From the Guidelines
The best management for a pregnancy patient with a history of Preterm Premature Rupture of Membranes (PPROM) is individualized counseling about the maternal and fetal risks and benefits of both abortion care and expectant management to guide an informed decision 1.
Key Considerations
- Abortion care should be offered to all patients with previable and periviable PPROM, while expectant management can also be offered in the absence of contraindications (GRADE 1C) 1.
- Antibiotics are recommended for pregnant individuals who choose expectant management after PPROM at 24 0/7 weeks of gestation (GRADE 1B) 1, and can be considered after PPROM at 20 0/7 to 23 6/7 weeks of gestation (GRADE 2C) 1.
- Antenatal corticosteroids and magnesium sulfate are not recommended until the time when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient (GRADE 1B) 1.
- Cerclage management after previable and periviable PPROM is similar to cerclage management after PPROM at later gestational ages, and it is reasonable to either remove the cerclage or leave it in situ after discussing the risks and benefits and incorporating shared decision-making (GRADE 2C) 1.
Clinical Factors
- Later gestational age at PPROM and higher residual amniotic fluid volume are most consistently associated with improved perinatal survival 1.
- Neonatal survival is more likely when PPROM occurs at later gestational ages 1.
Future Directions
- Additional research is needed to inform individual management decisions, such as the timing of antibiotics 1.
- Monitoring adverse outcomes among pregnant individuals who are unable to access abortion care due to lack of clarity about exceptions to state abortion restrictions will be important to add to the existing literature 1.
From the Research
Management of Preterm Premature Rupture of Membranes (PPROM)
The management of PPROM is crucial to ensure the safety of both the mother and the child. According to current guidelines, inpatient management until birth is considered standard in pregnant women with PPROM 2. However, outpatient management is a possible alternative to inpatient monitoring, with the most important criterion being the safety of both the mother and the child.
Inpatient vs. Outpatient Management
Studies have compared inpatient and outpatient management of PPROM, with mixed results. A review of eight retrospective comparative studies found no significant differences in maternal complications and neonatal morbidity, but significantly prolonged latency period, higher gestational age at birth, and higher birth weight of neonates with outpatient management 2. However, concerns regarding outpatient management include unpredictable complications that may require rapid obstetric interventions, which cannot be performed in time in an outpatient setting.
Criteria for Outpatient Management
Several studies have identified criteria that contraindicate home care management of PPROM. These include:
- PPROM occurring before 26 weeks 3
- Non-cephalic fetal presentation 3
- Oligoamnios 3
- Presence of multiple unfavorable criteria, which increases the risk of severe complications 3
Recommendations for Management
The American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynaecologists, and the Society of Obstetricians and Gynaecologists of Canada have published guidelines on the diagnosis and management of PPROM 4. These guidelines recommend:
- Diagnosis of PPROM based on sterile speculum examination and patient's history, followed by additional tests in equivocal cases
- Performance of vaginal and rectal swabs, evaluation of fetal and maternal status, administration of antibiotics and corticosteroids, and immediate induction of labor if severe complications are identified
- Expectant management from viability until late preterm period, with discrepancies on the optimal timing of delivery
- Administration of magnesium sulfate in case of imminent preterm delivery, but no consensus on the upper gestational age limit
Key Considerations
The management of PPROM requires balancing the potential neonatal benefits from prolongation of the pregnancy with the risk of intra-amniotic infection and its consequences for the mother and infant 5. Close monitoring for signs of chorioamnionitis and other complications is necessary to minimize the risk of neonatal and maternal complications. The use of broad-spectrum antibiotics and corticosteroids has been shown to improve neonatal outcome, but the optimal management strategy remains unclear 5.