What is the management for a ruptured bag of water (amniotic sac)?

Management of Ruptured Bag of Water (Preterm Prelabor Rupture of Membranes)

For patients with preterm prelabor rupture of membranes (PPROM), management should include individualized counseling about maternal and fetal risks, with all patients offered abortion care, while expectant management can be offered in the absence of contraindications. 1

Initial Assessment and Classification

• PPROM is defined as membrane rupture before labor that occurs before 37 weeks of gestation 2
• Classification by gestational age is critical for management decisions:
  • Previable PPROM: occurs when the fetus would not survive outside the uterus 2
  • Periviable PPROM: occurs during 20 0/7 to 25 6/7 weeks when the fetus may survive with interventions but with high risk 2

Management Algorithm Based on Gestational Age

For Previable and Periviable PPROM (Before 24 weeks)

• All patients should receive individualized counseling about maternal and fetal risks of both abortion care and expectant management 1
• Important considerations for counseling:
  • Expectant management is associated with higher maternal morbidity (60.2%) compared to abortion care (33.0%) 1
  • Common complications include intraamniotic infection (38.0% with expectant management vs 13.0% with abortion care) and postpartum hemorrhage (23.1% vs 11.0%) 1
  • Only 16% of patients with expectant management avoid maternal morbidity and have an infant who survives to discharge 1

For patients choosing abortion care:

• Procedural abortion (D&E) may have fewer complications than medication abortion (induction of labor) 1
• Complications are more frequent after induction of labor than after D&E (hemorrhage >500cc: 28.3% vs 9.1%; infection: 23.9% vs 1.3%) 1

For patients choosing expectant management:

• Antibiotics can be considered after PPROM at 20 0/7 to 23 6/7 weeks 1
• Monitor closely for signs of intraamniotic infection, which may present without maternal fever 1
• Serial amnioinfusions and amniopatch are considered investigational and should only be used in clinical trial settings 1, 3

For PPROM at 24 0/7 to 33 6/7 weeks:

• Antibiotics are recommended for patients choosing expectant management 1
• Antenatal corticosteroids and magnesium sulfate are not recommended until the time when neonatal resuscitation would be considered appropriate 1
• Cerclage management after PPROM requires shared decision-making regarding removal or retention 1, 2

For PPROM at 34 0/7 to 36 6/7 weeks:

• Delivery is generally recommended when PPROM occurs at or after 34 weeks due to increased risk of infection with minimal benefit of continued pregnancy 4
• Oxytocin may be indicated for induction of labor when membranes are prematurely ruptured 5

Monitoring During Expectant Management

• Regular assessment for signs of intraamniotic infection (maternal temperature ≥38°C, maternal tachycardia, purulent cervical discharge, fetal tachycardia, uterine tenderness) 1
• Clinical diagnosis of infection should not be delayed due to absence of maternal fever 1
• Monitor for other contraindications to expectant management including hemorrhage and fetal demise 1

Common Pitfalls and Caveats

• Delaying intervention when signs of infection are present can lead to serious maternal complications including sepsis and death 1
• Clinical symptoms of infection may be less overt at earlier gestational ages 1
• The majority of women with PPROM will deliver within 7 days following rupture, regardless of management approach 2
• Perinatal outcome is significantly worse in the presence of amnionitis 6

Management of Subsequent Pregnancies

• In pregnancies following previable or periviable PPROM, follow guidelines for management of pregnant persons with a previous spontaneous preterm birth 1