Premature Rupture of Membranes (PROM) and Preterm PROM (PPROM)

Symptoms

• Sudden 'gush' of fluid from the vagina, followed by continuous leakage
• Wet undergarments; fluid often clear, may be blood-tinged or meconium-stained
• Decreased fetal movement may indicate cord compression or fetal distress

Signs / physical exam

• Sterile speculum exam: pooling of fluid in the posterior fornix (most specific)
• Nitrazine paper turns blue (amniotic fluid pH 7.1-7.3; vaginal pH 4.5-6.0)
• Ferning pattern of dried fluid on microscopy
• Avoid digital cervical exam if not in labor — increases infection risk

Classic findings

Pooling, nitrazine positive, ferning. Confirmatory immunoassays (PAMG-1, IGFBP-1) when exam equivocal.

Diagnostic criteria

Sterile speculum demonstrating pooling plus nitrazine or ferning is diagnostic. Equivocal cases may use PAMG-1 (AmniSure) or IGFBP-1 (Actim PROM).

Labs

• GBS culture if not done in last 5 weeks
• CBC, CRP if chorioamnionitis suspected
• Cervical/vaginal cultures (GC, chlamydia, BV) per indication
• Urinalysis and urine culture

Imaging

• Transabdominal ultrasound: amniotic fluid index (AFI), fetal presentation, biometry, placental location
• Continuous external fetal monitoring for category, variability, decelerations, contractions

First-line

• Term PROM (>=37 wk): expectant management up to 12-24 h is acceptable, but induction with oxytocin is generally recommended to reduce chorioamnionitis risk
• Late preterm PPROM (34 0/7 to 36 6/7 wk): shared decision-making; ACOG considers either expectant management (not beyond 37 0/7 wk) or immediate delivery reasonable; immediate delivery does not reduce neonatal sepsis and increases neonatal RDS and cesarean birth, whereas expectant management increases maternal hemorrhage and infection (PPROMT); latency antibiotics are not indicated at 34 wk or later
• PPROM 24 0/7 to 33 6/7 wk: expectant management with hospitalization is standard
• Antenatal corticosteroids for fetal lung maturity (24 0/7 to 33 6/7 wk; consider 34 0/7 to 36 6/7 wk if not previously given) — betamethasone 12 mg IM x 2 doses 24 h apart, or dexamethasone 6 mg IM x 4 doses 12 h apart
• Latency antibiotics for PPROM <34 wk (prolong latency and reduce maternal and neonatal infection and gestational-age-dependent morbidity; they do not replace intrapartum GBS prophylaxis): ampicillin + erythromycin IV x 48 h, then amoxicillin + erythromycin PO x 5 days (or azithromycin single dose as alternative to erythromycin)
• GBS intrapartum prophylaxis if GBS positive, or if GBS status is unknown with preterm gestation (<37 wk), ROM >=18 h, or intrapartum fever: penicillin G (ampicillin alternative); cefazolin if the penicillin allergy is low risk (e.g., nonurticarial maculopapular rash); if high risk (anaphylaxis, angioedema, respiratory distress, urticaria), clindamycin only if the isolate is susceptible, otherwise vancomycin
• Magnesium sulfate for neuroprotection if delivery anticipated before 32 weeks

Periviable PPROM (<24 wk)

• Counseling regarding fetal and maternal risks (pulmonary hypoplasia, limb contractures, sepsis)
• Offer expectant outpatient or inpatient management vs pregnancy termination
• Latency antibiotics may be considered from 20 0/7 wk (recommended from 24 0/7 wk); corticosteroids, magnesium sulfate, and GBS prophylaxis are not given until the gestational age at which neonatal resuscitation is planned (as early as 22-23 wk)

Second-line / adjunct

• Tocolysis is NOT routinely recommended in PPROM; short-term use only to permit corticosteroid completion or transfer
• Cerclage with PPROM: either removal or retention is reasonable (individualize with shared decision-making); if retained, do not extend antibiotics beyond the 7-day latency course