Corticosteroids 34-36 Weeks

  • ALPS trial: Betamethasone reduces respiratory morbidity 34-36⁶ weeks
  • ACOG guidance: Recommends for women at risk of delivery within 7 days
  • Question: Does this apply to PPROM when delivery recommended at 34 weeks?

Areas of Controversy

Amniocentesis for Infection Assessment

  • Potential: Could identify subclinical intraamniotic infection
  • Challenges: Technical difficulty with oligohydramnios; unclear impact on management
  • Current practice: Not routinely performed; rely on clinical signs

Evidence Summary

Level A Strong Evidence (RCT/Meta-analysis)

  • Latency antibiotics prolong pregnancy, reduce morbidity
  • Corticosteroids reduce RDS, IVH, NEC
  • Magnesium sulfate reduces cerebral palsy <32 weeks
  • Delivery at 34 weeks superior to expectant management

Level C Consensus-Based

  • Inpatient vs. outpatient management
  • Antenatal testing protocols
  • Periviable PPROM counseling and management

Clinical Pearls

  • PPROM accounts for 30-40% of preterm births
  • Diagnosis primarily clinical; avoid digital exams
  • Antibiotics and steroids are evidence-based interventions
  • Deliver at 34 weeks; expectant management before
  • Infection risk increases with latency but balanced against prematurity
  • Counseling must be GA-specific and individualized

Summary

PPROM management balances risks of prematurity against risks of infection and oligohydramnios
  • Evidence-based interventions: antibiotics, corticosteroids, magnesium sulfate
  • GA-specific protocols optimize outcomes
  • Shared decision-making essential for periviable cases
  • Ongoing research addresses areas of uncertainty

References

ACOG Practice Bulletin No. 217: Prelabor Rupture of Membranes. Obstet Gynecol. 2020.

ACOG Committee Opinion No. 713: Antenatal Corticosteroid Therapy for Fetal Maturation. Obstet Gynecol. 2017.

ACOG Committee Opinion No. 455: Magnesium Sulfate Before Anticipated Preterm Birth for Neuroprotection. Obstet Gynecol. 2010 (Reaffirmed 2020).

Morris JM et al. Immediate delivery vs expectant management after preterm prelabour rupture of the membranes close to term (PPROMT trial). Lancet. 2016.

Mercer BM et al. Antibiotic therapy for reduction of infant morbidity after preterm premature rupture of the membranes. JAMA. 1997.