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  • What is included in the differential diagnosis for suspected premature rupture of membranes (PROM)?

  • How is the diagnosis of ruptured membranes typically established, and what methods of evaluation are available when the diagnosis is equivocal?

  • What are some absolute and relative contraindications to expectant management of preterm premature rupture of membranes (PPROM)?

  • Describe expectant management of PPROM.

  • What are the risks, benefits, and management options of PPROM at a previable gestational age?

CASE 46-1

A 29-y.o. gravida 2, para 1 at 28 weeks gestation presents to L&D reporting leaking fluid. She endorses normal fetal movement and denies uterine contractions or vaginal bleeding. Her first pregnancy was complicated by cervical insufficiency, with a physical exam indicating cerclage placed at 22 weeks gestation and subsequent PPROM at 26 weeks. During this pregnancy, a cerclage was placed when cervical shortening was seen at 18 weeks gestation, and she has been receiving weekly injections of 17-hydroxyprogesterone. She has a history of genital HSV infection and has been on suppression therapy with acyclovir. A speculum exam reveals a small pool of clear fluid, closed cervix, and no HSV lesions. The fetal heart tracing is reactive, without decelerations or contractions on a tocodynamometer.

Preterm premature rupture of membranes (PPROM) is defined as rupture of the fetal membranes <37 complete weeks gestation and before the onset of spontaneous labor. It complicates approximately 3% of all pregnancies in the United States1 and is a significant cause of spontaneous preterm birth.2 The most significant sequelae of PPROM are the complications related to prematurity, and gestational age is strongly correlated with prognosis. Umbilical cord compression or prolapse, placental abruption, nonreassuring fetal heart tracing, chorioamnionitis, and maternal or neonatal sepsis are additional complications associated with PPROM. While PPROM is associated with significant perinatal morbidity and mortality, there are many evidence-based management options available to optimize outcomes.


Premature rupture of membranes (PROM) refers to rupture of the fetal membranes prior to the onset of labor, and it occurs in approximately 8% of pregnancies at term.3 PPROM complicates approximately 3% of pregnancies and is the etiology of 25% to 30% of preterm births.4,5


Several risk factors for PPROM have been identified, and they are similar to the risk factors for spontaneous preterm labor. A history of PPROM in a previous pregnancy is a major risk factor, and the recurrence risk in such instances is 13.5% to 32%.6,7 Additional risk factors include antepartum bleeding, multiple gestation, polyhydramnios, cervical shortening, positive fetal fibronectin (FFN), cerclage, low body mass index (BMI), cigarette smoking, urogenital tract infection, and illicit drug use.8,9 Procedures that result in disruption of the amnion, such as amniocentesis or fetal surgery, have a risk of membrane rupture. However, PPROM often occurs in the absence of any identifiable risk factors.


The fetal membranes are composed of the chorion and the amnion, closely adherent ...

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