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ob.pprom.v1

Preterm Premature Rupture of Membranes (PPROM)

obstetricsacuteadultpregnancy
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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`).

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Advance rule
Set
Advance when

GA tier + PPROM confirmation (speculum or PAMG-1 assay) documented

Patient inputs (26)

ROM > 18 h is CDC IAP indication + chorio antecedent risk; informs latency-antibiotic timing + chorio surveillance cadence

Twin/triplet — PPROM management complicated by shared circulation in monochorionic twins; cord prolapse + abruption risk elevated; MFM co-management

Non-cephalic presentation + PPROM + oligohydramnios increases cord prolapse risk; influences delivery planning + ED monitoring

Maternal tachycardia > 100 supports chorio; sepsis screen if disproportionate to fever

Tachypnea > 22 is qSOFA component (sepsis flag); magnesium toxicity surveillance (RR < 12)

Hypoxemia unusual in PPROM — consider PE / pneumonia / AFE differential

FHR > 160 sustained × 10 min with maternal fever is Higgins 2016 chorio secondary criterion; Category III FHR mandates emergent delivery

GA partitions decision branches: < 23 wk previable (counseling-heavy); 23+0 - 25+6 periviable (active management vs termination); 26+0 - 33+6 early preterm (full intervention + expectant); 34+0 - 36+6 late preterm (favor delivery per ACOG PB 217); ≥ 37+0 wk term PROM (out of scope)

PPROM diagnosis confirmed via sterile speculum (pooling + nitrazine + ferning) OR commercial PAMG-1 assay (AmniSure / ROM-Plus); avoid digital exam until delivery anticipated

WBC > 15K without antenatal steroids is Higgins 2016 chorio secondary criterion; daily during expectant PPROM management

Asymptomatic bacteriuria / pyelonephritis common in pregnancy + can trigger preterm contractions; rule out as PPROM mimic + treat if positive

GBS culture if not done within 5 wk antepartum; informs IAP empirics until result available (treat empirically as GBS-positive when status unknown)

Renal function for magnesium dosing (toxicity if CrCl < 30); baseline before infusion; LFTs for HELLP overlap if PE features

Confirm GA + EFW + AFI (oligohydramnios supports PPROM); placenta location for abruption ddx; fetal presentation for cord-prolapse risk + delivery planning

Continuous EFM (Category I/II/III) once admitted with PPROM; FHR > 160 sustained is Higgins 2016 chorio criterion; Category III mandates emergent delivery

Fever ≥ 39.0 °C single OR 38.0-38.9 °C × 2 ≥ 30 min apart is gateway chorio criterion per Higgins 2016; routes to ob.chorioamnionitis.v1

BP screens for superimposed pre-eclampsia + sepsis (hypotension MAP < 65 → emergent resuscitation per SSC 2026 OB adaptation)

GBS-positive OR unknown-GBS + PPROM at any GA → IAP indication; informs penicillin G dosing + alternative-regimen decisions

Anaphylaxis → vancomycin or clindamycin (susceptible) for GBS IAP; mild → cefazolin substitute (cross-reactivity ~ 1-2 % per Macy 2014)

Recurrence ~ 16-32 % in subsequent pregnancy; preconception MFM consultation for next-pregnancy planning

Prior spontaneous PTB increases recurrence risk; relevant for next-pregnancy MFM consultation (not acute decision)

PPROM with cerclage in situ — case-by-case removal decision usually within 24-48 h given ascending infection risk

Bishop score guides induction-vs-cesarean decision at 34+0 wk PPROM or chorio-driven delivery; unfavorable cervix may favor cervical ripening with misoprostol / dinoprostone / Foley balloon

Bacteremia in chorio ~ 5-10 %; mandatory if SIRS / qSOFA features → routes to id.sepsis.core.v1

Pre-procedural workup for cesarean if anticipated; abruption-DIC monitoring if abruption overlay

Erythromycin intolerance (GI), drug shortage, or QTc concerns → azithromycin 1 g PO × 1 as alternative per SMFM 2025

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Severity triggers (10)

