What are the initial assessments, risks, and nursing interventions for Premature Preterm Rupture of Membranes (PPROM)?

Assessment, Risks, and Nursing Interventions for Premature Preterm Rupture of Membranes (PPROM)

Immediate assessment and management of PPROM should focus on identifying infection, monitoring maternal and fetal status, and implementing interventions to reduce morbidity and mortality risks, with all patients receiving counseling about both expectant management and abortion care options. 1, 2

Initial Assessment

• Confirm diagnosis through patient history, physical examination, and diagnostic tests (nitrazine test, ferning pattern, pooling of amniotic fluid) 3
• Determine gestational age accurately, as management and outcomes are highly dependent on gestational age at PPROM 2
• Evaluate for signs of infection: maternal fever ≥38°C, maternal tachycardia, purulent cervical discharge, fetal tachycardia, uterine tenderness 1
• Note that intraamniotic infection may present without maternal fever, especially at earlier gestational ages 1
• Assess amniotic fluid volume via ultrasound, as higher residual fluid volume is associated with improved perinatal survival 2
• Monitor vital signs, including temperature, heart rate, blood pressure, and respiratory rate 2
• Perform laboratory evaluation including complete blood count, C-reactive protein, and cultures as indicated 2

Maternal Risks

• Intraamniotic infection (clinical chorioamnionitis) occurs in 38% of expectant management cases versus 13% with immediate intervention 1
• Maternal sepsis occurs in up to 6.8% of previable and periviable PPROM cases, with higher rates in expectant management 1
• Maternal death has been reported at a rate of 45 per 100,000 patients with previable PPROM (compared to baseline maternal mortality of 8-12 per 100,000) 1
• Infection can progress rapidly - median time from first signs of infection to death was only 18 hours in one study 1
• Other complications include:
  • Postpartum hemorrhage (12-20% of cases) 1, 4
  • Retained placenta (21% of cases) 4
  • Need for intravenous antibiotics (38% of cases) 4
  • Endometritis, sepsis, and need for unplanned operative procedures 1

Fetal and Neonatal Risks

• Overall mortality rate is extremely high (95%) with midtrimester PPROM 4
• Neonatal survival varies by gestational age at PPROM:
  • No surviving neonates reported after PPROM at <16 weeks 2
  • 20% survival after PPROM at 16-19 weeks 1
  • 30% survival after PPROM at 20-21 weeks 1
  • 41% survival after PPROM at 22-23 weeks 1
• Pulmonary hypoplasia due to insufficient amniotic fluid during critical lung development 1
• Respiratory distress and bronchopulmonary dysplasia in up to 50% of surviving neonates 1
• Other complications include skeletal deformities, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, and retinopathy of prematurity (5-25% of cases) 1
• Long-term respiratory problems requiring medication in 50-57% of surviving children 1

Nursing Interventions

Antibiotic Therapy

• Administer broad-spectrum antibiotics for PPROM at <34 weeks to prolong latency and reduce neonatal morbidity 2
• Recommended regimen: intravenous ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 additional days 2
• Azithromycin can substitute for erythromycin when unavailable 2
• Avoid amoxicillin-clavulanic acid due to increased risk of necrotizing enterocolitis 2

Monitoring During Expectant Management

• Perform frequent (often weekly) outpatient monitoring of maternal vital signs, fetal heart rate, physical examination, and laboratory evaluation 2
• Educate patient to monitor temperature daily and report signs of PPROM complications, including vaginal bleeding, discolored or malodorous discharge, and abdominal pain 2
• Monitor for rapid progression of infection, as deterioration can occur within hours 1
• Assess for signs of labor, as the majority of women with PPROM will deliver within 7 days following rupture 5

Gestational Age-Specific Management

• For previable PPROM (<24 weeks): offer abortion care as an option, and consider antibiotics for PPROM at 20-23 weeks 2
• For periviable PPROM (24-34 weeks): administer recommended antibiotic regimen and monitor for signs of infection 2
• For PPROM after 34 weeks: benefits of delivery clearly outweigh risks of expectant management 3

Critical Considerations

• Infection can progress rapidly without obvious symptoms - vigilant monitoring is essential 1
• Diagnosis of intraamniotic infection should not be delayed due to absence of maternal fever 1
• Document all counseling and shared decision-making, and revisit if clinical scenario changes 1
• Patients have the right to change management plans and should have access to all options throughout care 1
• The risk-benefit assessment changes with gestational age - management should be adjusted accordingly 3