Preterm Premature Rupture of Membranes

Preterm premature rupture of membranes (PPROM) occurs when the protective sac surrounding your baby breaks before 37 weeks of pregnancy and before labor begins. This complication affects about 3% of pregnancies and requires careful medical management to balance the risks of premature birth against the dangers of infection and other complications.

Table of contents

• What is preterm premature rupture of membranes?
• How common is this condition?
• What causes PPROM?
• Who is at risk?
• What are the symptoms?
• What complications can occur?
• How is PPROM diagnosed?
• How is PPROM treated?
• When should you contact your healthcare provider?

What is preterm premature rupture of membranes?

Preterm premature rupture of membranes (PPROM) is a pregnancy complication where the amniotic sac (the fluid-filled membrane that surrounds and protects your baby in the womb) breaks before 37 weeks of pregnancy and before labor contractions begin.^[1] The amniotic sac is sometimes called the “bag of waters,” and when it breaks, you may experience what is commonly known as your “water breaking.”^[1]

The amniotic fluid inside this sac serves several important functions during pregnancy. It protects the fetus from infection, cushions its movements, and helps develop muscles and bones.^[1] When the membranes rupture too early, the amniotic fluid surrounding the fetus starts to leak or gush out through your vagina. This can be concerning because without adequate amniotic fluid, the chances of infection, premature birth, and other complications increase significantly.^[1]

PPROM is different from premature rupture of membranes (PROM), which occurs when the membranes break before labor starts but after 37 weeks of pregnancy. It is also distinct from normal rupture of membranes, which typically happens during labor as a natural part of the birthing process.^[3]

How common is this condition?

PPROM occurs in approximately 3% of all pregnancies.^[4] Despite affecting a relatively small percentage of pregnancies, PPROM is responsible for about one-quarter to one-third of all preterm births, making it a leading cause of babies being born too early.^[2]

Studies show that PPROM is more likely to affect pregnancies with twins or multiple babies.^[1] When the membranes rupture prematurely, most women will deliver their babies within a relatively short time. Research indicates that 50 to 75 percent of patients with PPROM deliver within one week of the membrane rupture.^[4]

What causes PPROM?

In most cases of PPROM, the exact cause is not known.^[5] However, several factors are believed to contribute to this condition. PPROM is often due to an infection in the uterus.^[2] When infection or inflammation occurs in the tissues surrounding the fetus, it may weaken the membranes and cause them to break early.

A decrease in the collagen content of the membranes has been suggested to predispose certain patients to PPROM.^[4] It appears that multiple factors likely work together to cause the membranes to rupture prematurely, rather than a single cause.^[4]

At the end of a normal pregnancy, the membranes rupture due to programmed cell death and activation of certain enzymes, such as collagenase, combined with mechanical forces.^[6] PPROM probably occurs due to the same mechanisms but with premature activation of these pathways. Early PPROM also appears to be linked to underlying disease processes, most likely due to inflammation or infection of the membranes.^[6]

Who is at risk?

Several factors can increase your risk of experiencing PPROM. Understanding these risk factors can help you and your healthcare provider monitor your pregnancy more closely.

Previous pregnancy complications: Having a preterm birth or PPROM in a previous pregnancy significantly increases your risk of experiencing it again.^[2]

Infections: Having an infection in your reproductive system, including sexually transmitted infections such as chlamydia and gonorrhea, or bacterial vaginosis, increases your risk.^[2]

Vaginal bleeding: Bleeding during pregnancy is associated with a higher risk of PPROM.^[2]

Smoking: Cigarette smoking during pregnancy increases your risk of membrane rupture.^[2]

Socioeconomic factors: Women in lower socioeconomic conditions are at increased risk, possibly because they are less likely to receive proper prenatal care.^[2] Additionally, studies show that Black patients are at increased risk of PPROM compared with white patients.^[4]

Uterine distension: Carrying multiple babies (twins, triplets) or having too much amniotic fluid can stretch the uterus and membranes, increasing the risk of rupture.^[4]

Medical procedures: Certain procedures during pregnancy, such as amniocentesis (a test where fluid is removed from the amniotic sac) or cervical cerclage (a stitch placed in the cervix), may increase the risk of PPROM.^[4]

What are the symptoms?

