Guidelines for the Management of Preterm Premature Rupture of Membranes (PPROM)
Purpose of Policy:
PPROM occurs in approximately 3% of pregnancies, affects over 120,000 pregnancies
annually in the US, and is responsible for over one third of all preterm births. PPROM is
associated with a significant increase in maternal, fetal, and neonatal morbidity and
mortality which result from infection/amnionitis, umbilical cord compression, abruption
placenta and prematurity. The risk of these complications decreases with increasing
gestational age. A vast body of literature characterizes the PPROM including the
pathophysiology, diagnosis and management. This report summarizes the available
evidence into evidence-based management strategies of PPROM by gestational age.
Scope of Policy:
Clinical Personal
Diagnosis:
History, vaginal pool with +ferning/nitrazine, amniocentesis with indigo-carmine infusion (dye test)
Policy/guideline:
Evaluation:
1. Ultrasound for gestational age, growth, anomalies, AFI
2. Cervical culture for Gonorrhea, Chlamydia; Anovaginal culture for GBS, urine culture
3. Initial continuous monitoring of fetal status and for labor
If evidence of amnionitis, abruptio placenta, non-reassuring fetal status, advanced labor, or fetal
death recommend moving toward delivery with intraparum GBS prophylaxis or broad spectrum
antibiotics if amnionitis present
If the aforementioned conditions are not met, the recommendations are as follows by gestational
age:
1. PREVIABLE PPROM (< 23.0 weeks)


Provide counseling regarding immediate delivery versus conservative management.
Counseling should include a detailed discussion of maternal and neonatal risks of
conservative management and a realistic appraisal of neonatal outcomes.
If conservative management is undertaken, recommendation is for a brief period (2448 hours) of inpatient monitoring with bed/pelvic rest to evaluate for evolving
infection, abruption, or labor. Detailed ultrasound should be performed to
identify/exclude fetal anomalies. Serial ultrasound should be offered every 1-2 weeks
to evaluate AFV and interval pulmonary growth. Patients may be discharged to
home if clinically stable for close follow-up with readmission when viability is reached.
Patients should be re-counseled at close intervals to maintain a plan consistent with
maternal wishes and the current maternal/fetal clinical status.
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2. PERI-VIABLE PPROM (23.0 — 23.6 weeks)


Provide counseling regarding immediate delivery versus conservative management.
Counseling should include a detailed discussion of maternal and neonatal risks of
conservative management and a realistic appraisal of neonatal outcomes.
If conservative management is undertaken, the decision to pursue antibiotics for
latency and antenatal corticosteroids to decrease the complications of prematurity
may be offered. This decision may vary by provider, the gestational age at
presentation, and other prognostic factors.
3. PPROM REMOTE FROM TERM (24.0 – 31.6weeks)




Conservative inpatient management with modified bedrest, serial evaluation of fetal
well being and growth, serial evaluation for evolving infection, abruption, or labor.
Administer antenatal corticosteroids and antibiotics for latency per the MFMU-NIH
protocol
o Ampicillin 2gm IV q6 hours and Erythromycin 250mg IV q6 hours x 48 hours
followed by Amoxicillin 250mg po q8 hours and erythromycin 333mg po q8
hours x 5 days.
o Azithromycin may be substituted for Erythromycin with equivalent dosing
regimen of 500mg po on day 1 followed by 250mg po daily x 6 days.
Tocolytics should be used with caution in the setting of PPROM. However, initial
labor inhibition to achieve corticosteroid benefit may be considered in the absence of
clinically-apparent or subclinical intrauterine infection, abruption, non-reassuring fetal
status, or other contraindication to labor inhibition.
Recommend delivery for amnionitis, non-reassuring fetal testing, abruption, or labor
prior to 34.0 weeks. Otherwise delivery at 34.0 is indicated.
4. PPROM NEAR TERM (32.0 – 33.6 weeks)

5.
Collect amniotic fluid (transvaginal pooling or amniocentesis) if possible for fetal lung
maturity studies.
o If testing indicates lung maturity, delivery should be considered
 If no fluid is available for testing or testing is not consistent with lung
maturity, patients should be offered conservative management with
administration of antenatal corticosteroids, latency antibiotics as per
the MFMU-NIH protocol, and delivery indications as outlined above.
PPROM NEAR TERM (≥ 34.0 weeks)

At or beyond 34.0 weeks gestational age, conservative management is not indicated
and expeditious delivery should be pursued by induction of labor or cesarean section
as clinically indicated.
PRIMARY REFERENCE:
Mercer BM. Preterm Premature Rupture of the Membranes. Obstet Gynecol 2003;101:178-93.
Please see references for this review article for further details.
Revised and Approved 2/16/11 at the MacDonald Quality Council
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