Ep 165: How Preterm Premature Rupture of Membranes (PPROM) Contributes to Preterm Birth

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This is the 3rd episode in a series about preterm birth. The first episode, 163, was about risk factors for preterm birth. 164 was about preterm labor which accounts for 40-50% of preterm birth. That episode covered what preterm labor is, how to recognize it, and how it’s treated. In this episode you will learn about preterm premature (or prelabor) rupture of membranes (PPROM).

Approximately one third of preterm births are associated with PPROM. Prelabor rupture of membranes, or PROM, refers to membrane rupture before the onset of uterine contractions - when this occurs before 37 weeks it is called PPROM. In this episode we’ll get into how common PPROM is and how it can be treated. Though the cause is unknown, there are risk factors that you can be aware of and ways to manage it that improve outcomes for your baby.

In this Episode, You’ll Learn About:

  • What PPROM is and how common it is
  • What the risk factors are
  • How it’s diagnosed - it’s not always straightforward
  • What warning signs to look out for
  • What questions your doctor might ask if you are concerned you’re experiencing PPROM
  • How your doctor determines the clinical course
  • What “expectant management” is
  • What the outcomes for PPROM babies can be

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Ep 165: How Preterm Premature Rupture of Membranes (PPROM) Contributes to Preterm Birth

Nicole: In this episode, you are going to learn about preterm premature rupture of membranes. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Hello there. Welcome to another episode of the podcast. This is episode number 100 and 65. Thank you for being here with me today. So this is the third episode in a series about preterm birth. The first episode, episode one sixty three, was about risk factors for preterm birth episode. One sixty four was about preterm labor, which accounts for 40 to 50% of preterm birth. And in that episode, you learn what it is, how to recognize it, how it's treated. So definitely go back and listen to those two episodes, if you haven't. And in this episode, you're gonna be learning about PPROM, which stands for preterm premature rupture of membranes or preterm - rupture of membranes. And that accounts for about 20 to 30% of preterm birth. So preterm labor and PPROM together account for most cases of preterm birth. So in this episode, you're going to learn about risk factors for PPROM.

Nicole: You're going to learn how we diagnose it. It's actually not always straightforward. You learn about the management and then the typical clinical course of what happens if your water breaks and you're preterm. Now, before we begin to the episode, I want to give a big listener shout out to all of you who messaged me last week, when the podcast episode didn't come out on Tuesday as scheduled, we had a little human error on our side, which happens. Nobody's perfect. But the reason I knew about it is because folks reach, folks reached out and said, Hey, where is the episode? So thank you to all of you loyal listeners who spoke up and let me know that you look forward to the episode being released on Tuesdays and that you missed it. It really did warm my heart. All right, so let's hop into the episode about PPROM.

Nicole: So PPROM again stands for preterm premature rupture of membrane that's P P R O M or preterm pre-labor rupture of membranes. Um, side note prom pre-labor rupture of membranes refers to when your membranes break before the onset of contractions and you're full term, when you add that extra P it's PPROM, and I'm gonna say PPROM for the rest of the episode, cuz is because it is too long to say all of that out. So PPROM refers to your water breaking before 37 weeks. And again, it's responsible for up to about a third of cases of preterm birth. Now, thankfully it is not that common. It occurs in about 3% of pregnancies, happens in approximately 0.5% of pregnancies less than 27 weeks. And then in about 1% of pregnancies between 27 to 34 weeks and 1% of pregnancies between 34 to 37 weeks.

Nicole: And unfortunately we do not know what causes it, just like we don't know what causes preterm labor. However, we do know some risk factors and many of the risk factors are similar to those for preterm birth. There are a few risk factors that are particularly strongly associated with PPROM and I'm gonna go through those. Now, the first one is genital tract infection. That is the single most common identifiable risk factor for pre for P prom and by genital tract infection. I mean, um, gonorrhea, chlamydia, um, bacterial vaginosis, yeast infections do not do not, um, count. They don't, uh, increase the risk per PPROM. And this makes sense because when you have an infection, it can be more, um, damaging to the membranes. It's not common, but it can increase the risk. So what I mean by that is that even if you have one of these infections like gonorrhea, chlamydia, bacterial vaginosis, uh, maybe even herpes, it doesn't mean that you are automatically going to have PPROM.

Nicole: It just means that you're at an increased risk. Now the second most identifiable factor that is a strong risk factor for PPROM is you might guess a previous history of PPROM. Okay. There is one study that showed that those who have a history of PPROM that led to preterm birth, they have a threefold higher risk of PPROM in a next pregnancy compared to those who don't have a history of PPROM, it's still low. So if you have a history of PPROM in this particular study, your risk in the next pregnancy was 13.5%. And that was compared to 4% in the general population.

