Preterm Premature Rupture of Membranes (PPROM)

Call 911 or go to the nearest emergency room right away if you have:

• PPROM < 34+0 wk + expectant management (no chorio, no abruption, no non-reassuring fetal status) → 7-day course of ampicillin + erythromycin (NICHD-MFMU Mercer JAMA 1997 PMID 9307346) — 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. Azithromycin 1 g PO × 1 acceptable alternative per SMFM 2025 if erythromycin intolerance / shortage. AVOID amoxicillin-clavulanate (NEC risk per ORACLE-II Kenyon 2008). Concurrent corticosteroids 23-33+6 wk + magnesium neuroprotection if < 32 wk + close chorio surveillance (Higgins 2016).
• Maternal fever ≥ 39.0 °C OR 38.0-38.9 °C × 2 + ≥ 1 of (FHR > 160 sustained × 10 min, WBC > 15K without steroids, purulent cervical discharge) in PPROM → suspected Triple I per Higgins 2016 PMID 26855098. Routes to ob.chorioamnionitis.v1 with PPROM carryover. Discontinue latency antibiotics + tocolysis (if any). Start ampicillin + gentamicin empirics (ACOG CO 712 2017). Expedite delivery — chorio source IS the gravid uterus.
• PPROM at < 32+0 wk gestation with imminent delivery → magnesium sulfate 4-6 g IV load + 1 g/h × 12-24 h for fetal neuroprotection (BEAM NEJM 2008 PMID 18753646 + Doyle Cochrane 2009 PMID 19160238) — reduces cerebral palsy in survivors (RR 0.68). NOT a tocolytic — separate indication. Monitor toxicity hourly (RR < 12 / DTR loss / UO < 0.5 mL/kg/h → STOP + calcium gluconate 1 g IV antidote). Renal adjust if CrCl < 30 or AKI.
• PPROM at 23+0 - 33+6 wk with imminent delivery within 7 d → betamethasone 12 mg IM × 2 doses 24 h apart OR dexamethasone 6 mg IM × 4 doses 12 h apart for fetal lung maturity (ACOG CO 713 + Roberts Cochrane 2017 PMID 28321847). Rescue course per ACOG 2024 if > 14 d since prior + still < 34 wk + new imminent delivery. Less commonly applied in PPROM ≥ 34 wk where delivery is favored.
• Tocolysis is generally NOT recommended in PPROM — flag as RELATIVE CONTRAINDICATION (ACOG PB 217 2024). Brief use (≤ 48 h) MAY be considered SOLELY to complete an ANS window in absence of chorio + abruption + non-reassuring fetal status. Most experts avoid even brief tocolysis. Nifedipine preferred if used. ABSOLUTE contraindication when chorio confirmed, abruption present, or Category III FHR.
• Cord prolapse on speculum exam in PPROM → emergent cesarean Category 1 (decision-to-delivery interval < 30 min) per RCOG GTG 50 2014. Manual elevation of presenting part to relieve cord compression. Knee-chest or Trendelenburg position. Bladder filling 500-700 mL saline as adjunct. Terbutaline 0.25 mg SC for transient tocolytic relief while preparing OR. Higher risk at lower GA + oligohydramnios + non-cephalic presentation.(life-threatening)
• PPROM features + painful vaginal bleeding + tachysystole + tender uterus + non-reassuring FHR → placental abruption overlay; life-threatening. Routes to ob.placental-abruption.v1. Resuscitate + emergent delivery + MTP per Pacheco SMFM 47 (1:1:1 PRBC:FFP:platelets) + cryoprecipitate if fibrinogen < 200 + TXA 1 g IV within 3 h of birth (WOMAN trial Shakur Lancet 2017 PMID 28456509).(life-threatening)
• PPROM at < 23+0 wk gestation — periviable pathway. Survival rare (~ 1-5 % at 22 wk; ≥ 23 wk ~ 30-55 %; ≥ 24 wk ~ 60-80 %); severe neurodevelopmental impairment in survivors at 22-23 wk ~ 30-50 %. Extensive shared decision making between parents + OB + neonatal teams per ACOG/SMFM Obstetric Care Consensus 6 (2017, reaffirmed 2024). Offer expectant management (with active intervention if chosen) vs termination. Active management at ≥ 22 wk now considered acceptable (was previously ≥ 23 wk).