Preterm prelabour rupture of the membranes (PPROM) occurs in around 2% of pregnancies but is associated with around 40% of preterm deliveries.

Complications of PPROM

• fetal: prematurity, infection, pulmonary hypoplasia
• maternal: chorioamnionitis

Confirming PPROM

• a sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection
• if pooling of fluid is not observed, NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSure) or insulin-like growth factor binding protein-1 (IGFBP-1)
• ultrasound may also be useful to show oligohydramnios

Management

• admission (at least 48h) for observation, particularly to monitor for signs of infection or labour
• regular observations (e.g. temperature, pulse) to ensure chorioamnionitis is not developing
• oral erythromycin should be given for 10 days (or until labour is established, whichever is sooner)
• antenatal corticosteroids (typically dexamethasone) should be administered to reduce the risk of respiratory distress syndrome (especially before 34 weeks, and consider between 34–36 weeks)
  • IM Dexa 4.95 mg every 12 hours for 48 hours, to be given within 7 days prior to birth, treatment course may be repeated once as clinically indicated at least 7 days after completion of the first course, alternatively 9.9 mg OD can be given in some cases
• consider IV magnesium sulphate for fetal neuroprotection if < 30 weeks and birth is imminent
• delivery is generally recommended at 37 weeks of gestation if there are no other indications for earlier delivery (e.g. chorioamnionitis, fetal compromise). This balances the risks of infection with the benefits of further fetal maturation
• if meconium-stained liquor is present, close monitoring is required; earlier delivery may be indicated depending on clinical findings