Guidelines for the Management of Preterm Premature Rupture of Membranes (PPROM)

Purpose of Policy:

PPROM occurs in approximately 3% of pregnancies, affects over 120,000 pregnancies annually in the US, and is responsible for over one third of all preterm births. PPROM is associated with a significant increase in maternal, fetal, and neonatal morbidity and mortality which result from infection/amnionitis, umbilical cord compression, abruption placenta and prematurity. The risk of these complications decreases with increasing gestational age. A vast body of literature characterizes the PPROM including the pathophysiology, diagnosis and management. This report summarizes the available evidence into evidence-based management strategies of PPROM by gestational age.

Scope of Policy: Clinical Personal

Diagnosis: History, vaginal pool with +ferning/nitrazine, amniocentesis with indigo-carmine infusion (dye test)

Policy/guideline:

Evaluation:

1. Ultrasound for gestational age, growth, anomalies, AFI 2. Cervical culture for Gonorrhea, Chlamydia; Anovaginal culture for GBS, urine culture 3. Initial continuous monitoring of fetal status and for labor

If evidence of amnionitis, abruptio placenta, non-reassuring fetal status, advanced labor, or fetal death recommend moving toward delivery with intraparum GBS prophylaxis or broad spectrum antibiotics if amnionitis present

If the aforementioned conditions are not met, the recommendations are as follows by gestational age:

1. PREVIABLE PPROM (< 23.0 weeks)

 Provide counseling regarding immediate delivery versus conservative management. Counseling should include a detailed discussion of maternal and neonatal risks of conservative management and a realistic appraisal of neonatal outcomes.  If conservative management is undertaken, recommendation is for a brief period (24- 48 hours) of inpatient monitoring with bed/pelvic rest to evaluate for evolving infection, abruption, or labor. Detailed ultrasound should be performed to identify/exclude fetal anomalies. Serial ultrasound should be offered every 1-2 weeks to evaluate AFV and interval pulmonary growth. Patients may be discharged to home if clinically stable for close follow-up with readmission when viability is reached. Patients should be re-counseled at close intervals to maintain a plan consistent with maternal wishes and the current maternal/fetal clinical status.

- 1 - 2. PERI-VIABLE PPROM (23.0 — 23.6 weeks)

 Provide counseling regarding immediate delivery versus conservative management. Counseling should include a detailed discussion of maternal and neonatal risks of conservative management and a realistic appraisal of neonatal outcomes.  If conservative management is undertaken, the decision to pursue antibiotics for latency and antenatal corticosteroids to decrease the complications of prematurity may be offered. This decision may vary by provider, the gestational age at presentation, and other prognostic factors.

3. PPROM REMOTE FROM TERM (24.0 – 31.6weeks)

 Conservative inpatient management with modified bedrest, serial evaluation of fetal well being and growth, serial evaluation for evolving infection, abruption, or labor.  Administer antenatal corticosteroids and antibiotics for latency per the MFMU-NIH protocol o Ampicillin 2gm IV q6 hours and Erythromycin 250mg IV q6 hours x 48 hours followed by Amoxicillin 250mg po q8 hours and erythromycin 333mg po q8 hours x 5 days. o Azithromycin may be substituted for Erythromycin with equivalent dosing regimen of 500mg po on day 1 followed by 250mg po daily x 6 days.  Tocolytics should be used with caution in the setting of PPROM. However, initial labor inhibition to achieve corticosteroid benefit may be considered in the absence of clinically-apparent or subclinical intrauterine infection, abruption, non-reassuring fetal status, or other contraindication to labor inhibition.  Recommend delivery for amnionitis, non-reassuring fetal testing, abruption, or labor prior to 34.0 weeks. Otherwise delivery at 34.0 is indicated.

4. PPROM NEAR TERM (32.0 – 33.6 weeks)

 Collect amniotic fluid (transvaginal pooling or amniocentesis) if possible for fetal lung maturity studies. o If testing indicates lung maturity, delivery should be considered . If no fluid is available for testing or testing is not consistent with lung maturity, patients should be offered conservative management with administration of antenatal corticosteroids, latency antibiotics as per the MFMU-NIH protocol, and delivery indications as outlined above.

5. PPROM NEAR TERM (≥ 34.0 weeks)

 At or beyond 34.0 weeks gestational age, conservative management is not indicated and expeditious delivery should be pursued by induction of labor or cesarean section as clinically indicated.

PRIMARY REFERENCE: Mercer BM. Preterm Premature Rupture of the Membranes. Obstet Gynecol 2003;101:178-93. Please see references for this review article for further details.

Revised and Approved 2/16/11 at the MacDonald Quality Council