Nicole: And if you have a risk of PPROM, you're also at a higher risk of having a very premature PPROM in the next pregnancy. So before 28 weeks, the absolute number is low. So 1.8%, if you had PPROM before that, in the next pregnancy, there's a 1.8% chance that you'll have PPROM before 28 weeks. So not likely to happen, but it is much higher than those who don't have a history of PPROM. It's only 0.13% in that population. Now the third risk factor that is associated with PPROM is bleeding during your pregnancy. So first trimester vaginal bleeding is associated with a small, but statistically significant increased risk of PPROM. And if you have bleeding in more than one trimester, it can increase the risk by three to seven fold. I don't wanna scare you though. Remember that three to seven fold.

Nicole: You have to look back and think about what the absolute risk is and the absolute risk of having PPROM just because you have vaginal bleeding is very, very small, well, less than 1%, but when you can do like 0.1 to 0.3, that's gonna be three times, but it's still an overall low number. This in, and in fact, bleeding in pregnancy is so common that we don't necessarily like raise red flags in our mind, just because you have bleeding that you're gonna be at a higher risk for PPROM. I'm just telling you what some of the data shows. And then the final strong risk factor for PPROM is smoking. Smoking can increase the risk by two to fourfold compared with non-smokers and why this happens is not clear. Okay. So how do we diagnose PPROM? So the classic presentation of water breaking is sudden gush of fluid soaks through the clothes.

Nicole: And this is whether, whether it's, um, preterm or term, however, both preterm and term that actually may not always be the case. Many folks often describe leaking just small amounts of fluid, either small amounts, continuously, or intermittently leaking fluid, or a little bit here a little bit there. So actually it is not always as straightforward as you might think to diagnose that the water is broken. So typically how it happens if someone comes in to the hospital and for the most part, people tend to be evaluated on labor and delivery, especially if they're preterm and they think their water is broken as opposed to the office, but either way the, the evaluation is pretty similar. So the first thing we're gonna do is just look and see what we see. Like, sometimes it is obvious you're sitting in a pool of fluid. It's obvious that fluid is coming outta your body.

Nicole: In that case, it is straightforward to diagnose, okay. Now, if it is not so straightforward, then we go through a process and that process is as follows. We start with, and I should say, I should back up and say, every place may be a little bit different in how they approach things. This is kind of a, a generalization about how practice is done. Also, uh, a little bit of a generalization or combination of how I've seen things done over my 15 plus years of practice. So this is generally how it's done, and I've been at, you know, five or six different hospitals, but it may be slightly different depending on where you are. Okay? So we're gonna start with a sterile speculum exam where we look inside your vagina to see if we see the fluid, if your amniotic fluid is leaking, you can actually directly see it leaking from the opening of the cervix.

Nicole: And it may pool in the back of the vagina. And if it's not immediately visible, we may ask you to cough, typically cough. And just even that sensation of coughing can cause fluid to leak from the cervical OS. And we can see it there. Now, typically we're gonna test that fluid to confirm what we see that it actually is amniotic fluid, unless it's really, really obvious. Sometimes you look inside and you see it's like pouring out amniotic fluid, but if you don't or if we don't rather, then we typically start with something called nitrazine paper. Nitrazine paper is a little strip. It looks like a little yellow strip of paper. And it's used to test the pH of vaginal fluid. We may get a little Q-tip swab and get some of the contents of the fluid in your vagina. Or if we see fluid out on your skin, we may just touch it to your skin where we see fluid and nitrazine is a pH indicator dye.

Nicole: And it indicates the pH in roughly the 4.5 to 7.5 range. And pH is a measure of how acidic things are. Okay. So amniotic fluid usually has a pH that's higher. It's more alkaline. So it's in the range of seven to 7.3. Whereas the typical vaginal pH is much lower 3.8 to 4.2. So when we swab vaginal secretions, if it's amniotic fluid, it's gonna turn that nitrogen paper pretty blue, like bright blue. If it's not amniotic fluid, when you swab it, it just stays kind of yellow. There is kind of an intermediate zone where it looks, eh, maybe is a little bit turned blue, is it not turned blue? And in that case, we'll do additional test, but it can be helpful if it's obviously blue or if it's obviously not blue. Okay. Also note that the pH of amniotic fluid is different than the pH of vaginal, uh, secretions, which is different than the pH of urine.