The symptoms of PPROM can vary slightly from one pregnancy to another, but there are key signs to watch for:^[5]

• A sudden gush of fluid from your vagina
• Leaking of fluid from your vagina
• A feeling of wetness in your vagina or underwear

The fluid may leak slowly as a trickle or come out quickly as a gush. You may notice that fluid continues to leak over time.^[1]

Sometimes it can be difficult to tell the difference between amniotic fluid, urine, and normal vaginal discharge. Amniotic fluid is usually clear and odorless, which helps distinguish it from urine.^[8] One helpful method is to place a white paper towel on the fluid to check if it is clear.^[7]

You should contact your pregnancy care provider right away if you experience any of these symptoms. It is better to seek medical attention than to wait and risk complications.^[1]

What complications can occur?

PPROM can lead to serious complications for both you and your baby. Understanding these risks is important as your healthcare team decides on the best treatment approach.

For the mother:

The most serious maternal complication is infection. When the protective barrier of the amniotic sac is broken, bacteria can enter the uterus and cause chorioamnionitis, a serious infection of the placental tissues and amniotic fluid.^[2] This infection occurs in 13 to 60 percent of cases with PPROM and can be very dangerous for both mother and baby.^[4]

Other maternal complications include:^[4]

• Placental abruption: This occurs when the placenta separates from the wall of the uterus before delivery, happening in 4 to 12 percent of PPROM cases
• Heavy bleeding (hemorrhage) that may require blood transfusion or immediate delivery^[7]
• Increased likelihood of needing a cesarean section (C-section) delivery^[5]

For the baby:

The earlier in pregnancy that PPROM occurs, the more serious the potential complications for the baby. The risk of fetal death is 1 to 2 percent.^[4]

Babies born after PPROM may experience:^[4]

• Respiratory distress syndrome: This occurs in about 35 percent of cases when babies are born with underdeveloped lungs that cannot work properly on their own
• Problems with body temperature regulation and difficulty staying warm^[1]
• Cord compression, affecting 32 to 76 percent of cases, which can reduce oxygen and blood flow to the baby
• Intraventricular hemorrhage: Bleeding in the brain that can lead to neurological problems
• Necrotizing enterocolitis: A serious intestinal condition where tissue in the intestine becomes inflamed and dies
• Infection and neonatal sepsis (overwhelming infection in the bloodstream)
• Developmental problems, including cerebral palsy, blindness, and deafness
• Poorly developed bones due to lack of amniotic fluid^[7]

The position of the baby may also change when fluid levels are low, which can complicate delivery.^[1]

How is PPROM diagnosed?

If you think your membranes have ruptured, your healthcare provider will perform several examinations and tests to confirm the diagnosis.

Physical examination:

Your provider will perform a vaginal examination using a speculum (a tool that allows them to look inside your vagina) to check for fluid leaking from your cervix.^[5] They will look for pooling of fluid in the vagina, which is the most accurate sign of membrane rupture.^[6]

It’s important to note that your provider should avoid digital cervical examinations (inserting fingers into the cervix to check dilation) because this is associated with a decreased time period before delivery and potential complications.^[4] A speculum examination is preferred instead.

