12-phase flow (12)

1. 1FRAME
   Preterm premature rupture of membranes (PPROM) = spontaneous rupture of fetal membranes at < 37+0 wk of gestation prior to onset of labor. Partition by GA tier (previable < 23 / periviable 23-25+6 / early preterm 26-33+6 / late preterm 34-36+6 / term ≥ 37 = PROM out-of-scope) and chorioamnionitis status (absent: expectant management eligible / present: immediate delivery + ampicillin + gentamicin per ob.chorioamnionitis.v1). Distinguishes from preterm labor with intact membranes (`ob.preterm-labor.v1`), term PROM (≥ 37 wk; routine), placental abruption (painful bleed + tachysystole; `ob.placental-abruption.v1`), and cervical insufficiency (painless 2nd-tri dilation without ROM; `ob.cervical-insufficiency.v1`).
   inputs: gestational_age_weeks, membrane_status_confirmed_pprom
   advance: GA tier + PPROM confirmation (speculum or PAMG-1 assay) documented
2. 2ENTRY
   Recognise PPROM via patient-reported leak + sterile speculum showing pooling + nitrazine + ferning OR commercial PAMG-1 assay (AmniSure / ROM-Plus) when speculum equivocal. Oligohydramnios on US supports diagnosis. **Avoid digital cervical exam** until delivery anticipated (ascending infection risk per ACOG PB 217 2024).
   inputs: gestational_age_weeks
   advance: PPROM diagnosed; sterile speculum or PAMG-1 confirmation documented
3. 3CONTEXT
   GA exact + ROM duration + maternal GBS status + IAP adequacy + maternal penicillin allergy severity + erythromycin intolerance / QTc concerns + multifetal status + fetal presentation (cephalic vs non-cephalic; cord prolapse risk) + cerclage in situ + prior PPROM / PTB history + comorbidities (DM, HTN, smoking). Critical decision context for latency antibiotic choice, ANS timing, magnesium indication, GBS IAP regimen, and delivery-vs-expectant decision.
   inputs: gestational_age_weeks, membrane_status_confirmed_pprom, rom_duration_hours, maternal_gbs_status_and_iap_adequacy, maternal_pen_allergy_severity, erythromycin_intolerance_or_qtc_concern, multifetal_gestation_status, fetal_presentation_cephalic_vs_non_cephalic, cerclage_in_situ_status, maternal_hr, maternal_rr, maternal_spo2, fetal_heart_rate_baseline
   advance: Risk-factor profile + GA-tier-specific decision context captured
4. 4RED_FLAGS
   Maternal fever ≥ 39.0 °C OR 38.0-38.9 °C × 2 + secondary criteria → routes to ob.chorioamnionitis.v1 with PPROM carryover; expedite delivery. Painful vaginal bleeding + tachysystole + tender uterus → ob.placental-abruption.v1; tocolysis CONTRAINDICATED. Cord prolapse on speculum → emergent cesarean per RCOG GTG 50 + manual elevation + terbutaline tocolytic adjunct. Non-reassuring FHR Category III → emergent delivery. Severe HTN ≥ 160/110 + proteinuria → ob.preeclampsia-early-onset.v1. Maternal sepsis (qSOFA ≥ 2 / SIRS ≥ 2 / lactate ≥ 2 / MAP < 65) → emergent delivery + id.sepsis.core.v1 with OB carryover.
   inputs: maternal_temperature, maternal_bp, maternal_hr, fetal_heart_rate_baseline
   actions: protocol.septic_shock
   advance: Red-flag routing decisions documented (chorio / abruption / cord prolapse / Cat III FHR / severe PE / sepsis)
5. 5INITIAL_WORKUP
   Maternal CBC with diff (Higgins 2016 WBC > 15K secondary criterion) + CMP (renal for magnesium dosing) + UA + urine culture (pyelonephritis mimic) + cervicovaginal GBS culture if not recent + coag baseline if cesarean anticipated. Obstetric US for AFI (oligohydramnios supports PPROM) + EFW + placenta location (abruption ddx) + fetal presentation (cord prolapse risk). Continuous EFM once admitted. Document GA exactly (23+0 / 26+0 / 32+0 / 34+0 are decision-tier boundaries).
