Preterm prelabour rupture of membrane (PPROM)

1.0
a)
b)
c)

Background
Responsible for 40% of preterm deliveries
PPROM complicates 2% of pregnancies
3 causes of death:
a. Prematurity
b. Sepsis
c. Pulmonary hypoplasia
d) Evidence of PPROM and intrauterine infection
a. Ascending infection from lower genital tract
b. 1/3 PPROM have positive amniotic fluid cultures
c. Bacteria have ability to cross intact membrane
Depending on the bacterial load and cervical resistance, bacterial
may ascend through the cervix and reach the fetal membranes. This
activates the decidua, increasing prostaglandin and trigger
contraction. Alternatively, it weakens membrane, leading to
rupture.

2.0
Diagnosis of PPROM
a) Maternal history
i)
gush of fluids, followed by more-or-less continuous dribble
ii)
TRO urinary incontinence or urinary tract infection
iii)
Fetal movement may reduce in strength or frequency
iv)
+/- uterine irritability or contractions
b) Physical examination
i)
Flushed appearance, increase in pulse and temperature: infection
ii)
Oligohydramnios or uterine tenderness (chorioamnionitis,
abruptio)
c) Sterile speculum examination
i)
Pool of amniotic fluid in the posterior vaginal
ii)
Dilatation can be assessed
iii)
DO NOT performed digital vaginal examination significant
reduction in latent interval before labor
d) Investigations
Current test
i)
Genital tract swab high vaginal swab helps to guide antibiotic
therapy, if subsequently required. Screening for group B
streptococcus (GBS) as substantial risk of labor in next few days
vaginal-rectal swab is more sensitive compared to vaginal swabs alone
for detection of GBS
ii)
AmniSure newest confirmatory test immunochromatographic
assay which detect the trace amounts of placental alpha
microglobulin-1 protein (PAMG-1) in vaginal fluid after rupture
of fetal membrane (figure 3)
iii)
Cardiotogography- gradually increasing baseline heart rate or fetal
tachycardia can be first sign of intrauterine infection

iv)

v)
vi)
vii)

Ultrasound- amniotic fluid volume (established PPROM, there is a

direct correlation between the amount of AF remaining and latency
period) - AFI 5 cm is associated with an increased risk of caesarean
section for fetal distress and an APGAR score of less than 7 in 5
minute.
Amniocentesis- sample of amniotic fluid sent for gram stain,
microscopy and culture
Other test (a decade ago)
Nitrazine testing: amniotic fluid is alkaline, turn nitrazine stick
blue/black (figure 1)
Microscopic examination: characteristic ferning of crystalline
pattern of dried amniotic fluid owning to its sodium chloride
and protein content (figure 2)
*NICE GUIDELINE recommend that if pool of amniotic fluid in
the posterior vaginal fornix do not performed any
investigation and treat the patient as PPROM.
**IF no pooling of amniotic fluid is observed then used the
AmniSure test to detect placenta alpha-microglobulin-1 test to
confirmed leakage (If negative and no amniotic fluid is
observed patient should be told that it is unlikely that she
has PPROM, and do NOT offer antenatal prophylactic
antibiotics)
***NICE guideline suggest not to use nitrazine to diagnosed
PPROM.

3.0

4.0

Antenatal test that should be performed?

a) Women should be observed for signs of clinical chorioamnionitis
b) Clinical chorioamnionitis include maternal pyrexia, tachycardia,
leukocytosis, uterine tenderness, offensive vaginal discharge and
fetal tachycardia
c) Cardiotogography is useful and indeed fetal tachycardia Is used in the
definition of clinical chorioamnionitis
d) Every 4-8 hourly, maternal temperature, pulse and fetal heart rate
auscultation should be performed
Management
4.1
Antibiotics
a) Rapid intrapartum nucleic acid amplification test (NAAT) should be
performed on women with unknown GBS colonization. When negative but
she developed one of the below indication: delivery before 37 weeks of
gestation, there is rupture of membrane rupture of membranes of
18 hours, temperature of 100.4 F (38oC), previous infant with
GBS disease, GBS bacteriuria during current pregnancy
prophylaxis antibiotics should be given
b) Antibiotics should be initiated 4 hours prior to delivery for optimal prophylaxis,
and continue as long as active, progressive labor continues.
c) GBS antibiotics: ampicillin (2g IV STAT, then 1g IV every 6 hours for at least 48 hours)

