Premature Rupture of Membranes (PROM) and Preterm PROM (PPROM)
Rupture of fetal membranes before labor onset; preterm form (<37 wk) carries highest risk.
Also known as: PROM, PPROM, ruptured membranes, leaking amniotic fluid, premature rupture of membranes
Overview
Rupture of the amniotic membranes prior to onset of labor. PROM is rupture at or after 37 weeks gestation; PPROM is rupture before 37 weeks. Prolonged rupture refers to membranes ruptured >18 hours.
Epidemiology
PROM complicates approximately 8% of term pregnancies; PPROM occurs in 2-3% of pregnancies but accounts for nearly one-third of all preterm births.
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Membrane integrity depends on collagen-rich chorioamnion. Local inflammation, infection (ascending genital tract organisms), oxidative stress, and apoptosis activate matrix metalloproteinases that degrade chorionic collagen. The membrane weakens and ruptures, often without overt labor contractions.
Clinical presentation
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
Continuous external fetal monitoring for category, variability, decelerations, contractions
Diagnostic algorithm
Gestational Age
Recommended Management
<23 wk (periviable)
Counsel; offer expectant vs termination; limited steroids/abx if intervention planned
23 0/7 - 33 6/7 wk
Hospitalize, steroids, latency abx, MgSO4 if <32 wk, fetal surveillance
34 0/7 - 36 6/7 wk
Shared decision: delivery vs expectant; GBS prophylaxis; consider steroids
>=37 wk (term PROM)
Induction of labor with oxytocin; GBS prophylaxis as indicated
Gestational-age-based management of PROM and PPROM (ACOG PB 217).
Treatment
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 supports either expectant management or delivery — recent data favor delivery
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: ampicillin + erythromycin IV x 48 h, then amoxicillin + erythromycin PO x 5 days (or azithromycin single dose as alternative to erythromycin)
GBS intrapartum prophylaxis (penicillin G; cefazolin if mild PCN allergy; clindamycin/vancomycin if anaphylactic)
Magnesium sulfate for neuroprotection if delivery anticipated before 32 weeks
Placental abruption, cord prolapse (especially with malpresentation)
Preterm birth and associated neonatal morbidity (RDS, IVH, NEC, sepsis)
Pulmonary hypoplasia and limb contractures with early/prolonged oligohydramnios
Endometritis and postpartum sepsis
PANCE pearls
Avoid digital cervical exams in PPROM unless delivery is imminent — significantly shortens latency and increases infection.
Latency antibiotics for PPROM should NOT include amoxicillin-clavulanate (associated with neonatal necrotizing enterocolitis in the ORACLE trial).
Maternal temperature >=39.0 C once or 38.0-38.9 C with one other criterion (maternal HR >100, fetal HR >160, WBC >15k, purulent discharge) = intra-amniotic infection — deliver and treat with broad-spectrum antibiotics.
Speculum exam is preferred over digital exam at any gestational age when PROM is suspected.
References
ACOG PB 217 — ACOG Practice Bulletin 217: Prelabor Rupture of Membranes (Obstet Gynecol 2020)
ACOG CO 713 — Antenatal Corticosteroid Therapy for Fetal Maturation (Obstet Gynecol 2017, reaffirmed)
ORACLE I — Kenyon et al., Lancet 2001 — broad-spectrum antibiotics for PPROM
PPROMT Trial — Morris et al., Lancet 2016 — immediate delivery vs expectant management at 34-36 wk PPROM
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