10 need judgement
  • informationallife_threateningcord_prolapse_with_pprom
    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.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningplacental_abruption_overlap_pprom
    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).
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepprom_under_34wk_expectant_management
    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).
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverechorio_emergence_in_pprom
    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.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepprom_under_32wk_magnesium_neuroprotection
    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.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepprom_23_to_33wk_corticosteroid_window
    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.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretocolysis_contraindication_in_pprom
    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.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereperiviable_pprom_under_23wk
    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).
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepprom_at_or_after_34wk_delivery
    PPROM at 34+0 - 36+6 wk → induction of labor (or expectant management) per ACOG PB 217 2024 — favors delivery; balance neonatal RDS risk (low at ≥ 34 wk) against chorio + cord compression + cord prolapse risk from continued PPROM. Late preterm steroids per ALPS 2016 if no prior course + delivery anticipated within 7 d + low chorio risk (less commonly applied here where delivery is favored). GBS IAP intrapartum.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategbs_iap_pen_allergy_with_pprom
    PPROM at any GA + GBS-positive OR unknown-GBS intrapartum + maternal penicillin allergy → substitute regimen per CDC Verani 2010 PMID 21088663 + ACOG CO 797 2020. Mild allergy (rash only, no anaphylaxis): cefazolin 2 g IV load → 1 g IV q8h (cross-reactivity ~ 1-2 % per Macy 2014). Severe allergy (anaphylaxis): clindamycin 900 mg IV q8h if GBS susceptible (resistance 15-20 %) OR vancomycin 20 mg/kg IV q8h (max 2 g) if clinda-resistant or unknown susceptibility.
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

PPROM expectant management + delivery-timing axis (ACOG PB 217 2024 + SMFM 2025 + NICE NG201 2024 + RCOG GTG 73 2024 + NICHD-MFMU 1997 + BEAM 2008 + ALPS 2016 + CDC Verani 2010)
axis: pprom_managementstep latency_antibiotics_under_34wk - Latency antibiotics for PPROM < 34 wk expectant management (NICHD-MFMU Mercer JAMA 1997 PMID 9307346)
Selected step "Latency antibiotics for PPROM < 34 wk expectant management (NICHD-MFMU Mercer JAMA 1997 PMID 9307346)" — PPROM < 34+0 wk + expectant management + no chorio + no abruption + no non-reassuring fetal status; goal extend latency + reduce chorio + neonatal sepsis
  • ampicillin
    first line
    aminopenicillin
    2 g IV q6h × 48 h then amoxicillin 250 mg PO q8h × 5 d (total 7 d) • IV then PO • q6h IV → q8h PO
    triggers: pprom_under_34wk_expectant_no_chorio
    NICHD-MFMU Mercer JAMA 1997 PMID 9307346 — reduces chorio (RR 0.74) + neonatal sepsis (RR 0.68) + extends latency (≥ 7 d effect); ACOG PB 217 2024
    rxcui 733
  • erythromycin
    first line
    macrolide
    250 mg IV q6h × 48 h then 333 mg PO q8h × 5 d (total 7 d) • IV then PO • q6h IV → q8h PO
    triggers: pprom_under_34wk_expectant_no_chorio
    NICHD-MFMU Mercer JAMA 1997 PMID 9307346 + ORACLE-I Kenyon 2001 PMID 11293640; Ureaplasma + Mycoplasma coverage; AVOID amoxicillin-clavulanate per ORACLE-II (NEC risk)
    rxcui 4053
  • azithromycin
    contraindication substitute
    macrolide
    1 g PO × 1 dose • PO • single dose
    triggers: pprom_under_34wk_erythromycin_intolerant_or_qtc_concern_or_shortage
    SMFM 2025 PPROM consult — acceptable alternative to erythromycin for intolerance / drug shortage / QTc concerns; convergent observational + small RCT efficacy data
    rxcui 18631

outpatient playbook — drug actions (4)

  1. 1. iron repletion if antepartum anemia or postpartum
    rxcui 4053
    Ferrous sulfate 325 mg PO TID; IV iron if severe • PO/IV • TID PO or per infusion protocol
    trigger: Hgb < 11 g/dL
    Restore iron stores; reduce fatigue + improve recovery
  2. 2. contraception postpartum
    Per ACOG MEC + patient preference (LARC, COC, POP, DMPA) • PO/IM/implant/IUD • per agent
    trigger: Patient request + medical eligibility
    Interpregnancy interval ≥ 18 mo associated with reduced PTB / PPROM recurrence
  3. 3. Tdap, influenza, COVID per ACIP
    Per ACIP • IM • per schedule
    trigger: Postpartum or antepartum per gestational age
    Standard ACIP
  4. 4. mental health pharmacotherapy if indicated (SSRI for PPD)
    Sertraline 50 mg PO daily titrated; lactation-compatible per LactMed • PO • daily
    trigger: EPDS ≥ 10 or PHQ-9 ≥ 10 with persistent symptoms
    Sertraline preferred for breastfeeding; ACOG CO 757 2018

