Management of Preterm Prelabor Rupture of Membranes

Initial Assessment and Classification

The American College of Obstetricians and Gynecologists defines preterm prelabor rupture of membranes (PPROM) as membrane rupture before labor that occurs before 37 weeks of gestation 2

For patients with previable and periviable PPROM, the American College of Obstetricians and Gynecologists recommends individualized counseling about maternal and fetal risks of both abortion care and expectant management 1
Expectant management is associated with higher maternal morbidity (60.2%) compared to abortion care (33.0%) in patients with PPROM 3
Common complications of expectant management include intraamniotic infection (38.0% with expectant management vs 13.0% with abortion care) and postpartum hemorrhage (23.1% vs 11.0%) 3
Only 16% of patients with expectant management avoid maternal morbidity and have an infant who survives to discharge 4
For patients choosing abortion care, procedural abortion (D&E) may have fewer complications than medication abortion (induction of labor) 5
Complications are more frequent after induction of labor than after D&E (hemorrhage >500cc: 28.3% vs 9.1%; infection: 23.9% vs 1.3%) 5
For patients choosing expectant management, antibiotics can be considered after PPROM at 20 0/7 to 23 6/7 weeks 1
Monitor closely for signs of intraamniotic infection, which may present without maternal fever 5
Serial amnioinfusions and amniopatch are considered investigational and should only be used in clinical trial settings 1, 6

Antibiotics are recommended for patients choosing expectant management at 24 0/7 to 33 6/7 weeks 1
Antenatal corticosteroids and magnesium sulfate are not recommended until the time when neonatal resuscitation would be considered appropriate 1
Cerclage management after PPROM requires shared decision-making regarding removal or retention 1, 2
Regular assessment for signs of intraamniotic infection (maternal temperature ≥38°C, maternal tachycardia, purulent cervical discharge, fetal tachycardia, uterine tenderness) is necessary during expectant management 5
Clinical diagnosis of infection should not be delayed due to absence of maternal fever 5
Delaying intervention when signs of infection are present can lead to serious maternal complications including sepsis and death 1
Clinical symptoms of infection may be less overt at earlier gestational ages 5
In pregnancies following previable or periviable PPROM, follow guidelines for management of pregnant persons with a previous spontaneous preterm birth 1