What is the management of Premature Rupture of Membranes (PROM) versus Preterm Premature Rupture of Membranes (PPROM)?

Management of PROM vs PPROM

The fundamental distinction is gestational age: PROM occurs at ≥37 weeks and mandates delivery, while PPROM occurs <37 weeks and requires gestational age-specific management with antibiotics, corticosteroids, and expectant management until 34 weeks when delivery benefits outweigh risks. 1, 2, 3

Key Definitions

• PROM (Premature Rupture of Membranes): Membrane rupture at ≥37 weeks before labor onset 4
• PPROM (Preterm Premature Rupture of Membranes): Membrane rupture before 37 weeks gestation 4, 5
• PPROM complicates 3% of pregnancies and accounts for one-third of all preterm births 3, 4

Management Algorithm by Gestational Age

PROM at ≥37 Weeks (Term)

Deliver immediately—do not pursue expectant management. 2

• Admit to labor and delivery unit for continuous fetal monitoring 2
• Proceed with induction of labor unless cesarean indications exist 2
• Risk of maternal infection (chorioamnionitis) increases to 38% with expectant management versus 13% with immediate intervention 1, 2
• Maternal sepsis risk reaches 6.8% if delivery is delayed 1, 2
• Monitor maternal vital signs every 4 hours, including temperature 2

PPROM at 34-36 Weeks

Deliver at 34 weeks or beyond—the benefits of delivery clearly outweigh risks of expectancy. 3

• At 36 weeks specifically, delivery is the primary management approach 2
• Remove cerclage if present, as retention does not prolong pregnancy and increases infection risk 2
• Corticosteroids are not indicated at ≥34 weeks due to adequate fetal lung maturity 2
• Magnesium sulfate for neuroprotection is not indicated beyond 32 weeks 2

PPROM at 32-34 Weeks

Administer antibiotics and corticosteroids, then deliver when lung maturity is documented or at 34 weeks. 6, 3

• Hospital admission for initial evaluation and stabilization 6
• Administer broad-spectrum antibiotics: IV ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 additional days 1
• Azithromycin can substitute for erythromycin when unavailable 1
• Avoid amoxicillin-clavulanic acid due to increased necrotizing enterocolitis risk 1
• Administer antenatal corticosteroids to accelerate fetal lung maturity 6
• Consider magnesium sulfate for neuroprotection if delivery appears imminent 6
• Lung maturity assessment may guide delivery timing in the 32-34 week interval 3

PPROM at 24-32 Weeks (Periviable)

Pursue expectant management with antibiotics (Grade 1B), corticosteroids when resuscitation would be pursued, and close monitoring for infection. 7, 1

• Administer antibiotics for all patients choosing expectant management at ≥24 weeks (Grade 1B) 7
• Use the same antibiotic regimen as above: IV ampicillin and erythromycin for 48 hours, then oral therapy for 5 days 1
• Do not administer corticosteroids or magnesium sulfate until the gestational age when neonatal resuscitation would be pursued (Grade 1B) 7
• Weekly outpatient visits for maternal vital signs, fetal heart rate, physical examination, and laboratory evaluation for leukocytosis 1
• Daily home monitoring for temperature, vaginal bleeding, discolored or malodorous discharge, contractions, and abdominal pain 1

PPROM at 20-24 Weeks (Previable)

Offer individualized counseling about abortion care versus expectant management; antibiotics can be considered but evidence is weaker (Grade 2C). 7, 1

• All patients should be offered abortion care as an option (Grade 1C) 7
• Expectant management at <24 weeks carries 60.2% maternal morbidity versus 33.0% with abortion care (adjusted OR 3.47) 1
• Antibiotics can be considered at 20-23 6/7 weeks (Grade 2C), though evidence is weaker than at later gestational ages 7, 1
• Shared decision-making regarding antibiotic timing: immediate versus delayed until later gestational age 7
• Neonatal survival: 20% after PPROM at 16-19 weeks, 30% at 20-21 weeks, 41% at 22-23 weeks 1

PPROM at <20 Weeks

Offer abortion care; expectant management has no surviving neonates reported at <16 weeks and carries extreme maternal risk. 1

• No surviving neonates reported after PPROM at <16 weeks 1
• Given lack of evidence for antibiotic benefit, use shared decision-making about antibiotic use 7
• Maternal death rate: 45 per 100,000 patients with previable PPROM 1

Critical Monitoring During Expectant Management

Signs Requiring Immediate Delivery

• Maternal fever ≥38°C, maternal tachycardia, or uterine tenderness 1, 2
• Purulent or foul-smelling cervical discharge 1, 2
• Fetal tachycardia or compromise on surveillance testing 1, 2
• Placental abruption or significant hemorrhage 1, 2
• Infection may present without fever, especially at earlier gestational ages—do not delay diagnosis 1

Surveillance Protocol

• Initial hospital observation to ensure stability without preterm labor, abruption, or infection 1
• After stabilization, outpatient management with weekly visits for vital signs, fetal heart rate, physical exam, and CBC with differential 1
• Daily patient self-monitoring for temperature, bleeding, discharge changes, contractions, and pain 1
• Hospital readmission criteria: hemorrhage, infection, fetal demise, or reaching gestational age when resuscitation would be appropriate 1

Interventions NOT Recommended

• Serial amnioinfusions and amniopatch are investigational only (Grade 1B)—two large trials showed no reduction in perinatal morbidity 1, 6
• Prolonged or repeated antibiotic courses beyond standard PPROM protocols to optimize antibiotic stewardship 1
• Corticosteroids or magnesium sulfate before the gestational age when neonatal resuscitation would be pursued 7

Cerclage Management

• Either remove the cerclage or leave it in situ after discussing risks and benefits (Grade 2C) 1
• A randomized trial showed no pregnancy prolongation benefit with cerclage retention 1
• Removal is generally preferred to reduce infection risk 2

Subsequent Pregnancy Management

• Nearly 50% of immediate subsequent pregnancies result in recurrent preterm birth after previable/periviable PPROM 1
• Follow guidelines for management of pregnant persons with previous spontaneous preterm birth, typically including progesterone supplementation and increased surveillance (Grade 1C) 7, 1

Common Pitfalls to Avoid

• Do not rely solely on maternal fever to diagnose intraamniotic infection—infection can progress rapidly without obvious symptoms, especially at earlier gestational ages 1
• Do not delay delivery at ≥34 weeks waiting for spontaneous labor—infection risk increases with time 2, 3
• Do not use amoxicillin-clavulanic acid—it increases necrotizing enterocolitis risk 1
• Do not administer prolonged antibiotic courses beyond standard protocols 1
• Do not give corticosteroids or magnesium sulfate at previable gestational ages when resuscitation would not be pursued 7