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Patient reports gush or persistent leakage of clear or blood-tinged fluid at < 37+0 wk gestation (ACOG PB 217 2024); Amniotic fluid pooling in posterior fornix on sterile speculum exam at < 37+0 wk — gold-standard PPROM diagnostic finding (ACOG PB 217 2024); AmniSure (PAMG-1) or ROM-Plus (PAMG-1 + IGFBP-1) positive assay — sens 98-99 %, spec 87-100 % when speculum equivocal (ACOG PB 217 2024).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Preterm Premature Rupture of Membranes (PPROM)** (ob.pprom.v1).
Phenotype framing: 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).
Scope: 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`).

No severity triggers fired against current inputs.

Plan

Regimen axis: **PPROM expectant management + delivery-timing axis (ACOG PB 217 2024 + SMFM 2025 + NICE NG201 2024 + RCOG GTG 73 2024 + NICHD-MFMU 1997 + BEAM 2008 + ALPS 2016 + CDC Verani 2010)** — step "Latency antibiotics for PPROM < 34 wk expectant management (NICHD-MFMU Mercer JAMA 1997 PMID 9307346)".
1. ampicillin 2 g IV q6h × 48 h then amoxicillin 250 mg PO q8h × 5 d (total 7 d) IV then PO q6h IV → q8h PO (aminopenicillin, first line) — NICHD-MFMU Mercer JAMA 1997 PMID 9307346 — reduces chorio (RR 0.74) + neonatal sepsis (RR 0.68) + extends latency (≥ 7 d effect); ACOG PB 217 2024
2. erythromycin 250 mg IV q6h × 48 h then 333 mg PO q8h × 5 d (total 7 d) IV then PO q6h IV → q8h PO (macrolide, first line) — NICHD-MFMU Mercer JAMA 1997 PMID 9307346 + ORACLE-I Kenyon 2001 PMID 11293640; Ureaplasma + Mycoplasma coverage; AVOID amoxicillin-clavulanate per ORACLE-II (NEC risk)
3. azithromycin 1 g PO × 1 dose PO single dose (macrolide, contraindication substitute) — SMFM 2025 PPROM consult — acceptable alternative to erythromycin for intolerance / drug shortage / QTc concerns; convergent observational + small RCT efficacy data

Setting playbook (outpatient) — 6-week postpartum visit + PPROM-specific anticipatory guidance + preconception MFM counseling for next pregnancy; newborn outpatient follow-up especially for late preterm with developmental tracking through 12 mo + extreme preterm tracking through 18-22 mo. (Outpatient expectant management of PPROM in selected stable patients is emerging but NOT standard practice and is not routinely offered.)
4. iron repletion if antepartum anemia or postpartum Ferrous sulfate 325 mg PO TID; IV iron if severe PO/IV TID PO or per infusion protocol — Hgb < 11 g/dL (Restore iron stores; reduce fatigue + improve recovery)
5. contraception postpartum Per ACOG MEC + patient preference (LARC, COC, POP, DMPA) PO/IM/implant/IUD per agent — Patient request + medical eligibility (Interpregnancy interval ≥ 18 mo associated with reduced PTB / PPROM recurrence)
6. Tdap, influenza, COVID per ACIP Per ACIP IM per schedule — Postpartum or antepartum per gestational age (Standard ACIP)
7. mental health pharmacotherapy if indicated (SSRI for PPD) Sertraline 50 mg PO daily titrated; lactation-compatible per LactMed PO daily — EPDS ≥ 10 or PHQ-9 ≥ 10 with persistent symptoms (Sertraline preferred for breastfeeding; ACOG CO 757 2018)

Non-pharmacologic actions:
- Mental health counseling / therapy if EPDS ≥ 10 or PCL-5 elevated; peripartum PTSD risk elevated after preterm + NICU
- Preconception MFM consultation for next pregnancy planning — early TVUS CL surveillance, vaginal progesterone planning if short cervix, cerclage indication review
- Pediatric follow-up coordination for late preterm + very preterm + extreme preterm — 24-48 h post-discharge peds for late preterm; first-year developmental tracking; AAP NRN framework
- Lactation support continued for breastfeeding (PPROM regimens not contraindicated per LactMed)
- VTE prophylaxis follow-up if extended postpartum thromboprophylaxis prescribed (cesarean + chorio + immobility increase VTE risk)
- Smoking cessation, substance use reduction, glycemic control if DM, BP control if HTN — modifiable risk factors for PPROM recurrence

