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

Treatment of Preterm Premature Rupture of Membranes (PPROM)

For PPROM at ≥24 weeks with expectant management, administer broad-spectrum antibiotics (intravenous ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 additional days) to prolong latency and reduce neonatal morbidity. 1

Gestational Age-Specific Treatment Algorithm

Previable PPROM (<20 weeks)

• Offer abortion care as the primary option, as there are no surviving neonates reported after PPROM at <16 weeks of gestation 1
• If expectant management is chosen, use shared decision-making regarding antibiotic timing, as evidence for benefit is lacking at this gestational age 2
• Do not administer corticosteroids or magnesium sulfate until reaching gestational age when neonatal resuscitation would be pursued 2, 1

Periviable PPROM (20 0/7 to 23 6/7 weeks)

• Offer both abortion care and expectant management in the absence of contraindications 1
• Consider antibiotics (Grade 2C) if expectant management is chosen, though evidence is weaker than at later gestational ages 2, 1
• Withhold corticosteroids and magnesium sulfate until the gestational age when neonatal resuscitation would be appropriate and desired 2, 1

PPROM at 24-34 weeks

• Administer antibiotics immediately (Grade 1B): intravenous ampicillin and erythromycin for 48 hours, then oral amoxicillin and erythromycin for 5 additional days 1
• Azithromycin can substitute for erythromycin when erythromycin is unavailable 1
• Avoid amoxicillin-clavulanic acid due to increased risk of necrotizing enterocolitis 1
• Administer corticosteroids once neonatal resuscitation would be pursued 2, 1

PPROM at ≥34 weeks

• Proceed with delivery, as the benefits of delivery clearly outweigh the risks of expectant management 3

PPROM at 36 weeks

• Delivery is the primary management approach, as the risks of prolonging pregnancy (maternal infection risk of 38% with expectant management versus 13% with immediate intervention) outweigh any benefits 4

Monitoring Protocol During Expectant Management

Initial Hospitalization

• Observe in hospital initially to ensure stability without preterm labor, placental abruption, or infection before considering discharge 2, 1
• Perform continuous fetal heart rate monitoring initially 4
• Monitor maternal vital signs every 4 hours, including temperature 4

Outpatient Management (After Stabilization)

• Weekly outpatient visits for assessment of maternal vital signs, fetal heart rate, physical examination, and laboratory evaluation for leukocytosis 1
• Daily home monitoring by patient for temperature, vaginal bleeding, discolored or malodorous discharge, contractions, and abdominal pain 1

Immediate Readmission Criteria

• Signs of infection (fever, maternal tachycardia, purulent discharge, fetal tachycardia, uterine tenderness) 1, 4
• Hemorrhage or placental abruption 1
• Fetal demise or fetal compromise on surveillance testing 1
• Reaching gestational age when neonatal resuscitation would be appropriate 1

Critical Pitfalls to Avoid

Infection Recognition

• Do not delay diagnosis of intraamniotic infection due to absence of maternal fever, as infection may present without fever, especially at earlier gestational ages 2, 1
• Clinical chorioamnionitis occurs in 38% of expectant management cases, and maternal sepsis occurs in up to 6.8% of previable and periviable PPROM cases 1
• Infection can progress rapidly without obvious symptoms—vigilant monitoring is essential 1

Antibiotic Stewardship

• Do not use prolonged or repeated antibiotic courses beyond what would be used for PPROM at later gestational ages 1

Timing of Interventions

• Do not administer corticosteroids or magnesium sulfate until the time when neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient (Grade 1B) 2, 1

Interventions NOT Recommended

• Serial amnioinfusions are not recommended for routine care (Grade 1B)—two large trials showed no reduction in perinatal morbidity 1
• Amniopatch is investigational only and should be used only in clinical trial settings (Grade 1B) 1

Cerclage Management

• Either remove the cerclage or leave it in situ after discussing risks and benefits through shared decision-making (Grade 2C) 2, 1
• A randomized trial showed no pregnancy prolongation benefit with cerclage retention (45.8% versus 56.2% had 1-week prolongation with removal) 5
• Cerclage retention did not significantly increase rates of chorioamnionitis, postpartum endometritis, or neonatal morbidity 5

Subsequent Pregnancy Management

• Follow guidelines for management of pregnant persons with a previous spontaneous preterm birth (Grade 1C), which typically includes progesterone supplementation and increased surveillance 1
• Nearly 50% of immediate subsequent pregnancies result in recurrent preterm birth after previable/periviable PPROM 1