What is PPROM?
Preterm Prelabor Rupture of Membranes, or PPROM, happens when the amniotic sac — the fluid-filled membrane that surrounds and protects the fetus in utero — breaks before 37 weeks of pregnancy and before labor has started. It is often referred to as “your water breaking early.”
Amniotic fluid is important for fetal health because it allows for normal growth and helps with lung development. PPROM can lead to several complications for both the fetus and the pregnant individual. The risks are generally higher the earlier the rupture occurs. PPROM can lead to complications such as miscarriage, preterm birth, infection (chorioamnionitis), fetal lung underdevelopment (pulmonary hypoplasia), bleeding (i.e., placental abruption) umbilical cord issues, and orthopedic issues (e.g., clubfoot).
What Causes PPROM?
While PPROM can occur spontaneously in otherwise healthy pregnancies without a clear cause, several known risk factors have been identified, including:
- Infections in the uterus or cervix
- Previous PPROM or spontaneous preterm birth
- Vaginal bleeding
- Overdistention of the uterus (e.g., twins or too much amniotic fluid)
- Smoking, poor nutrition, or low BMI
- Trauma
- Cervical insufficiency
- Structural issues with the uterus
- In utero procedures such as amniocentesis and fetoscopic surgery due to the need to access the amniotic sac with needles or surgical instruments.
- These procedures, while minimally invasive, puncture the fetal membranes, increasing the risk of separation from the uterine wall and/or PPROM. The fetal membranes do not have an inherent ability to heal, unlike other parts of the body such as the uterus or skin. To minimize these risks, surgeons use the smallest possible instruments and carefully select the entry site. Post-procedure care includes close monitoring for membrane separation, fluid leakage, and infection.
How Is PPROM Diagnosed?
In cases of leaking fluid, a provider may perform:
- A physical exam to check for fluid in the vagina
- Examining the fluid under the microscope or with lab tests to determine if it’s amniotic fluid
- An ultrasound to measure the amniotic fluid level
- In rare instances, instillation of dye (tampon test) into the amniotic sac may be performed to determine if the fetal membranes are intact or ruptured
How Is PPROM Managed?
The management of pregnancies complicated by PPROM depends on several factors including the gestational age and the health of both the pregnant individual and the fetus.
PPROM occurring before the lower limit of neonatal viability (approximately 22 to 23 weeks of gestation) is associated with serious morbidity and mortality. The management of such cases is individualized.
For most pregnancies under 34 weeks without signs of infection or labor:
- Hospitalization for maternal and fetal monitoring is typically recommended
- Antibiotics to reduce the risk of maternal and fetal infection
- Steroids are often given to help the fetal lungs mature and decrease the risk of complications after delivery
- Magnesium sulfate is often administered to protect the fetal brain
- Medications to stop contractions (tocolysis) may be given to prolong the pregnancy
Between 34 and 37 weeks, delivery may be recommended based on the balance of risks and benefits. If there are any signs of infection, labor, or fetal distress, earlier delivery may be necessary.
Is There a Treatment for PPROM?
If spontaneous PPROM occurs, most patients will continue to leak fluid throughout the pregnancy. In rare cases, some patients will ‘re-seal’ the membranes with no further leakage and normalization of the amniotic fluid level.
If PPROM occurs after an invasive in utero procedure, some patients may be eligible for a treatment called ‘amniopatch’ which can help re-seal the fetal membranes. Amniopatch is performed at specialized centers on a case-by-case basis.
What Are the Outcomes?
Although PPROM is a serious condition, many babies born after PPROM do well, especially with advances in modern neonatal care. Outcomes depend on:
- The gestational age at the time of membrane rupture
- How much residual amniotic fluid is present in the sac
- The gestational age at delivery
- Whether complications, such as infection, occur
The earlier PPROM occurs, the higher the risks—particularly those related to lung development and prematurity. However, with early intervention and close monitoring, it is often possible to extend the pregnancy and improve the baby’s chances for a healthy start.
References:
Chmait RH, Kontopoulos EV, Chon AH, Korst LM, Llanes A, Quintero RA. Amniopatch treatment of iatrogenic preterm premature rupture of membranes (iPPROM) after fetoscopic laser surgery for twin-twin transfusion syndrome. J Matern Fetal Neonatal Med. 2017 Jun;30(11):1349-1354. doi: 10.1080/14767058.2016.1214123. Epub 2016 Aug 10. PMID: 27686840.
Provided by: OHSU Hospital, Portland | OHSU