Management Guidelines for Preterm Premature Rupture of Membranes (PPROM)
The management of preterm premature rupture of membranes requires individualized counseling about maternal and fetal risks, with specific interventions determined by gestational age, including antibiotics after 20 weeks and antenatal corticosteroids at appropriate timing. 1, 2
Initial Assessment and Counseling
- All patients with PPROM should receive individualized counseling about maternal and fetal risks of both abortion care and expectant management to guide decision-making 1, 2
- All patients with previable PPROM (<20 weeks) should be offered abortion care due to poor fetal outcomes 2
- Expectant management can be offered in the absence of contraindications 1
- Clinical factors that predict better outcomes with expectant management include later gestational age at PPROM and higher residual amniotic fluid volume 1
Management Based on Gestational Age
Previable PPROM (<20 weeks)
- High risk of poor outcomes - no surviving neonates reported after PPROM at <16 weeks in the PPROMEXIL-III cohort 1
- Offer abortion care to all patients 1
- Limited evidence for benefit of antibiotics; shared decision-making recommended 1
Periviable PPROM (20 0/7 to 23 6/7 weeks)
- Antibiotics can be considered to prolong latency (GRADE 2C) 1, 2
- Antenatal corticosteroids and magnesium sulfate not recommended until the time when neonatal resuscitation would be considered appropriate 1
PPROM at ≥24 weeks
- Antibiotics strongly recommended (GRADE 1B) 1, 2
- Antenatal corticosteroids recommended between 24+0 and 34+0 weeks 2, 3
- After 34 weeks, the benefits of delivery clearly outweigh the risks 4
Antibiotic Regimen
- Recommended 7-day course: 1
- IV ampicillin and erythromycin for 48 hours
- Followed by oral amoxicillin and erythromycin for 5 additional days
- Azithromycin can be used as an alternative to erythromycin 1, 2
- Avoid amoxicillin-clavulanic acid due to increased risk of necrotizing enterocolitis 1, 2
Other Interventions
- Magnesium sulfate for fetal neuroprotection when delivery is anticipated before 32 weeks 2
- Serial amnioinfusions and amniopatch are considered investigational and should only be used in clinical trial settings (GRADE 1B) 1, 2
- Cerclage management: reasonable to either remove or leave in situ after discussing risks and benefits (GRADE 2C) 1, 2
Monitoring During Expectant Management
- Close monitoring for signs of:
- Placental abruption
- Infection
- Labor
- Non-reassuring fetal status 4
- Consider delivery after 32 weeks, especially with documented fetal lung maturity 5
- Delivery clearly recommended after 34 weeks 4
Common Pitfalls to Avoid
- Using amoxicillin-clavulanic acid increases risk of necrotizing enterocolitis 1, 2
- Delaying antibiotics in PPROM at ≥24 weeks 1
- Failing to offer both abortion care and expectant management options to patients with previable/periviable PPROM 1
- Administering antenatal corticosteroids before the appropriate gestational age when neonatal resuscitation would be considered 1
Long-term Considerations
- In subsequent pregnancies after previable or periviable PPROM, follow guidelines for management of pregnant persons with previous spontaneous preterm birth 1
- Long-term follow-up of children born after previable/periviable PPROM shows potential for respiratory problems requiring treatment with medications (50-57%) 1