Preterm Premature Rupture of Membranes (PPROM)

Chorioamnionitis is the thing that changes your plan - Diagnosis is fever of at least 39 C, or 38 to 39 C persisting at 30 minutes plus one of maternal or fetal tachycardia, uterine tenderness, or foul-smelling discharge. Don't lean on the white count — it has poor sensitivity and specificity here, and steroids alone produce a transient leukocytosis. Treatment is ampicillin plus gentamicin.

Chorioamnionitis brings hemorrhage with it - Maternal complications include postpartum hemorrhage, operative delivery, pelvic infection, and maternal sepsis, and endometritis follows up to a third of cesareans done for chorioamnionitis. Have oxytocin and a backup uterotonic ready before the placenta is out.

The delivery trigger can fire at any hour - Non-reassuring fetal status and chorioamnionitis are indications for delivery, and vaginal bleeding raises the question of abruption. Place and test the labor epidural early rather than assuming you will have time later.

Don't expect a tocolytic window - Unlike preterm labor with intact membranes, prophylactic tocolysis after PPROM has shown no clear maternal or neonatal benefit and raises chorioamnionitis risk before 34 weeks. There is no reliable 48-hour pause here to set up in.

Latency antibiotics are already on board - Under 34 weeks the regimen is IV ampicillin 2 g every 6 hours plus erythromycin 250 mg every 6 hours for 48 hours, then oral amoxicillin 250 mg every 8 hours with erythromycin base 333 mg every 8 hours to complete 7 days. Amoxicillin-clavulanate is avoided for necrotizing enterocolitis risk. Check what she has had before you dose surgical prophylaxis, and remember GBS coverage is a separate question.

Steroids and magnesium windows - A single course of antenatal corticosteroids is given between 24 0/7 and 34 0/7 weeks when delivery is likely within 7 days; magnesium goes on when delivery is anticipated before 32 0/7 weeks to reduce cerebral palsy. If magnesium is infusing, it prolongs rocuronium, vecuronium, and cisatracurium — titrate to a twitch monitor. Succinylcholine is unaffected.

Speculum, not fingers - The diagnosis is made on sterile speculum exam looking for pooling, ferning, and a vaginal pH of 7.1 to 7.3; digital exams are avoided to limit infection unless delivery is imminent. That same exam is what identifies cord prolapse or fetal prolapse — either one is a crash cesarean.

Oligohydramnios has consequences - Prolonged loss of fluid at early gestational age contributes to pulmonary hypoplasia and cord compression. Expect a fetal heart tracing that deteriorates quickly and a neonate who needs the full team at delivery.

PPROM is rupture of the membranes before labor and before 37 weeks. The membranes fail because local cytokines rise, matrix metalloproteinases outrun their tissue inhibitors, and collagenase and protease activity climbs until the membrane gives way. Intra-amniotic infection is the association that dominates at the earliest gestational ages; the other drivers are prior PPROM, short cervical length, second- or third-trimester bleeding, uterine overdistension, connective tissue disease, low BMI, and smoking.

What separates PPROM from term PROM is the goal. At term you deliver; preterm you buy latency, and about half of these patients still deliver within a week. Prenatal morbidity and mortality with PPROM exceeds 20% and tracks with gestational age at delivery, so the pregnancy is managed inpatient with antibiotics, steroids, and surveillance until infection, abruption, or fetal compromise forces the issue.