AVOID / contraindication checks:
- Avoid digital cervical exam in PPROM until delivery anticipated ascending infection risk (ACOG PB 217 2024)
- Avoid amoxicillin clavulanate in PPROM NEC risk (ORACLE II Kenyon Lancet 2008)
- Tocolysis relative contraindication in PPROM brief use only for ANS window without chorio abruption nonreassuring (ACOG PB 217 2024)
- Tocolysis ABSOLUTE contraindication in confirmed chorio or abruption or Category III FHR (ACOG PB 217 + ACOG CO 712)
- Indomethacin contraindication at or after 32wk ductus closure and oligohydramnios (ACOG PB 234) — and not recommended in PPROM at any GA due to existing oligohydramnios
- Terbutaline FDA black box no chronic or oral use cardiac death risk brief acute SC only (FDA 2011)
- Magnesium toxicity RR lt 12 OR DTR loss OR UO lt 0.5mL per kg per h antidote calcium gluconate 1g IV (ACOG PB 234)
- Magnesium renal adjust if CrCl lt 30 or AKI (ACOG PB 234)
- NSAIDs avoid intrapartum PDA constriction and bleeding (ACOG PB 188)
- Erythromycin QTc prolongation monitor baseline and as clinically indicated (FDA labeling)
- Azithromycin alternative to erythromycin only for intolerance or shortage or QTc concern (SMFM 2025)
- GBS IAP clindamycin only if susceptible per antibiogram resistance 15 to 20 percent (CDC Verani 2010)
- Cefazolin cross reactivity low 1 to 2 percent in mild pen allergy no anaphylaxis (Macy 2014; ACOG CO 797)
- Rescue corticosteroid course allowed once if gt 14d since prior and still lt 34wk and new imminent delivery (ACOG 2024 + CO 713)
- Late preterm ALPS steroids only if no prior course and no chorio and delivery within 7d (ALPS NEJM 2016)
- Periviable counseling required under 23wk PPROM (ACOG/SMFM OCC 6 2017)
- Cord prolapse emergent cesarean Category 1 decision to delivery under 30min with manual elevation and Trendelenburg (RCOG GTG 50 2014)

Monitoring

Regimen monitoring:
- Maternal vitals q15 min during active labor or magnesium load; q1 h post-load; q4 h stable
- Continuous EFM during PPROM admission (Category I/II/III interpretation)
- Maternal temperature q4 h — chorio surveillance (Higgins 2016 fever criterion)
- Daily CBC + CMP during expectant PPROM management — WBC trend for chorio surveillance + renal for magnesium dosing
- Magnesium toxicity surveillance hourly — DTR + RR + UO; STOP + calcium gluconate 1 g IV if RR < 12 / DTR loss / UO < 0.5 mL/kg/h
- Weekly amniotic fluid volume US during expectant PPROM management
- Fetal growth US q2-4 wk during expectant PPROM management
- Continuous EFM during corticosteroid administration + magnesium load (transient FHR variability reduction expected)
- Newborn handoff at delivery: maternal antibiotic timing + GBS IAP adequacy + ANS course + magnesium exposure → peds / neonatology (AAP Puopolo 2018 + Kaiser EOS calculator)
- Bishop score reassessment when delivery planned at 34+0 wk — informs induction-vs-cesarean + cervical-ripening agent decision

Setting (outpatient) monitoring:
- 6-week postpartum visit; additional 1-2 wk visit if cesarean wound concern or extended episiotomy
- Maternal mental health re-screen at 6 wk + 3 mo + 6 mo (peripartum PTSD risk elevated)
- Newborn outpatient peds at 24-48 h then 1 wk then 1 mo for late preterm
- Very preterm + extreme preterm developmental tracking at 4 / 12 / 18-22 mo (AAP NRN framework)
- Preconception MFM consultation when contemplating next pregnancy

Follow-up plan: 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.
- Close-out criterion: Postpartum visit complete; preconception MFM counseling delivered; mental health + immunization + newborn developmental tracking arranged

Monitoring phase: 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).

