Management

of PPROM
 Index
• Introduction
• Classification
• Risk factors
• Diagnosis
• Differential diagnosis
• Investigations
• Management
• Case Scenarios
PRETERM PRELABOUR RUPTURE OF
MEMBRANES(PPROM)
• DEFINITION: Spontaneous rupture of the
fetal membranes before 37 completed weeks
of gestation in the absence of uterine
contractions or before onset of labor.

ACOG 2016
 Incidence of PPROM
Complicates 3 % of all pregnancies.

30- 40% of cases deliver within 48 hrs.

56-63% deliver within 7 days.

ACOG 2016
 Classification

Previable PPROM (<24 Weeks)

PPROM remote from term(24-31 weeks)

PPROM near term ( 32-36 weeks)

 RISK FACTORS
OBSTETRIC RISK FACTORS:
• History of previous PTL or second trimester
loss
• Overdistended uterus : multiple pregnancy/
hydramnios
• Medical and obstetric indication for preterm
termination of pregnancy
• Inter-pregnancy interval <6months
Contd. :
• Cervical incompetence and short cervix
• Increased friability and decreased tensile
strength of membranes
• Fetal abnormalities and IUFD
• Iatrogenic invasive procedures- amniocentesis,
fetal blood sampling
RACE :
• Black women have 2 times higher risk
• Explained by multiple factors

DEMOGRAPHIC FACTORS :
• Low BMI <18.5 kg/m2
• Poor maternal weight gain
• Overweight and obesity
• Age <17yrs/ >35yrs
• Low socioeconomic status
PSYCHOSOCIAL FACTORS :
• Anxiety
• Stress
• Depression
• Negative life events
• Domestic violence
• Work related stress >42hrs/wk or >6hrs/day
DIETARY FACTORS :
• Deficiency of zinc and iron
• Cigarette Smoking
• Alcohol consumption
INFECTION :
• 50% association
• Earlier the onset – more the chances of
infective etiology
• Ascending infection.
 Microbiota of genital tract:
- Bacterial vaginosis
- Chlamydia trachomatis
- Neisseria Gonorrhoeae
- Trichomonas vaginalis
- Group B streptococcus
- Gardnerella vaginalis
 DIAGNOSIS

HISTORY

PHYSICAL EXAMINATION

INVESTIGATIONS
 DIAGNOSIS OF PPROM
• HISTORY BASED:
- Gush of fluid from vagina
- Moistening is noted in perineum.
- Preceding symptoms like change in
vaginal discharge and pelvic pressure
- Prior history of preterm birth
• CLINICAL EXAMINATION
BASED:
PER SPECULUM EXAMINATION:

Pooling of fluid in posterior vaginal fornix.

Leaking from the endocervical canal.

If there is no leak seen and history suggestive of

PPROM, then leakage can be exaggerated by erect
posture and straining of abdominal muscles .
 PER SPECULUM EXAMINATION:

Vernix particles/ meconium if present are

diagnostic of amniotic fluid.

Woman is asked to wear a vulval pad and is

allowed to ambulate for an hour and soakage of
pad is noted.

Endocervical and high vaginal swab is taken for

culture sensitivity.


 PHYSICAL EXAMINATION
• Vitals: Pulse, blood pressure, temperature
• Abdominal palpation for
– Fetal size,
– Presentation,
– Liquor volume,
– Uterine tenderness,
– Multiple gestation.
 ULTRASOUND EXAMINATION BASED:

 Assessment of fetal growth and position

 Residual amniotic fluid volume assessment
 Gross fetal abnormalities.
 INVESTIGATION
1. Full blood count for leucocytosis and CRP.

2. Urine routine analysis, culture and sensitivity

3. A) High vaginal swab for gram staining and culture

B) Endocervical swab for Neisseria gonorrhoea and

Chlamydia trachomatis.
C) Collect vaginal fluid for
microbiological culture and fetal lung maturity studies.
4. Rarely Amniocentesis is done to provide
uncontaminated amniotic fluid for culture and
fetal lung maturity.
 Diagnostic Tests
• NON- INVASIVE TESTS:
 pH test:

• Litmus paper
• Bromothymol blue.
• Nitrazine test
Fern test
Microscopic examination of vaginal fluid:
 Cytodiagnosis: done on vaginal fluid by
Papanicolaou test
Nile blue sulfate test
Masson’s trichome
Acridine orange
Pinacyanol
 Immunochromatographic method
(Amnisure) to detect trace amounts of
placental microglobulin-1 (PAMG-1)
 Fetal fibronectin
• INVASIVE TEST:
Ultrasonographically guided transabdominal
instillation of 1ml indigocarmine in 9ml sterile
saline, followed by the passage of blue-dyed fluid
into the vagina documented by a stained tampon or
pad.

