Management of Pregnancy with History of PPROM and Current Elevated PTT

Progesterone Therapy for Prevention of Recurrent Preterm Birth

The American College of Obstetricians and Gynecologists recommends 17-alpha-hydroxyprogesterone caproate (17P) 250 mg intramuscularly weekly from 16-20 weeks until 36 weeks of gestation for women with a history of spontaneous preterm birth, including PPROM, as first-line therapy to reduce the risk of recurrent preterm birth 1, 2, 3
17P has consistently demonstrated efficacy in reducing delivery at <37, <35, and <32 weeks of gestation in women with prior spontaneous preterm birth, with a moderate strength of evidence 1, 2, 3
While 17P reduces recurrent preterm birth overall, there is insufficient evidence that it specifically prevents PPROM as a complication, with a low strength of evidence 2, 1

The American College of Obstetricians and Gynecologists recommends continuing serial transvaginal cervical length assessments every 2-4 weeks from 16-24 weeks of gestation for women with a history of prior spontaneous preterm birth, including PPROM 2, 5
If cervical length shortens to ≤25 mm before 24 weeks despite 17P therapy, cervical cerclage should be offered, with a moderate strength of evidence 2, 3

The American College of Obstetricians and Gynecologists recommends ruling out antiphospholipid syndrome (APS) with lupus anticoagulant, anticardiolipin antibodies, and anti-beta-2-glycoprotein I antibodies, as APS can cause both PPROM and intrauterine growth restriction (IUGR) with stillbirth 1
If APS is confirmed, low-dose aspirin (81 mg daily) plus prophylactic low-molecular-weight heparin should be initiated immediately, with a high strength of evidence 1

The risk of recurrent preterm birth after PPROM at <24 weeks is approximately 50%, with 30% delivering <34 weeks and 17% delivering <24 weeks in subsequent pregnancies, with a moderate strength of evidence 1
The most important independent predictor of recurrent preterm birth after previable PPROM is a history of another previous preterm birth beyond the PPROM pregnancy itself, with a high strength of evidence 1

The American College of Obstetricians and Gynecologists recommends not prescribing vaginal progesterone as primary prevention in patients with prior spontaneous preterm birth, as it lacks proven efficacy for this indication, with a low strength of evidence 4, 1
The American College of Obstetricians and Gynecologists recommends not recommending bed rest or activity restriction, as these interventions have no proven benefit and may cause harm, with a moderate strength of evidence 1
The American College of Obstetricians and Gynecologists recommends not placing prophylactic cerclage at this time with a normal cervical length of 4.5 cm—cerclage is only indicated if cervical shortening develops, with a moderate strength of evidence 2, 5