Preterm Premature Rupture of Membranes

Definition and Characteristics

Preterm Premature Rupture of Membranes (PPPROM) is defined as the rupture of fetal membranes before labor begins and before 37 weeks of gestation, characterized by spontaneous rupture of the amniotic sac before the onset of labor (pre-labor) and occurring before 37 weeks of gestation, according to the American College of Obstetricians and Gynecologists 1

PPPROM is associated with significant maternal and neonatal risks, including maternal infectious morbidity and mortality, as stated by the American College of Obstetricians and Gynecologists 1, 2
Neonatal morbidity and mortality related to prematurity are also associated with PPPROM, as reported by the American College of Obstetricians and Gynecologists 1

PPPROM can be further categorized based on gestational age, including previable PPPROM, which occurs when the fetus would not survive outside the uterus and is not a candidate for life-sustaining interventions, as defined by the American College of Obstetricians and Gynecologists 1, 3
Periviable PPPROM occurs during the period when the fetus may survive outside the uterus with life-sustaining interventions but still with high risk of death or severe morbidities (typically 20 0/7 to 25 6/7 weeks), according to the American College of Obstetricians and Gynecologists 1, 3

All patients with previable and periviable PPPROM should be offered abortion care, and expectant management can also be offered in the absence of contraindications, as recommended by the American College of Obstetricians and Gynecologists 4, 5

The majority of women with PPPROM will deliver within 7 days following rupture, as reported by the Royal College of Obstetricians and Gynaecologists 6, 7

In patients with preterm premature rupture of membranes (PPROM), the American College of Obstetricians and Gynecologists recommends discussing the risks and benefits of cerclage removal or retention with the patient through shared decision-making 8

There is a lack of consensus surrounding cerclage management after PPROM at any gestational age, with limited high-quality evidence to guide decision-making, as noted by the American College of Obstetricians and Gynecologists 9, 10
The only randomized clinical trial evaluating cerclage removal after PPROM (22-32 weeks) showed no significant pregnancy prolongation with cerclage retention compared to removal (45.8% vs 56.2% had 1-week prolongation), according to the American Journal of Obstetrics and Gynecology 9
Cerclage retention did not significantly increase rates of chorioamnionitis (41.6% vs 25.0%), postpartum endometritis (12.5% vs 3.1%), composite neonatal morbidity (56% vs 50%), or perinatal mortality (16% vs 12%) compared to cerclage removal, as reported by the American College of Obstetricians and Gynecologists 9

Premature infants born after premature rupture of membranes are at risk of developing prematurity-related complications, including respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, and retinopathy of prematurity, with up to 50% of surviving neonates developing bronchopulmonary dysplasia 11
Pulmonary hypoplasia can result from insufficient amniotic fluid during critical fetal lung development, leading to respiratory problems 11
Skeletal deformities are observed in 5-25% of cases 11

Children born after previable and periviable PPROM face significant long-term health challenges, with respiratory problems requiring treatment with respiratory medications occurring in 50-57% of children at ages 2-5 years 11
At age 10, these children demonstrate worse lung function, mild pulmonary hypertension, and lower peak oxygen consumption compared to children delivered at similar gestational ages after PPROM at ≥28 weeks 11