SMFM provides important guidance that addresses the management of preterm prelabor rupture of membranes (PPROM). PPROM is defined as rupture of membranes without labor prior to 37 weeks gestation. In those that undergo PPROM in the periviable period (20w0d to 25w6d), only 15% of individuals have neonatal survival at discharge in the absence of maternal complications. Among the newborn survivors, there is a high rate of complications, including chronic obstructive pulmonary disease. Approximately 30% of patients experience both perinatal demise and maternal morbidities, and the remainder undergo either maternal morbidity or perinatal demise. Given the high rate of maternal morbidity with the unlikely event of neonatal survival, all patients should be offered pregnancy termination after individualized counseling regarding the maternal and fetal outcomes. Rupture of membranes occurs in 1% of all pregnancies.

Definitions

• Prelabor rupture of membranes is defined as rupture of membranes (ROM) without labor
• Preterm prelabor ROM is defined as ROM < 37w0d
• Periviable is defined as between 20w0d to 25w6d by AAP and ACOG and is based on the medical capabilities at the site and gestational age
• Previable is defined as the period in which a fetus would not survive after birth, thus not being a candidate for intervention
• Average latency period in the pre and periviable period is defined between 7 to 15 days

Neonatal Survival

• 5% to 6% prior to 23 weeks
• Morbidity 98 to 100% among survivors
  • 42% to 59% at 24 weeks
  • 67% to 76% at 25 weeks
• Factors affecting neonatal survival
  • Estimated fetal weight, multiple gestations, anomalies or other fetal genetic disorders.

Expectant Care vs Termination

• Counseling
  • Should be individualized
  • Should address both pregnancy termination and expectant care

Expectant Care

• Expectant care can be offered in the absence of contraindications
• Expectant care is contraindicated if there is increased risk for
  • Fetal demise | Maternal infection | Hemorrhage | Death
• One retrospective cohort study (Sklar et al) comparing expectant management to pregnancy termination
  • 37% maternal morbidity without neonatal survival
  • 23% maternal morbidity with neonatal survival to hospital discharge
  • 24% no maternal morbidity and no neonatal survival
  • 16% no maternal morbidity and neonatal survival to discharge

Termination

• The type of pregnancy termination chosen should prioritize safety and include
  • Medical termination (labor induction)
  • Surgical termination (dilation and evacuation)

Ethical Considerations

• Maternal health is the priority over fetal health
• Patients desire to accept health risks to pursue fetal benefit

Medical Management

• Evaluate for Intraamniotic infection
• Maternal temperature ≥ 38 degrees C and ≥1 other sign including
  • Purulent discharge | Maternal or fetal tachycardia | Uterine tenderness
• Signs, especially an elevated maternal temperature may not be obvious
• Absence of maternal fever should not preclude the diagnosis of intraamniotic infection
• Treatment with antibiotics and pregnancy termination should not be delayed

Antibiotic Therapy

• Antibiotics recommended at ≥24 weeks gestation
• Antibiotics should be considered between 20w0d and 23w6d
• 7 day course consisting of
  • 48 hours of intravenous ampicillin and erythromycin
  • 5 day course of oral amoxicillin and erythromycin
    • Amoxicillin-clavulanic acid should not be used due to risks of necrotizing enterocolitis
    • Azithromycin can be used in place of erythromycin
• Do not use prolonged or repeat courses of antibiotic therapy

Additional Considerations

• Neither magnesium sulfate nor corticosteroids should be considered prior to a gestational age that would recommend neonatal resuscitation
• If a cerclage is in situ shared decision making should be utilized with respect to whether or not to remove the cerclage
• Serial amnioinfusions or amniopatch are not recommended
• Inpatient vs outpatient
  • Limited data is available regarding the use of inpatient versus outpatient management
  • If outpatient management is considered, detailed counseling regarding signs of PPROM complications should be reviewed including
    • Daily temperature checks | Vaginal bleeding | Contractions | Discharge | Abdominal pain
  • Weekly visits should be offered

KEY POINTS:

• Counseling regarding management should be individualized and use shared decision making
• Expectant management can be offered if contraindications are not present however counseling should include the risks vs termination of pregnancy
  • ACOG has addressed this issue in a practice advisory and states “It is critically important that patients are counseled on the higher rates of morbidity associated with expectant management, which may be greater than previously reported, to ensure they can make a fully informed decision regarding their care”
• Antibiotic should be given during the first week and not be repeated
• Steroids and magnesium sulfate should not be used until the gestational age of the fetus meets recommendations for resuscitation
• Serial amniocenteses or the use of the amniopatch should not be used
• Removal of a cerclage is in situ should be individualized
• Management in a subsequent pregnancy should be similar to a history of a prior preterm birth

Learn More – Primary Sources:

SMFM Consult Series 71: Management of previable and periviable preterm prelabor rupture of membranes

ACOG Practice Advisory: Increased Risk of Maternal Morbidity Associated With Previable and Periviable Preterm Prelabor Rupture of Membranes

ACOG / SMFM Obstetric Care Consensus 6: Periviable Birth

Maternal morbidity after preterm premature rupture of membranes at <24 weeks’ gestation

Locate a Specialist:

Locate a Maternal Fetal Medicine Specialist: SMFM

Related ObG Topics:

What is the Best Course of Action Following PPROM Between 24 and 37 Weeks?

Can Azithromycin Be Used in Place of Erythromycin for Preterm PROM?

Remove or Retain Cervical Cerclage After PPROM?