Disposition

Current setting: outpatient — 6-week postpartum visit + PPROM-specific anticipatory guidance + preconception MFM counseling for next pregnancy; newborn outpatient follow-up especially for late preterm with developmental tracking through 12 mo + extreme preterm tracking through 18-22 mo. (Outpatient expectant management of PPROM in selected stable patients is emerging but NOT standard practice and is not routinely offered.)

Disposition criteria:
- Resolution: 6-wk postpartum visit complete, mental health stable, contraception in place, immunizations up to date, newborn developmental tracking in place → discharge to routine primary care + preconception MFM for next pregnancy when contemplated

Escalation triggers (move to higher acuity):
- 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

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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).
- [SEVERE] 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).

Citations

- ACOG Practice Bulletin 217 (2020, reaffirmed 2024) Prelabor Rupture of Membranes + SMFM 2025 PPROM consult + NICE NG201 (2024) + RCOG Green-top Guideline 73 (2024) + ACOG CO 712 (2017, reaffirmed 2022) Intrapartum Management of IAI + ACOG CO 713 (2017, reaffirmed) Antenatal Corticosteroids + ACOG CO 797 (2020) Prevention of GBS Early-Onset Disease + ACOG CO 871 (2020) Magnesium Sulfate + ACOG/SMFM Obstetric Care Consensus 6 (2017, reaffirmed 2024) Periviable Birth + BEAM Rouse NEJM 2008 (PMID 18753646) + Doyle Cochrane 2009 (PMID 19160238) + Roberts Cochrane antenatal corticosteroids 2017 (PMID 28321847) + ALPS Gyamfi-Bannerman NEJM 2016 (PMID 26842679) + NICHD-MFMU Mercer JAMA 1997 (PMID 9307346) + ORACLE-I Kenyon Lancet 2001 (PMID 11293640) + CDC GBS Verani 2010 (PMID 21088663) + Higgins NICHD/ACOG/SMFM 2016 (PMID 26855098) + Pacheco SMFM 47 (PMID 30684460) + WOMAN Shakur Lancet 2017 (PMID 28456509) + RCOG Green-top Guideline 50 (2014) Umbilical Cord Prolapse [PMID:9307346](https://pubmed.ncbi.nlm.nih.gov/9307346/)
- Cited evidence (PMID 11293640) [PMID:11293640](https://pubmed.ncbi.nlm.nih.gov/11293640/)
- Cited evidence (PMID 18753646) [PMID:18753646](https://pubmed.ncbi.nlm.nih.gov/18753646/)
- Cited evidence (PMID 19160238) [PMID:19160238](https://pubmed.ncbi.nlm.nih.gov/19160238/)
- Cited evidence (PMID 28321847) [PMID:28321847](https://pubmed.ncbi.nlm.nih.gov/28321847/)

Last reconciled with current guidelines: 2026-05-15.
References
  • ACOG Practice Bulletin 217 (2020, reaffirmed 2024) Prelabor Rupture of Membranes + SMFM 2025 PPROM consult + NICE NG201 (2024) + RCOG Green-top Guideline 73 (2024) + ACOG CO 712 (2017, reaffirmed 2022) Intrapartum Management of IAI + ACOG CO 713 (2017, reaffirmed) Antenatal Corticosteroids + ACOG CO 797 (2020) Prevention of GBS Early-Onset Disease + ACOG CO 871 (2020) Magnesium Sulfate + ACOG/SMFM Obstetric Care Consensus 6 (2017, reaffirmed 2024) Periviable Birth + BEAM Rouse NEJM 2008 (PMID 18753646) + Doyle Cochrane 2009 (PMID 19160238) + Roberts Cochrane antenatal corticosteroids 2017 (PMID 28321847) + ALPS Gyamfi-Bannerman NEJM 2016 (PMID 26842679) + NICHD-MFMU Mercer JAMA 1997 (PMID 9307346) + ORACLE-I Kenyon Lancet 2001 (PMID 11293640) + CDC GBS Verani 2010 (PMID 21088663) + Higgins NICHD/ACOG/SMFM 2016 (PMID 26855098) + Pacheco SMFM 47 (PMID 30684460) + WOMAN Shakur Lancet 2017 (PMID 28456509) + RCOG Green-top Guideline 50 (2014) Umbilical Cord Prolapse — PMID:9307346
  • Cited evidence (PMID 11293640) — PMID:11293640
  • Cited evidence (PMID 18753646) — PMID:18753646
  • Cited evidence (PMID 19160238) — PMID:19160238
  • Cited evidence (PMID 28321847) — PMID:28321847