Nicole: So it's gonna help us determine between those three things. Now, false negative and false positive nitrazine test can occur in up to about 5% of cases. False negative results can occur if there's just not a lot of fluid there. So maybe we didn't get a good sample and then false positive results can occur. If there are a lot of alkaline fluids and alkaline fluids are blood, blood is an alkaline fluid. Semen is an alkaline fluid. So those are things that can turn it falsely positive. So that's the nitrazine test. Now another test that can be done is something called ferning. And what that is is we take a swab of the fluid and put it on a slide. You're supposed to allow it to dry for about 10 minutes. Uh, and then when you see it, when it's dried amniotic fluid dries in a characteristic pattern, it's called ferning.

Nicole: It actually looks really pretty when you see it under a microscope. Okay? Now you have to be careful about this because cervical mucus can also fern, but it has a different appearance than amniotic fluid ferning and you also have to be careful because, um, some hospitals, a lot of hospitals don't do this test anymore because when you do test in the hospital, you have to make sure that they're standardized and they can be repeated. And everyone who's doing it is trained and all of those things. And that can be a little bit of a challenge. You also have to have the microscope, um, to be, uh, carefully monitored and, and make sure it's standardized and all of those things. So our hospital does not permit physicians to do ferning anymore because they couldn't do quality control for it. And a lot of hospitals are like that.

Nicole: It's often done in the office though, if you go to see if your water is broken in the office. So in addition to the nitrazine, in addition to looking in the vagina, seeing if we see fluid, there are also some commercial tests that can check for specific proteins that we know are in amniotic fluid, and, um, to look to make, to see if your water's broken. One that we use in our hospital is something called amnishore. And it looks for a particular protein in the vaginal fluid that is present once the water is broken. So the way this test works is that it's a sterile swab, little tiny Q-tip that's inserted into the vagina. You leave it there for one minute. Then you place the little swab in a special solvent, and then you dip the amnishore test strip into the vial. It kind of looks like a pregnancy test sorta, and then it's one or two lines, and you have to wait for 10 minutes to make sure that the test has been done.

Nicole: So if it's one line, then it's a negative test result for amniotic fluid. If it's two lines, then it's a positive test result that there is amniotic fluid in the vagina. This test can also sometimes have false positives, but it's not as nearly as common as the nitrazine tests. It's also not affected by semen and it's not affected by trace amounts of blood. So we in our hospital use amnishore. There are other tests with different names. I think there's one called rom plus another one called, uh, prom. So there are other tests tests like that that are available, but those are tests that are often used as well to confirm the diagnosis because we really wanna be sure if we think your water is broken early, because it's gonna have big implications for how we manage your pregnancy. You're gonna hear that coming up.

Nicole: Now, ultrasound can be used, but ultrasound actually is not definitively diag diagnostic of your water breaking. A lot of people when their water breaks, they will have oligohydramnios, which is low amniotic fluid. However, if your fluid was on the higher side of normal, or if you're not leaking a ton of fluid, your fluid may not necessarily be low, even though your water is broken. So ultrasound can be helpful, but even if the fluid is low, it is not definitively diagnostic of your water being broken. So don't expect that you're automatically gonna get an ultrasound just to check, to see if your water's broken, cuz again, it's not 100%. So those are the things that we typically do. Okay. Now, in extremely hard to diagnose cases. Back in the day we used to do something called a tampon test. I have not seen this done in years and years and years, but what that is is that, um, dye is instilled into the uterus like through the abdomen, uh, dye is instilled into the uterus and then a tampon is placed in the vagina, wait 20 minutes.

Nicole: And the tampon is removed. If the tampon has colored staining on it from the dye, then that indicates leakage of amniotic fluid. Again, this has not been used very, um, recently, just because those other tests that I talked about, like the amnishore are very good at determining if your water's broken, but they can be used in very, very difficult cases. Also sometimes we may admit people to the hospital if it's not straightforward, watch and see you for a day or so to kind of evaluate and make sure we confirm the correct diagnosis. Because again, it has implications for how we manage your pregnancy going forward. Now, unfortunately there are no home tests in order to diagnose your water being broken in the US. Apparently there is one in the UK, but there are no home tests like home pregnancy test kind of thing, um, available in the US.

Nicole: Okay. Now really quickly. Some other things that may cause fluid leaking or may cause you to suspect that your water is broken. So things that we'll ask about, um, when you come in and say, Hey, I'm concerned. I think I'm leaking fluid. The biggest one is urinary incontinence is really, really, really, really, really common to leak urine during pregnancy. It is so, so, so, so common. So do not feel alone in that regard. And the difference is with urine leaking, it's typically gonna be typically gonna be like a one time thing. And then you won't continue to see leaking after that. When the water breaks, it generally continues to, to leak. Even if it's not a continuous flow, it's like, oh, I had a little bit. Then I had some more leaking. Then I had some more leaking and you don't have any control over it.

