Preterm Premature Rupture of Membranes

Also known as: PPROM

Rupture of the fetal membranes before 37 weeks gestation and before the onset of labor (PPROM), distinct from term PROM (see next entry).

Carries risks of chorioamnionitis, cord prolapse, placental abruption, and, with prolonged rupture at early gestations, pulmonary hypoplasia and limb contractures.

Sterile speculum examination (avoid digital vaginal examination unless labor is suspected, given infection risk) to visualize pooling of amniotic fluid in the posterior fornix, confirming the diagnosis
If not visually obvious, testing for placental alpha microglobulin-1 (PAMG-1) or insulin-like growth factor binding protein-1 (IGFBP-1) in vaginal fluid supports diagnosis where clinical assessment is equivocal
Ultrasound assesses liquor volume and fetal presentation
FBC and CRP support monitoring for evolving infection; high vaginal and low vaginal swabs for group B streptococcus and other organisms

Admission for close monitoring of maternal temperature, fetal heart rate, and signs of chorioamnionitis
Prophylactic antibiotics: erythromycin 250 mg PO qds for 10 days, reduces the risk of chorioamnionitis and prolongs latency to delivery (co-amoxiclav is specifically avoided given an association with neonatal necrotizing enterocolitis in the ORACLE trial)
Corticosteroids (betamethasone as above) for anticipated preterm delivery
Magnesium sulfate for neuroprotection if delivery under roughly 30 to 32 weeks is anticipated, as per Preterm Labour entry
Chorioamnionitis (fever, uterine tenderness, maternal or fetal tachycardia, offensive liquor) mandates prompt delivery regardless of gestation, alongside IV broad-spectrum antibiotics (commonly a combination such as IV amoxicillin/ampicillin plus gentamicin, or per local sepsis protocol) and supportive management as for sepsis (see that entry)
Expectant management is generally continued until 34 to 37 weeks in the absence of infection or other complication, balancing prematurity risk against infection risk, with the specific gestation threshold for planned delivery guided by local protocol and specialist input
Group B streptococcus prophylaxis in labor as per Preterm Labour entry

Referral: obstetric-led care with neonatal input; urgent escalation for any sign of chorioamnionitis.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Labour Dystocia

Dystocia is the broader clinical term encompassing abnormal, difficult, or prolonged labor from any cause, of which prolonged labor and obstructed labor (see those entries) represent points along a spectrum of increasing severity.

The term is often used clinically to describe difficult progress attributable to the "three Ps": power (uterine contraction inadequacy), passenger (fetal size, presentation, position, or, rarely, anomaly), and passage (bony pelvis or soft tissue).

Systematic assessment of each of the three Ps in turn: palpation and, where available, intrauterine pressure catheter assessment of contraction adequacy; vaginal examination for fetal position, station, and degree of molding/caput; and clinical assessment of pelvic capacity, alongside consideration of estimated fetal size.

Partograph monitoring, as detailed in the Prolonged Labour entry, remains the primary tool for identifying dystocia in real time.

Management follows directly from identifying which of the three Ps is the dominant contributor, as detailed in the Prolonged Labour entry: oxytocin augmentation for a power problem with confirmed inadequate contractions, positional changes and, where appropriate, instrumental delivery or cesarean for a passenger problem (malposition, macrosomia), and cesarean section for a genuine passage problem where vaginal delivery is not achievable
Adequate analgesia, hydration, and emotional support throughout, given the physical and psychological toll of prolonged, difficult labor
Careful reassessment at defined intervals rather than open-ended augmentation, to avoid delaying necessary escalation to cesarean where true disproportion exists
Vigilance for progression to obstructed labor (see that entry) if dystocia is not appropriately managed

Referral: obstetric-led care throughout, with senior review triggered by partograph action line crossing or failure to respond to initial corrective measures.

Preterm Premature Rupture of Membranes

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management