Side note: optimal timing for prenatal GBS screening is 35-37 weeks of
gestation; or 6 weeks prior to delivery.
d) Erythromycin- offer to women with established diagnosis of PPROM oral erythromycin
250mg 4 times a day for a maximum of 10 days or until women is in established labor
(whichever is sooner): it delays delivery, reduced the incidence of clinical or pathologic
chorioamnionitis and neonatal sepsis;
a. ANTIBIOTICS should not be given to women with PPROM and in an active
preterm labor with intact membrane- because it increases the incidence
of cerebral palsy in infants
** chorioamnionitis leads to 2- to 3-fold increase risk for cesarean
section, and 2- to 4-fold increase in endomyometritis, wound
infection, prelvic abscess, bacteremia and postpartum
hemorrhage. The increase in postpartum hemorrhage appears to
be due to dysfunctional uterine muscle contraction as a result of
inflammation.
4.2
Corticosteroids
a) Evidence shows a reduced risk of RDS, intraventricular hemorrhage and
necrotizing enterocolitis
b) Indications include women with PPROM between 23 +0 and 35+6 weeks of
gestation who are suspected, diagnosed, or established preterm labor, are
having a planned preterm birth or have PPROM
Side note: Established pre-term labor is defined by NICE guideline with
regular uterine contraction and progressive cervical dilatation to 4cm with
evidence of diagnosed preterm labor (sterile speculum examination) and
History of preterm labor.
4.3
MgSO4
Offer IV MgSO4 for neuroprotection of the baby to women between 24 +0
and 29+6 weeks of pregnancy who are:
a) Established preterm labor
b) Planned preterm birth within 24 hours
Give 4g IV bolus over 30 minutes, then 1g/hour maintenance until birth or
for 24 hours (whichever is sooner). Monitor for magnesium sulfate
toxicity every 4 hourly- pulse, respiratory rate and deep tendon
(patellar) reflexes.
4.4
Tocolytic agent
Tocolytic agent to prolong pregnancy, in order to obtain short-term
benefits for the mother and the fetus, has been demonstrated in women
at risk of preterm birth with intact membrane. However, the use of
Tocolytic agent in the setting of PPROM is controversial. Tocolytic agent is
not recommended because this treatment does not significantly improved
perinatal outcomes. Their use should be considered in the setting of
PPROM at less than 34 weeks gestation for 48 hours if there is no
evidence of clinical chorioamnionitis or complication, which would

necessitate delivery, for the fetus to receive maximal benefits of

corticosteroid administration. Also it is indicated to enable transfer to a
tertiary center.
4.5
Delivery of the baby
a) Delivery should be considered at 34 weeks of gestation (RCOG-2010)
b) Where expectant management is considered beyond this gestation,
women should be informed of the increase risk of chorioamnionitis
and the decreased risk of respiratory problems in the neonate
c) Expectant management (wait and see option) is proportionate
to the increase risk of chorioamnionitis hence, current evidence
point towards conservative management before 34 weeks, and more
evidence on the optimal timing of delivery for women with PPROM at
gestations greater than 34 weeks.
Side note: Intrauterine infection predispose to white matter
injury and subsequent adverse neurodevelopmental problems
such as cerebral palsy.
d) Preterm birth and Cesarean section associated with higher
neonatal morbidity and mortality. In the presence of oligohydramnios,
the lower segment is poorly formed. A vertical (figure4) is often
necessary, and carries an up to 5% risk of uterine rupture in the
subsequent pregnancies.
e) Thus, normally the mode of delivery is through Vaginal
Delivery