Nicole: It's just coming out of your body without any control. So that's how it's differentiated from urine. The other differentiating factor is that amniotic fluid has no odor, no odor at all. Whereas urine smells like urine. Okay. And then for vaginal fluid or vaginal secretions, a lot of people have increased vaginal secretions during pregnancy. And that can be a normal physiologic, a physiologic change that happens during pregnancy, but your water, the amniotic fluid, your water breaking. We, we call it your water breaking because it literally has the consistency of water. Like it's, it's a thin fluid. Whereas vaginal discharge usually may have, it can look whiteish, it can be yellowish. Um, even if it has a little bit of thickness to it, anything that has any thickness or mucus consistency to it is not your water breaking amniotic fluid is literally like water. Okay. So those are the two most common things that it may be confused with and don't feel bad if you're unsure, if you're ever concerned, just go to be checked out.

Nicole: Because again, it's not always straightforward. And um, you wanna know for sure, so you can get the appropriate treatment. Okay. So speaking of treatment, how do we manage folks who have water that's broken early, who have PPROM? So I'm gonna talk about managing PPROM for a pregnancy that is considered viable, meaning that it, the baby could survive if the baby was born. So that means between 23 and 36 weeks. I'm not gonna talk about PPROM before viability. So before 23 weeks, I'm talking because the management is different. I'm talking about PPROM specifically for a viable pregnancy. So, so that's going to be between 23 weeks and 36 weeks. And what we're looking for in the management is deciding whether or not we can manage pregnancies, expectedly, meaning we wait and let the baby stay inside the uterus because despite all of the advances that we've made in medicine and in NICU care, there is nothing like the environment of the uterus to grow a baby inside of a uterus is almost always going to be the best environment.

Nicole: We, we just have not figured out how to duplicate that outside of the body. So the options are managed expectedly to help the baby grow longer, or do we need to induce labor? And the things that we are looking for or considering are how far along is the pregnancy? Um, definitely if the pregnancy is early, we want to get as much time in utero as possible. The further along you get, then it's, um, the better the outcomes will be if the baby's born. So we have to consider gestational age. We have to consider whether or not there's infection present. If there's infection present, then the safest thing is the baby to be for the baby to be on the outside. The baby ex existing in an infectious environment is not healthy and could cause, um, severe problems for mom and baby. Actually, we have to look at whether or not labor is happening.

Nicole: If labor is happening, we may try and stop it. At least for the benefit of steroids. I'm gonna talk about steroids in a minute, but if labor is continuing, then, um, we may not necessarily, uh, do, we may not be able to do expected management because labor is progressing. We look at the overall wellbeing of the baby. How is the heart rate tracing? Looking on the monitor, does the baby's heart rate tracing look reassuring? And we also want to look at the presentation, is the baby breach or not that's to determine whether or not vaginal or cesarean birth is an option. And then finally, if you're preterm are you in a hospital that has an appropriate level of NICU care, not every hospital has a NICU that can take babies of all gestational ages. Neonatal care tends to be a regionalized thing where you have hospitals, you have one or two hospitals that can take babies of all ages, and then other hospitals can take babies up to a certain age.

Nicole: I happen to work at a hospital has a level three NICU. We can take care of of just about everything. The highest levels is level four, where they can do complex surgery and things like that. So we also have to make sure you're at a hospital that can take care of the baby if need be, because although we can do neonatal transports, like if you go to a hospital and that hospital doesn't have a NICU available and you happen to deliver, we can do ne like the baby can be stabilized and do a Neo neonatal transport, but it's really better for the baby and the care that they receive, if they go transport happens in utero, as opposed to delivering in a hospital that doesn't have that NICU care. Okay. Okay. So we look at all of those things. And again, if there is infection, if baby's not looking well, if there's placenta abruption, any signs of distress, then the right thing is probably going to be delivery.

Nicole: Then if not, then we're gonna do expected management. And we do expected management up to a certain gestational age. That part is a little bit controversial. So I'm gonna split it up a bit. So it's very clear that before 34 weeks, everyone does expected management where we want to keep you pregnant. We do our best to support you staying pregnant until you get to 34 weeks. Now, some hospitals, some doctors will recommend inducing labor at 34 weeks. That's what we did for years and years and years, and years and years up until the last couple of years, some newer data came out and there's, um, now a change in how we manage timing of delivery between 34 and 37 weeks. And I will get into that in just a second. But in general, before 34 weeks, we always do expected management. And what expected management is, is a series of things in order to help support this early baby in the event, the baby is born early.