Maternal urine also will turn blue and can be

confused with amniotic fluid.
 DIFFERENTIAL DIAGNOSIS
• Maternal urinary incontinence.
• Vaginal discharge (candidal/ other type of
vaginitis)
• Cervical mucus discharge
• History of Vesicovaginal or rectovaginal
fistula during previous delivery.
• Urogenital tract trauma/ surgery
 GESTATIONAL AGE BASED
APPROACH FOR MANAGEMENT
 Previable PPROM (<24 Weeks)
• Patient counseling.
• Expectant management or induction of labor.
• Antibiotics may be considered as early as 20 weeks
of gestation.
• GBS prophylaxis, Corticosteroids, Tocolysis,
Magnesium sulfate for neuroprotection is not
recommended before viability.

-40–50% of patients with previable PROM will give birth within the first
week
-70–80% will give birth 2–5 weeks after membrane rupture
Preterm PPROM (24weeks–33 weeks)
Preterm PPROM (24weeks–33 weeks)
• Expectant management
• Antibiotics recommended to prolong latency if
there are no contraindications
• Single-course corticosteroids
• GBS prophylaxis as indicated
• Magnesium sulfate for neuroprotection
<32weeks
Near term PPROM (34 Weeks-37weeks)

• Delivery by labour induction.

• GBS prophylaxis as indicated.

• EXPECTANT MANAGEMENT(<34 WEEKS)

Diagnosis uncertain:
A. Admit the patient
B. Perform regular vaginal pad checks
C. Perform ultrasound for fetal well being and
liquor volume
D. Observe for features of chorioamnionitis
 Features of Chorioamnionitis
• SYMPTOMS: • SIGNS:
Fever  FEVER >100.4 F
Pain abdomen  Maternal Tachycardia
(>100bpm)
Malaise
 Fetal tachycardia
Foul smelling (>160 bpm)
vaginal discharge  Uterine Tenderness
 Foul smelling
amniotic fluid
 Diagnosis certain:

A. Contact NICU team

B. Admit for bed rest.

 Routine monitoring in expectant
management
• Maternal monitoring
- Vitals measurement Q 4th hourly.
- Abdominal palpation
- Thrice weekly total leucocyte count and
CRP
- Weekly high vaginal swab, urine routine,
microscopic examination and culture
sensitivity.
• FETAL MONITORING:
– Maternal perception of fetal activity
– Non Stress test
– 2-3 weekly growth scan
– Weekly amniotic fluid assessment
depending on gestation
– Fetal biophysical profile (including CTG) –
limited value
• Indications for immediate delivery
– Chorioamnionitis
– Onset of spontaneous labour
– Fetal compromise
– Fetal maturity achieved
 Role of Tocolysis
• Prophylactic tocolysis:
– Associated with prolongation of pregnancy and
an increased risk of chorioamnionitis without
significant maternal or neonatal benefit.
• Therapeutic tocolysis :
– In the setting of ruptured membranes with active
labor, therapeutic tocolysis does not prolong
latency or improve neonatal outcomes. Therefore,
therapeutic tocolysis is not recommended.

ACOG 2016
 ANTIBIOTIC THERAPY
• GROUP B STREPTOCOCCUS PROPHYLAXIS
- INJ. Penicillin IV 5x 106 U STAT 2.5X 106 U Q 4hrly
OR

- INJ Ampicillin IV 2gm STAT 1gm Q 4hrly

In case of penicillin allergy

Inj. Erythromycin Inj. Clindamycin

500mg IVQ6 hrly 900mg IVQ 8hrly

Amo
• THERAPEUTIC ANTIBIOTIC
PROPHYLAXIS(<34 weeks)
– INTRAVENOUS THERAPY(48HRS):
• Inj Ampicillin 2gm iv Q 6hrly
• Inj Erythromycin 250mg iv Q 6 hrly

– ORAL THERAPY(5 DAYS/Until delivery)

• Tab Amoxicillin 250mg Q 8hrly (ORACLE 1 TRIAL)
• Tab Erythromycin 400 mg Q 8hrly

Tab Co-amoxiclav was shown to cause stage 2-3 necrotizing

enterocolitis hence not used in prophylaxis.
• Antenatal corticosteroids:
– Single course of corticosteroids is
recommended between 24-34 weeks of
gestation and may be considered for
pregnant women as early as 23 weeks of
gestation who are at risk of preterm delivery
within 7 days.
– Inj. Betamethasone- 12mg 2 doses 24 hrs
apart or

– Inj. Dexamethasone- 6 mg 4 doses 12 hrs

apart
RCOG
 Role of Neuroprotection
• Ideally women with preterm PROM before 32
weeks of gestation at risk of imminent delivery
are considered candidates for fetal
neuroprotective treatment with magnesium
sulfate.
• Dosage: MgSO4 6gm bolus followed by
2gm/hr infusion x 12 hours
 BIBLIOGRAPHY
• Gabbe obstetrics- South asian edition
• Ian Donald Practical obstetrics problems- 7 th
edition
• ACOG Guidelines 2016
• RCOG Green top guideline No- 44
THANK
YOU!
 Case scenarios
1. Primi @ 31+4 weeks came with c/o leaking
pv since 2 hrs
p/s – clear leak +
Vitals- Stable

Management?
2. Primi @ 28 weeks came with c/o leaking pv
since 1 day
p/s – clear leak +
Vitals- temperature- 102 F
Pulse Rate- 110/min
Blood pressure- 110/60mmHg

Management?