INFORMATION FOR WOMEN WHO HAVE PRETERM PREMATURE RUPTURE OF MEMBRANES DURING PREGNANCY
What is Preterm Premature Rupture of Membranes?
The term premature rupture of membranes (PROM) refers to rupture of the amniotic sac (commonly called your water breaking) before the onset of uterine contractions. PROM that occurs before a gestational age of 37 weeks is called Preterm Premature Rupture of Membranes (PPROM). Both PROM and PPROM feature amniotic fluid leaking out through the vagina before your labor contractions have begun. However, while women with PROM at term can simply be admitted to the delivery room and have labor induced (if the membrane rupture does not trigger the labor on its own), or can be delivered through a cesarean section, PPROM presents a scenario in which the baby may not be ready to begin life outside the womb. How the situation plays out will then depend on the level of prematurity. Late PPROM PROM occurring at 34-37 weeks gestation requires a course of action that differs from what is required for PPROM occurring at 24-33 weeks, or from PPROM occurring at ages below 24 weeks.
How common is PPROM?
PPROM occurs in roughly 3 percent of pregnancies and accounts for about 33 percent of preterm births. Most of these cases involve viable babies (24-37 weeks gestation), whereas pre-viable PPROM (PROM before 24 weeks) occurs in less than 1 percent of pregnancies.
How is PPROM diagnosed?
Generally, PPROM can be diagnosed based on your history and physical exam, and some simple laboratory testing that is done on samples taken from your vagina or cervix. Usually, there is a large gush, or a steady leak, of clear fluid from the vagina. Doctors will then perform whats called a nitrazine test. If this reveals a high pH (your vagina is alkaline rather than acidic), this indicates that amniotic fluid has indeed leaked from within the womb. However, the nitrazine test can be falsely negative if you have experienced prolonged PPROM (the gush of fluid occurred many hours ago) since the vaginal pH will have returned to normal. Another test performed is called the fern test, which can support the diagnosis of PPROM based on the appearance of the cervical mucus under the microscope. This test is the most sensitive and specific in women who are already in labor.
The fetal fibronectin test is highly sensitive, but not so specific for PROM, and so useful in ruling out PROM; in other words, if it comes out negative, doctors can be very sure that your membranes are intact. Other tests for vaginal contents include the AmniSure test and the ROM Plus. Doctors also may use ultrasonography to measure the volume of amniotic fluid in your womb. If the amount of fluid is very low, this supports a diagnosis of PPROM.
Does PPROM cause problems during pregnancy?
PPROM can lead to infection of the amniotic fluid and membrane (intra-amniotic infection) around the developing baby and also placental abruption, separation of the placenta from the uterine wall. This, in turn, can lead to infection throughout your body (sepsis). It also can lead to inflammation of the uterine wall after birth (postpartum endometritis). Additionally, PPROM makes cesarean delivery much more likely.
Does PPROM during pregnancy cause problems for the baby?
Along with being a problem for the mother, the placental abruption that can occur puts the developing baby at extreme risk, since it means that circulation is cut off to the baby’s tissues, which can lead to the death of the baby (intrauterine fetal demise). Similarly, intra-amniotic infection is a major danger to the baby as well as the mother. It can lead the baby to develop sepsis and possibly die. The baby is also in danger of having underdeveloped lungs, respiratory distress syndrome, hemorrhage in the brain, skeletal deformities, problems with the umbilical cord, slowed neurological developmental or impairment, and death soon after birth.
What to consider about taking medications when you are pregnant:
- The risks to yourself and your baby if you do not treat the PPROM
- The risks and benefits of each medication you use when you are pregnant
- The risks and benefits of each medication you use when you are breastfeeding
What should I know about using medication to treat PPROM during pregnancy?
Since the principal treatment for PPROM, if the developing baby is at least 34 weeks is immediate induction of labor, the hormone oxytocin (or a synthetic version called pitocin) is given. This is safe for the soon-to-be-born baby and it works to stimulate uterine contractions. It is not given if a cesarean section is needed, in which case doctors need to do the opposite, namely to prevent or stop uterine contractions. Antibiotics must be given to treat intra-amniotic infection in order to prevent all of the grave consequences mentioned above that can arise for the mother and baby. Options include penicillin G and ampicillin; in place of these, for those who are allergic to penicillin, cephalosporin antibiotics can be given. Other options include lincomycin antibiotics (such as clindamycin), glycopeptide antibiotics, vancomycin, and erythromycin.
If the gestational age is below 34 weeks, amniocentesis may be performed to extract a sample of the remaining amniotic fluid for testing to assess the baby’s lung maturity. This test is not needed if the baby is much younger than 34 weeks, in which case lung immaturity is certain. In either case, if the lungs are immature, the mother must be given the corticosteroid drug betamethasone, which accelerates lung maturation. A drug called magnesium sulfate may be given if the gestational age is below 32 weeks in order to help protect the brain.
Who should NOT stop taking medication for PPROM during pregnancy?
Every category of medication given for PPROM is vital, so nobody should avoid medication.
What should I know about choosing a medication for my PPROM during pregnancy?
You may find Pregistrys expert reports about the individual medications to treat PPROM here. Additional information can also be found in the sources listed at the end of this report.
What should I know about taking a medication for my PPROM when I am breastfeeding?
PPROM is something that happens only during pregnancy. Once you have delivered it is over. You may still be taking antibiotics after the baby is delivered, but most of the antibiotic regimens that are given are not considered dangerous during breastfeeding.
What alternative therapies besides medications can I use to treat my PPROM during pregnancy?
The principal treatment for PPROM is not medication, but delivery of the baby as soon as possible, and medications are given in support of this strategy. If the developing baby is at least 34 weeks old, this means immediate delivery. If the gestational age is 24-33 weeks, the strategy is called expectant management. This means that the doctors prepare for delivery to occur soon, protect you and the baby with antibiotics, and give betamethasone to accelerated lung maturation. However, labor is not induced, unless the baby is close to 34 weeks and testing demonstrates that the baby’s lungs are mature. If the gestational age is below 24 weeks, expectant management is also the strategy, but the chances of the baby surviving are very poor in such a case.
What can I do for myself and my baby when I have PPROM during pregnancy?
Complete the entire course of your antibiotic regimen if you are g
iven antibiotics for an intra-amniotic infection. Cooperate with your physicians to make labor and delivery as soon and as smoothly as possible, depending on the gestational age of the fetus.
Resources for PPROM in pregnancy:
For more information about PPROM during and after pregnancy, contact http://www.womenshealth.gov/ (800-994-9662 [TDD: 888-220-5446]) or read the following articles:
- Mayo Clinic: Water Breaking: Understand this Sign of Labor
- University of Rochester Medical Center: Preterm Premature Rupture of Membranes (PPROM)