What is the management of preterm premature rupture of membranes (PPROM)?

Management of Preterm Premature Rupture of Membranes (PPROM)

The management of PPROM should include broad-spectrum antibiotics, individualized counseling about risks and benefits, and gestational age-specific interventions to optimize maternal and neonatal outcomes. 1

Initial Assessment and Counseling

• Patients with PPROM should receive individualized counseling about maternal and fetal risks and benefits of both abortion care and expectant management to guide informed decision-making 1
• All patients with previable and periviable PPROM should be offered abortion care, while expectant management can also be offered in the absence of contraindications 1
• Later gestational age at PPROM and higher residual amniotic fluid volume are most consistently associated with improved perinatal survival 1
• There are no surviving neonates reported after PPROM at <16 weeks of gestation 1

Antibiotic Therapy

• Broad-spectrum antibiotics are recommended for management of PPROM at <34 weeks of gestation to prolong latency and reduce neonatal morbidity 1, 2
• The recommended antibiotic regimen includes:
  • Intravenous ampicillin (2g every 6 hours) and erythromycin (250mg every 6 hours) for 48 hours 1, 2
  • Followed by oral amoxicillin (250mg every 8 hours) and erythromycin (333mg every 8 hours) for 5 additional days 1, 2
• Azithromycin can be used as an alternative to erythromycin when erythromycin is not available 1
• Amoxicillin-clavulanic acid should be avoided due to increased risk of necrotizing enterocolitis 1
• Antibiotics are strongly recommended (Grade 1B) for pregnant individuals who choose expectant management after PPROM at ≥24 weeks of gestation 1
• Antibiotics can be considered (Grade 2C) after PPROM at 20 0/7 to 23 6/7 weeks of gestation 1

Gestational Age-Specific Management

Previable PPROM (<24 weeks)

• Offer abortion care as an option 1
• If expectant management is chosen:
  • Consider antibiotics for PPROM at 20 0/7 to 23 6/7 weeks 1
  • Shared decision-making regarding antibiotics for PPROM <20 weeks 1
  • Close monitoring for signs of infection 1

Periviable PPROM (24-34 weeks)

• Administer recommended antibiotic regimen 1, 2
• Antenatal corticosteroids and magnesium sulfate are not recommended until the time when neonatal resuscitation would be considered appropriate 1
• Monitor for signs of chorioamnionitis (temperature, CTG, CRP, leukocytes) 3
• Consider delivery when benefits outweigh risks of pregnancy prolongation 4

PPROM ≥34 weeks

• Benefits of delivery clearly outweigh the risks of expectant management 4

Monitoring During Expectant Management

• Frequent monitoring (often weekly) in outpatient setting for:
  • Maternal vital signs
  • Fetal heart rate
  • Physical examination
  • Laboratory evaluation for signs of infection 1
• Daily temperature monitoring by patient 1
• Monitor for signs of PPROM complications:
  • Fever
  • Contractions
  • Vaginal bleeding
  • Discolored or malodorous vaginal discharge
  • Abdominal pain 1
• Hospital readmission should occur if there are contraindications to continued expectant management (hemorrhage, infection, fetal demise) 1

Interventions Not Recommended

• Serial amnioinfusions and amniopatch are considered investigational and should be used only in clinical trial settings (Grade 1B) 1
• Amoxicillin-clavulanic acid should be avoided due to increased risk of necrotizing enterocolitis 1
• Prolonged or repeated antibiotic courses beyond what would be used for PPROM at later gestational ages 1

Cerclage Management

• For patients with cerclage in place at time of PPROM, it is reasonable to either remove the cerclage or leave it in situ after discussing risks and benefits (Grade 2C) 1
• A randomized trial showed no evidence of pregnancy prolongation with cerclage retention compared to removal 1

Outcomes and Complications

• Neonatal complications after previable and periviable PPROM include:
  • Pulmonary hypoplasia (major contributor to neonatal mortality)
  • Respiratory distress and bronchopulmonary dysplasia (up to 50% of cases)
  • Skeletal deformities, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, and retinopathy of prematurity (5-25% of cases) 1
• Long-term complications include respiratory problems requiring treatment with respiratory medications in 50-57% of children 1

Subsequent Pregnancies

• In subsequent pregnancies after a history of previable or periviable PPROM, follow guidelines for management of pregnant persons with a previous spontaneous preterm birth (Grade 1C) 1