   inputs: maternal_cbc_with_diff, maternal_metabolic_panel, maternal_urinalysis_and_culture, cervicovaginal_gbs_culture_if_not_recent, obstetric_ultrasound_growth_and_afi
   actions: workup.preeclampsia, panel.cbc, panel.renal, panel.ua
   advance: Diagnostic labs + imaging drawn; GA tier confirmed; chorio surveillance baseline established
6. 6BRANCHING_WORKUP
   Branching by GA tier + chorioamnionitis status + abruption/cord-prolapse overlay. Previable < 23 wk: periviable counseling per ACOG/SMFM OCC 6 (2017); expectant vs termination. Periviable 23-25+6 wk: active management if chosen — latency abx + ANS + magnesium + IAP. Early preterm 26-33+6: full intervention; goal latency to 34 wk. Late preterm 34-36+6: deliver per ACOG PB 217 2024 (induction or expectant). Any GA + chorio: immediate delivery + ampicillin + gentamicin. Any GA + abruption: emergent delivery + MTP. Any GA + cord prolapse: emergent cesarean. Amniocentesis selectively for suspected subclinical IAI (rare; consider for puzzling chorio-like presentations).
   inputs: maternal_blood_culture_if_sirs, maternal_coag_panel
   actions: workup.fuo
   advance: GA-tier-specific + overlay-specific treatment plan documented; branching decisions complete
7. 7DIFFERENTIAL
   Urinary incontinence (common in pregnancy; nitrazine-negative + ferning-negative + PAMG-1 negative); vaginal discharge (BV, candidiasis; speculum + wet mount + KOH); cervical mucus / show with cervical change (PTL with intact membranes — routes to ob.preterm-labor.v1); placental abruption (painful bleed + tachysystole + tender uterus — routes to ob.placental-abruption.v1); chorioamnionitis (fever + Higgins 2016 — routes to ob.chorioamnionitis.v1 if PPROM confirmed with chorio overlay); pyelonephritis (UA + urine culture; can present with contractions); rupture of subchorionic hematoma (small amount of bloody fluid that may mimic PPROM); semen, urine, blood mimicking nitrazine positivity (false-positive avoidance).
   advance: Mimics excluded or co-managed; PPROM confirmation diagnostic + tier-specific plan set
8. 8RISK_STRATIFICATION
   GA tier + chorio status + fetal status (Category I/II/III) + AFI + fetal presentation drives imminence: high-risk (chorio confirmed OR abruption OR cord prolapse OR Cat III FHR) → emergent delivery; moderate-risk (early preterm + expectant management feasible) → full admission + intervention with chorio surveillance; lower-risk (34+0 - 36+6 + stable) → delivery (induction or expectant per local protocol). Previable < 23 wk → counseling-heavy pathway. qSOFA / SIRS / lactate screen for sepsis if febrile.
   inputs: gestational_age_weeks, maternal_temperature, fetal_heart_rate_baseline
   actions: calc.qsofa, calc.sirs
   advance: Imminence tier set; admit-vs-discharge-vs-deliver decision documented
9. 9TREATMENT
   LATENCY ANTIBIOTICS (PPROM < 34 wk + expectant management + no chorio): ampicillin 2 g IV q6h × 48 h then amoxicillin 250 mg PO q8h × 5 d + erythromycin 250 mg IV q6h × 48 h then 333 mg PO q8h × 5 d (total 7 d; NICHD-MFMU Mercer JAMA 1997 PMID 9307346). Azithromycin 1 g PO × 1 alternative per SMFM 2025 if erythromycin intolerance / drug shortage / QTc concern. AVOID amoxicillin-clavulanate (NEC per ORACLE-II Kenyon 2008). ANTENATAL CORTICOSTEROIDS (23+0 - 33+6 wk + delivery anticipated within 7 d): betamethasone 12 mg IM q24h × 2 doses OR dexamethasone 6 mg IM q12h × 4 doses (ACOG CO 713; Roberts Cochrane 2017 PMID 28321847). Rescue course per ACOG 2024 if > 14 d since prior + still < 34 wk + new imminent delivery. Late preterm 34+0 - 36+6 wk: betamethasone × 2 per ALPS NEJM 2016 PMID 26842679 IF no prior course + delivery anticipated within 7 d + low chorio risk (less commonly applied in PPROM ≥ 34 wk where delivery