Preterm Premature Rupture of Membrane (PPROM)

If the amniotic membranes rupture before week 37, it is considered to be preterm premature rupture of the membranes or PPROM. An uncontrollable gush or gradual leak of liquid occurs before the onset of labor, in some cases much before baby reaches term. In the past due to overwhelming concern for the mother and baby incurring infection due to prolonged rupture, babies were delivered when the rupture occurs regardless of gestational age. Today things are different and the actions taken after a PPROM without labor are either:

• A wait and see approach for labor to commence; meanwhile both mother and baby will be monitored continuously. Maternal temperature will be observed and vaginal examination will be totally avoided
• or corticosteroid therapy will be initiated to stop labor (medication may or may not be given)

The Facts..

• Miscarriage is a possibility if PPROM occurs before 20 weeks of pregnancy
• Premature delivery is a viable consequence if PPROM occurs after 20 weeks of pregnancy
• When membranes rupture, labor usually ensues. The closer the due date, the sooner labor is likely to begin
• PPROM poses a greater risk if it happens preterm, before baby is ready to be born. Since the fetus is not ready to live in the outside world, efforts will be made to keep the pregnancy going
• The mother needs to be hospitalized if premature rupture occurs irrespective of her being in labor or not for the medical staff to determine the cause and if delivery is imminent
• PPROM usually is a result of weakened membranes that have lost its elasticity
• The probable but not conclusive cause is bacterial infection; common invading bacteria are thought to be group B streptococcus (GBS), bacterial vaginosis (BV) among others
• If baby is 26 weeks or older the survival rate is high; a course of corticosteroids will be given to mature up baby's lungs quicker while it is still inside
• Delivery may be postponed anywhere from a few hours to a few weeks
• A close watch will be kept in a hospital setting with total bed rest

The Treatment..

• Correct diagnosis will be made before any treatment; a combination of history, physical exam to confirm the presence of amniotic fluid in the vagina, ultrasound to check on fluid level and lab tests will be carried out
• Treatment will depend on amniotic fluid level, if mother is at risk of getting an infection and the gestational age of the fetus
• Vaginal fluid will be taken and cultured to check for infection. Since results may take up to 48 hours, the mother may be started on antibiotics. Symptoms of infection may not manifest early enough
• The fluid quantity will be measured via an ultrasound
• Pregnancy will continue if the quantity is sufficient
• A small tear in the upper part of the uterus called 'high leak' usually means a small trickle of fluid is let out. However the status can change to continuous flow leading to premature labor
• Alternatively the tear can heal on its own, the leak will stop and pregnancy may continue to full term
• The mother will still be monitored carefully to watch out for infections
• Usually the mother will be discharged with a prescription for bed rest depending on certain other conditions besides the above. These conditions include:
  1. the baby should be in a vertex position,
  2. there should be no sign of infection,
  3. the mother should be able to rest,
  4. abstinence from vaginal intercourse,
  5. maternal temperature should be observed while at home
  6. mother must return for prenatal visits minimum on a weekly basis
• Sometimes in the event of an infection occurring your doctor may decide on prompt delivery

When Delivery is imminent..

• In the presence of maternal fever, infection is very probable. Delivery will be induced. Most cases of PPROM go into labor either immediately or within 48 hours.
• Many doctors will induce if the fetus is at term or near term following a rupture
• Otherwise induction only happens if there is an infection
• In situations when the infection is serious, the general consensus will be that baby be delivered within 12 hours, never mind if baby is premature
• Another complication is the possibility of a C-section. If the rupture occurs without contractions it usually implies that the cervix is not open so an operation becomes inevitable
• Infection of the amniotic sac results in either PPROM or other pregnancy complications.
• Bacteria that is initially found in the vaginal fluids starts to multiply and travel up, crossing into the uterus. These bacteria may spread to the sac and the baby
• Treatment with antibiotics becomes mandatory