What is the management of preterm prelabor rupture of membranes (PPROM) in a pregnant woman, according to the American College of Obstetricians and Gynecologists (ACOG)?

Management of Preterm Prelabor Rupture of Membranes (PPROM) According to ACOG

ACOG-endorsed guidelines recommend a gestational age-based approach to PPROM management, with individualized counseling about abortion care versus expectant management for previable/periviable cases (<24 weeks), and expectant management with antibiotics, corticosteroids, and close surveillance for cases ≥24 weeks until delivery is indicated. 1

Initial Assessment and Diagnosis

When PPROM is suspected, confirm the diagnosis and immediately assess for:

• Maternal fever ≥38°C (100.4°F), maternal or fetal tachycardia, purulent cervical discharge, or uterine tenderness to rule out intraamniotic infection 2
• Critical caveat: Infection may present without maternal fever, especially at earlier gestational ages—do not delay diagnosis based on absence of fever alone 2
• Gestational age determination (critical for management decisions) 1
• Amniotic fluid volume assessment (higher residual volume associated with improved perinatal survival) 2
• Signs of placental abruption, active labor, or fetal compromise 2

Gestational Age-Specific Management Algorithm

Previable PPROM (<20 weeks)

• No neonatal survival has been reported after PPROM <16 weeks gestation 2
• Offer abortion care as a primary option 1
• If expectant management chosen, counsel about extremely high maternal morbidity risk with minimal chance of neonatal survival 1

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

Counseling and Decision-Making:

• Provide individualized counseling about both abortion care and expectant management options (GRADE 1C recommendation) 1
• All patients must be offered abortion care; expectant management can also be offered in absence of contraindications 1
• Present realistic outcome data: Among those choosing expectant management, 37% experience maternal morbidity without neonatal survival, 23% have maternal morbidity with neonatal survival, 24% have no maternal morbidity and no neonatal survival, and only 16% avoid maternal morbidity with neonatal survival 1
• Neonatal survival rates: 20% after PPROM at 16-19 weeks, 30% at 20-21 weeks, 41% at 22-23 weeks 2

If Expectant Management Chosen:

• Consider antibiotics (GRADE 2C recommendation)—evidence is weaker than at later gestational ages 1, 2
• Do NOT administer corticosteroids or magnesium sulfate until gestational age when neonatal resuscitation would be pursued (GRADE 1B) 1, 2
• Initial hospitalization to ensure stability without preterm labor, abruption, or infection 2

PPROM at 24 0/7 to 33 6/7 weeks

Antibiotic Therapy (GRADE 1B recommendation):

• Administer IV ampicillin 2g every 6 hours PLUS erythromycin 250mg every 6 hours for 48 hours 2, 3
• Followed by oral amoxicillin 250mg every 8 hours PLUS erythromycin 333mg every 8 hours for 5 additional days (total 7-day course) 2, 3
• Azithromycin can substitute for erythromycin when unavailable 2
• AVOID amoxicillin-clavulanic acid—increases necrotizing enterocolitis risk 2, 3
• Do not use prolonged or repeated antibiotic courses beyond the standard 7-day regimen 2

Corticosteroids and Magnesium Sulfate:

• Administer antenatal corticosteroids when neonatal resuscitation would be pursued 1
• Administer magnesium sulfate for neuroprotection when delivery is imminent and neonatal resuscitation would be pursued 1

Surveillance Protocol:

• Initial hospitalization for stabilization 2
• After stabilization, outpatient management with close monitoring is reasonable 2
• Weekly outpatient visits for maternal vital signs, fetal heart rate, physical examination, and laboratory evaluation for leukocytosis 2
• Daily patient self-monitoring for temperature, vaginal bleeding, discolored or malodorous discharge, contractions, and abdominal pain 2

Hospital Readmission Criteria:

• Signs of infection (fever, tachycardia, purulent discharge, uterine tenderness) 2
• Vaginal hemorrhage or suspected abruption 2
• Fetal demise or compromise on surveillance testing 2
• Active labor 2
• Reaching gestational age when neonatal resuscitation would be appropriate 2

PPROM at 34 0/7 to 36 6/7 weeks

• Consider delivery versus continued expectant management based on individual circumstances 4, 5
• After 34 weeks, benefits of delivery increasingly outweigh risks of expectant management 6

Critical Maternal Risks to Monitor

Infection Complications:

• Intraamniotic infection occurs in 58.1% with expectant management versus 8% with abortion care in previable/periviable PPROM 1
• Maternal sepsis occurs in up to 6.8% of previable/periviable PPROM cases 1, 2
• Maternal death rate: 45 per 100,000 patients with previable PPROM 2
• Infection can progress rapidly—median time from first signs to death is only 18 hours in severe cases 7, 2

Other Maternal Complications:

• Antepartum hemorrhage/abruption more common with expectant management (41.9% vs 19% with abortion care) 1
• Overall maternal morbidity: 60.2% with expectant management versus 33.0% with abortion care at <24 weeks (adjusted OR 3.47) 2

Interventions NOT Recommended

• Serial amnioinfusions: NOT recommended for routine care (GRADE 1B)—two large trials showed no reduction in perinatal morbidity 2
• Amniopatch: Investigational only, use only in clinical trial settings (GRADE 1B) 1, 2

Cerclage Management

• Either remove cerclage or leave in situ after discussing risks and benefits (GRADE 2C)—randomized trial showed no pregnancy prolongation benefit with retention 1, 2

Neonatal Complications to Counsel About

• Pulmonary hypoplasia (especially with early PPROM and oligohydramnios) 2
• Respiratory distress syndrome and bronchopulmonary dysplasia (up to 50% of survivors) 2
• Skeletal deformities from compression 2
• Intraventricular hemorrhage, necrotizing enterocolitis, sepsis, retinopathy of prematurity 2
• Long-term respiratory problems requiring medications in 50-57% of children 2

Subsequent Pregnancy Management

• Nearly 50% of immediate subsequent pregnancies result in recurrent preterm birth after previable/periviable PPROM 2
• Follow guidelines for management of pregnant persons with previous spontaneous preterm birth (GRADE 1C)—typically includes progesterone supplementation and increased surveillance 2

Critical Pitfalls to Avoid

• Do not delay antibiotic administration in PPROM ≥24 weeks—start immediately upon diagnosis 3
• Do not wait for maternal fever to diagnose intraamniotic infection—infection can progress without fever, especially at earlier gestational ages 2
• Do not administer corticosteroids or magnesium sulfate before the gestational age when neonatal resuscitation would be pursued 1
• Do not use amoxicillin-clavulanic acid—associated with increased necrotizing enterocolitis 2, 3
• Patients have the right to change management plans throughout care—ensure ongoing access to all options including abortion care 2