is favored). MAGNESIUM NEUROPROTECTION (< 32 wk + imminent delivery): 4-6 g IV load over 20-30 min + 1 g/h × 12-24 h (BEAM NEJM 2008 PMID 18753646; Doyle Cochrane 2009 PMID 19160238). TOCOLYSIS: relative contraindication in PPROM; brief use (≤ 48 h) ONLY for ANS window completion in absence of chorio / abruption / non-reassuring fetal status (most experts avoid even brief tocolysis per ACOG PB 217). GBS IAP intrapartum: penicillin G 5 mU IV load → 2.5-3 mU q4h until delivery (or ampicillin 2 g + 1 g q4h; cefazolin 2 g + 1 g q8h mild pen-allergy; clindamycin 900 mg q8h IV if susceptible / vancomycin 20 mg/kg IV q8h for severe pen-allergy per CDC Verani 2010 + ACOG CO 797 2020). DELIVERY TIMING: ≥ 34+0 wk OR chorio OR abruption OR cord prolapse OR Cat III FHR → induction or cesarean per local protocol + cervical favorability (Bishop score). Acetaminophen 650-1000 mg PO/IV q6h PRN for maternal pain or fever; avoid NSAIDs intrapartum (PDA constriction + bleeding).
   inputs: gestational_age_weeks, maternal_gbs_status_and_iap_adequacy, maternal_pen_allergy_severity
   advance: Latency antibiotics, ANS (if indicated), magnesium (if < 32 wk + imminent), IAP plan, and delivery-vs-expectant decision documented and started
10. 10DISPOSITION
    L&D / antepartum admission for all PPROM at < 37 wk (most patients). Periviable counseling consultation if < 23 wk (ACOG/SMFM OCC 6 2017). Tertiary transfer if < 32 wk and current facility lacks NICU. ICU only if maternal sepsis / pulmonary edema / multi-organ dysfunction. Outpatient expectant management of PPROM in selected stable patients is emerging but NOT standard practice. Delivery at ≥ 34+0 wk via induction or expectant per ACOG PB 217 + cervical favorability (Bishop score). Cesarean for chorio + non-reassuring FHR OR cord prolapse OR abruption.
    inputs: gestational_age_weeks, maternal_bp, maternal_spo2, bishop_score_when_delivery_planned
    advance: Maternal level of care set; NICU coordination if delivery anticipated; tertiary-transfer decision if indicated
11. 11MONITORING
    Continuous EFM intrapartum (Category I/II/III); maternal vitals q15 min during active labor or magnesium loading; q1 h post-load; q4 h stable. Magnesium toxicity surveillance hourly (DTR + RR + UO; STOP + calcium gluconate 1 g IV antidote if RR < 12 / DTR loss / UO < 0.5 mL/kg/h). Maternal temperature q4 h (chorio surveillance). Daily CBC + CMP during expectant PPROM management. Weekly AFI surveillance + fetal growth q2-4 wk during expectant management. Continuous EFM during corticosteroid + magnesium load (transient FHR variability reduction expected).
    inputs: maternal_temperature, maternal_hr, maternal_rr, fetal_heart_rate_baseline, continuous_efm_intrapartum_or_admission
    actions: panel.cbc, panel.renal
    advance: Maternal-fetal status stable + no chorio emergence + ANS window completed (48 h) OR delivered with appropriate neonatal coordination
12. 12FOLLOWUP
    6-wk postpartum visit + PPROM-specific anticipatory guidance: recurrence ~ 16-32 % in subsequent pregnancy; preconception MFM consultation for next-pregnancy planning (early TVUS CL surveillance, vaginal progesterone planning if short cervix, cerclage indication review). Mental health screen (EPDS for postpartum depression; PCL-5 for peripartum PTSD especially after extreme preterm or NICU outcomes). Contraception counseling + interpregnancy interval ≥ 18 mo. Immunization audit (Tdap, flu, COVID per ACIP). Newborn outpatient peds visit 24-48 h post-discharge if late preterm; first-year developmental tracking if very preterm or extreme preterm.
    advance: Postpartum visit complete; preconception MFM counseling delivered; mental health + immunization + newborn developmental tracking arranged