Fluid testing:

Your provider will collect some of the fluid to test whether it is amniotic fluid, vaginal fluid, or urine. Several tests may be performed:^[5]

• pH (acid-base) balance testing: The pH balance of amniotic fluid is different from vaginal fluid and urine. Your healthcare provider will put the fluid on a test strip (nitrazine paper) to check the balance
• Microscopic examination: When amniotic fluid dries on a slide, it creates a distinctive fern-like pattern when viewed under a microscope

In some cases, blood contamination or cervical mucus may produce false-positive results, so healthcare providers look at multiple signs together.^[6]

Ultrasound examination:

You may have an ultrasound exam to check the amount of amniotic fluid around your baby.^[5] If all fluid has leaked out or levels are very low, this supports the diagnosis of PPROM.^[6]

How is PPROM treated?

Treatment for PPROM depends on several factors, including how many weeks pregnant you are, whether there are signs of infection, and the overall health of you and your baby. Your healthcare provider will carefully weigh the risks of continuing the pregnancy against the risks of premature birth.

Hospital admission and monitoring:

If you are diagnosed with PPROM, you will need to be admitted to the hospital until your baby is born.^[8] Your healthcare team will closely monitor you for:^[5]

• Signs of labor or contractions
• Your baby’s movement, heart rate, and other tests
• Symptoms of infection, which can include fever, pain, or an increase in your baby’s heart rate

Medications:

Several medications may be given to help improve outcomes:

Antibiotics: You will receive antibiotics to prevent or treat infection and to help prolong the pregnancy. Research shows that antibiotics are effective for increasing the time period between membrane rupture and delivery.^[4] A typical course involves 48 hours of intravenous ampicillin and erythromycin, followed by five days of oral amoxicillin and erythromycin.^[14]

Corticosteroids: These medicines help speed up the development of your baby’s lungs. If your baby is born early, their lungs may not be able to work on their own.^[5] Corticosteroids should be given to women with PPROM between 24 and 32 weeks of pregnancy to decrease the risk of intraventricular hemorrhage (brain bleeding), respiratory distress syndrome, and necrotizing enterocolitis (intestinal problems).^[4] However, multiple courses of corticosteroids and their use after 34 weeks of pregnancy are not recommended.^[4]

Tocolytic medicines: These medications may be used for a short time to stop preterm labor, allowing time for maternal transport to an appropriate facility and for corticosteroids and antibiotics to take effect.^[4] However, long-term use of tocolysis is not recommended for patients with PPROM.

Treatment based on gestational age:

Before 34 weeks: If your water breaks before 34 weeks and there are no signs of infection, your provider may try to delay delivery through expectant management with bed rest.^[8] This allows more time for the baby’s lungs and other organs to develop. You will receive steroid medicines to help speed lung maturity and antibiotics to prevent infections. You and your baby will be watched very closely in the hospital.^[8]

Between 34 and 37 weeks: If you are between 34 and 37 weeks when your water breaks, your provider will likely suggest that labor be induced (started with medication).^[8] Delivery is generally recommended when rupture of membranes occurs at or after 34 weeks of pregnancy.^[4] It is considered safer for the baby to be born a few weeks early than for you to risk an infection.

After 37 weeks: If the membranes rupture at or after 37 weeks (which is considered PROM rather than PPROM), labor should be induced immediately, generally with medication such as oxytocin, to reduce the risk of chorioamnionitis.^[14] Most women will go into labor on their own within 24 hours of membrane rupture at this stage.^[8]

Immediate delivery:

Labor should be induced immediately, regardless of gestational age, if you develop signs of intrauterine infection, placental abruption, or if there is evidence that your baby is in distress.^[14]

When should you contact your healthcare provider?

You should call your healthcare provider right away if you experience any signs of PPROM, including a sudden gush of fluid from your vagina, leaking of fluid, or a feeling of wetness in your vagina or underwear.^[5]

Contact your provider immediately if you notice any of these warning signs while being monitored for PPROM:

• Fever or feeling hot and cold
• Increased pain or cramping
• Changes in the smell or color of vaginal discharge
• More than six contractions in one hour
• Decreased baby movement
• Vaginal bleeding

Never ignore symptoms or assume they mean nothing. It is better to seek medical attention and be checked than to wait too long and risk serious complications for you and your baby.