Patient handout

Preterm Labor (PTL) / Preterm Prelabor Rupture of Membranes (PPROM)

PRODUCTION

1. Your condition

This handout is for preterm labor (ptl) / preterm prelabor rupture of membranes (pprom). Your care team identified this based on: regular uterine contractions ≥ 4 in 20 min or ≥ 8 in 60 min between 20+0 and 36+6 wk (acog pb 130 2012).

Other reasons your team may use this plan: new low-back ache / pelvic pressure / vaginal pressure at < 37 wk — supportive ptl feature (acog pb 130); patient reports gush of clear or blood-tinged fluid; speculum shows pooling + nitrazine-positive + ferning or commercial pprom assay positive (acog pb 188 2018); cervix ≥ 2 cm dilated or > 80% effaced on speculum or digital exam at < 37 wk (acog pb 130).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
nifedipine	20-30 mg PO load → 10-20 mg PO q4-6h (max 180 mg/day)	PO	q4-6h	First-line tocolytic per ACOG PB 234 — reduces preterm birth + improves neonatal outcome; preferred over indomethacin and terbutaline; avoid in maternal hypotension MAP < 65 or LV dysfunction

Plan: Preterm labor + PPROM acute management — tocolysis + corticosteroids + magnesium neuroprotection + latency antibiotics + GBS IAP (ACOG PB 234 + PB 188 + CO 713 + CO 797 + BEAM 2008 + ALPS 2016 + NICHD-MFMU PPROM 1997)

3. When to call your provider

Contact your care team if any of the following happen:

Antepartum bleeding / cramping / decreased fetal movement → return to L&D / ED
Postpartum fever / chills / uterine tenderness / foul lochia → endometritis workup (ED visit + broad-spectrum + imaging)
New mental health crisis (PHQ-9 ≥ 15 or PCL-5 with suicidal ideation) → urgent mental health referral
Newborn high-risk features (persistent feeding issues, neurodevelopmental concerns, persistent jaundice) → urgent peds visit / ED

4. When to seek emergency care

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

PTL or 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. 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.
PTL or PPROM at 24+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). Can extend to 34+0 - 36+6 wk for late preterm per ALPS NEJM 2016 PMID 26842679 if no prior course + delivery anticipated within 7 d + low chorio risk.
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. AVOID amoxicillin-clavulanate (NEC risk per ORACLE-II Kenyon 2008). Concurrent corticosteroids + 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, WBC > 15K without steroids, purulent cervical discharge) in PPROM or PTL → suspected Triple I per Higgins 2016 PMID 26855098. Routes to ob.chorioamnionitis.v1 with PTL/PPROM carryover. Discontinue tocolysis (contraindicated in chorio). Start ampicillin + gentamicin empirics (ACOG CO 712 2017). Expedite delivery — chorio source IS the gravid uterus.
Indomethacin for tocolysis ONLY at < 32+0 wk — CONTRAINDICATED at or after 32 wk due to oligohydramnios + ductal closure + neonatal pulmonary HTN risk. 50-100 mg PO load → 25-50 mg PO q6h × 48 h max. Monitor amniotic fluid index weekly if used > 48 h. Switch to nifedipine if approaching 32 wk or refractory.
PTL features + painful vaginal bleeding + tachysystole + tender uterus + non-reassuring FHR → placental abruption overlay; life-threatening. Tocolysis CONTRAINDICATED. Routes to ob.placental-abruption.v1. Resuscitate + emergent delivery + DIC + MTP if hemorrhagic shock + cryoprecipitate if fibrinogen < 200.(life-threatening)
Terbutaline FDA black-box (2011) — restricts use to short-term acute tocolysis ≤ 48-72 h hospitalised setting only. NEVER oral or chronic (cardiac death risk). 0.25 mg SC q20 min × 3 doses for acute tocolysis if nifedipine and indomethacin both contraindicated or unavailable. Switch to nifedipine for sustained tocolysis.

5. Follow-up

6-week postpartum visit + preterm-birth-specific anticipatory guidance: recurrence ~ 15-30% in subsequent pregnancy; preconception MFM consult for next pregnancy planning (early CL surveillance, vaginal progesterone planning, cerclage indication review per Berghella Cochrane 2017). 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 (cerebral palsy + BPD + IVH risk monitoring per AAP NRN framework).

6. Sources

Guideline: ACOG Practice Bulletin 234 (2021, reaffirmed 2024) Antepartum Fetal Surveillance + ACOG PB 188 (2018, reaffirmed) Prelabor Rupture of Membranes + ACOG CO 713 (2017, reaffirmed) Antenatal Corticosteroids 24-33+6 wk + ACOG PB 130 (2012, reaffirmed) Prediction and Prevention of Preterm Birth + ACOG CO 797 (2020) Prevention of GBS Early-Onset Disease + ACOG CO 871 (2020) Magnesium Sulfate Before Anticipated Preterm Birth + BEAM Rouse NEJM 2008 (PMID 18753646) Magnesium for Neuroprotection + Doyle Cochrane 2009 (PMID 19160238) Magnesium meta-analysis + Roberts Cochrane antenatal corticosteroids 2017 (PMID 28321847) + Liggins 1972 (PMID 4561295) Original Betamethasone RCT + ALPS Gyamfi-Bannerman NEJM 2016 (PMID 26842679) Late-Preterm Steroids + NICHD-MFMU Mercer JAMA 1997 (PMID 9307346) PPROM Latency Antibiotics + ORACLE-I Kenyon Lancet 2001 (PMID 11293640) + Hassan Ultrasound Obstet Gynecol 2011 (PMID 21472815) Vaginal Progesterone + Romero AJOG 2018 (PMID 29157866) Vaginal Progesterone Meta-Analysis + PROLONG Blackwell 2020 (PMID 31652479) 17OHP-C No Benefit + CDC GBS Verani 2010 (PMID 21088663) + Higgins NICHD/ACOG/SMFM 2016 (PMID 26855098) Chorio Overlap + SSC 2026 (sepsis-pathway carryover)