Management of Preterm Premature Rupture of Membranes (PPROM)
The management of PPROM should be gestational age-dependent, with antibiotics strongly recommended for patients at ≥24 weeks gestation to reduce infant morbidity and mortality. 1, 2
Initial Assessment and Counseling
- Patients with previable and periviable PPROM should receive individualized counseling about maternal and fetal risks and benefits of both abortion care and expectant management 1, 3
- All patients with previable PPROM should be offered abortion care due to high maternal risks and poor fetal outcomes 3, 4
- Evaluate for signs of infection, including maternal fever, tachycardia, purulent cervical discharge, fetal tachycardia, and uterine tenderness 3
- Note that intraamniotic infection may present without maternal fever, especially at earlier gestational ages 3
Management Based on Gestational Age
Previable PPROM (<20 weeks)
- Offer both abortion care and expectant management options (Grade 1C) 1
- Shared decision-making regarding antibiotic use is recommended due to lack of clear benefit 1, 2
- Survival rates are extremely low, with no surviving neonates reported after PPROM at <16 weeks 3
Periviable PPROM (20-23 6/7 weeks)
- Antibiotics can be considered to prolong latency (Grade 2C) 1, 2
- Antenatal corticosteroids and magnesium sulfate are not recommended until neonatal resuscitation would be considered appropriate 1, 2
- Neonatal survival varies by gestational age: 20% survival after PPROM at 16-19 weeks, 30% at 20-21 weeks, and 41% at 22-23 weeks 3
PPROM at ≥24 weeks
- Antibiotics are strongly recommended (Grade 1B) to prolong pregnancy and reduce neonatal morbidity 1, 2, 5
- Consider antenatal corticosteroids between 24 and 34 weeks to accelerate fetal lung maturity 2, 6, 7
- Consider magnesium sulfate for fetal neuroprotection when delivery is anticipated before 32 weeks 2, 4
Antibiotic Regimens
- Recommended regimen: IV ampicillin 2g every 6 hours and erythromycin 250mg every 6 hours for 48 hours, followed by oral amoxicillin 250mg every 8 hours and erythromycin 333mg every 8 hours for 5 days 2, 5, 8
- Alternative regimen: Erythromycin 250mg orally every 6 hours for 10 days 8
- Azithromycin can be used as an alternative to erythromycin when unavailable 2, 3
- Avoid amoxicillin-clavulanic acid due to increased risk of necrotizing enterocolitis 2, 3, 8
Monitoring During Expectant Management
- Initial observation in hospital is reasonable to ensure stability before considering outpatient management 2
- For outpatient management, monitor for signs of maternal complications such as hemorrhage or infection 2, 3
- Weekly outpatient visits for assessment of maternal vital signs, fetal heart rate, physical examination, and laboratory evaluation 3
- Daily temperature monitoring by patient and vigilance for signs of PPROM complications 3
- Hospital readmission is indicated for hemorrhage, infection, fetal demise, or when reaching viability for administration of antenatal corticosteroids and magnesium sulfate 4
Special Considerations
- Serial amnioinfusions and amniopatch are considered investigational and should only be used in clinical trial settings (Grade 1B) 1, 4
- For cerclage management after PPROM, it is reasonable to either remove the cerclage or leave it in situ after discussing risks and benefits (Grade 2C) 1, 4
- 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
Common Pitfalls to Avoid
- Delaying diagnosis of intraamniotic infection due to absence of maternal fever 3
- Using amoxicillin-clavulanic acid, which increases risk of necrotizing enterocolitis 2, 8
- Prolonged or repeated antibiotic courses beyond what would be used for PPROM at later gestational ages 1, 2
- Failing to consider delivery after 34 weeks when the benefits of delivery clearly outweigh the risks of expectant management 9