Nicole: So the first thing we're gonna do is administer, uh, antinatal corticosteroids. So corticosteroids are steroids, and we definitely always give them for pregnancies after 23 weeks, if baby is going to be born early, antinatal corticosteroids is one of the biggest advances in care for premature babies that has led to dramatic improvements of babies' health and wellbeing. If you are ever in a position where your doctor is talking to you about you're having something going on with your pregnancy and recommending steroids, I, 1000% say accept the steroids because studies have shown that steroids can reduce the risk of problems from 30 to 60% and by problems. I mean reduce the risk of neonatal death, reduce respiratory distress syndrome, reduce intraventricular hemorrhage, which is bleeding in the brain, reduce necrotizing into choroiditis, which is a, um, infection of the intestines where part of the intestines die. It can reduce the need for respiratory support like ventilation when you have steroids.

Nicole: So steroids are one of the most like miraculous things about NICU medicine to happen in the last 30 years, actually NICU medicine is one of the, um, areas of medicine has shown such dramatic involvement or, or, or improvement. I should say. I think I mentioned in the preterm birth, one of the prior episodes that like John F Kennedy's baby who was born at 34 weeks was, uh, ended up dying. That would almost be unheard of today, would be extremely, extremely rare for a 34 week baby to die because we've made such advances. So, um, the, and the steroids that we specifically use are two different ones. Cuz there are lots of different types of steroids, but there are only two that are used in for this particular, um, indication, because these are the only two that cross the placenta. One is betamethasone is one and one is dexamethasone.

Nicole: They are IM inju injections, meaning intramuscular. The betamethasone is two shots giving given 24 hours apart. Sometimes we accelerate the second dose to 12 hours. If we think delivery is gonna happen soon, but in general, betamethasone is two shots. Given 24 hours apart, dexamethasone is four shots given 12 hours apart. So they happen over the course of about 48 hours. Now there have been multiple studies and things looking at how frequently do we give it? We used to give multiple doses over the course of weeks, but we found over time that really one dose or one course over that 48 hours works well. And we can repeat it one time if it's been more than 14 days since the first course, but we really don't repeat it more than once. And you only wanna repeat it if you think there's a high risk of delivery happening.

Nicole: So expected management, one of the major components is antinatal corticosteroids. All right, next thing for PPROM is that we do prophylactic antibiotic therapy and what that is prophylactic means prevent. So the goal of that, of the antibiotics is to reduce infection and increase something called the latency period. And the latency period is the period of time between water breaking and labor starting. All right. And multiple studies have shown across close to 7,000 women that prophylactic antibiotics help improve outcomes. It reduces chorioamnionitis, which is an infection of the membranes and the placenta. It reduces babies being born within 48 hours also within seven days. So it gives that time for the steroids to take effect. It reduces neonatal infection. It reduces neonatal oxygen use. It reduces the incidence of abnormal brain ultrasound after the baby is born. So we will recommend that in the setting of PPROM, you get latency antibiotics, and it's just a seven day course.

Nicole: And it's a combination of two antibiotics. One is azithromycin or erythromycin that's one class. And the second one is a penicillin medicine. It starts with IV ampicillin and then transitions to oral amoxicillin for five days. So it's a seven day course of antibiotics and we do that before 34 weeks. All right. So the data shows that this is helpful if your water breaks before 34 weeks, between 34 and 30 after 34 weeks, I should say in general, we don't do it. Okay. So next up is tocolysis. Tocolysis is stopping contractions. Lysis is stopped. Tocos contractions stopping contractions. So in the setting of PPROM, we typically start tocolysis to help delay delivery for at least 48 hours to allow for those steroids to get into the baby system. Because again, we know that there's, those steroids had the biggest, most positive effect. So we want to do tocolysis.

Nicole: And I talked about the tocolytic agents in the episode on preterm labor. And, uh, we, we want to give those in order to get those steroids on board and they can also be used to reduce the risk of delivery. If you're being transported to a facility that has a higher level of care, we don't do tocolysis for more than 48 hours though. Okay. Don't do it for more than 48 hours. We also don't do it, if there's obvious infection, if there's bleeding, if there's a reason or then we know that the baby's gonna deliver, then we don't do tocolysis in those instances. Okay. Final few things that we do for expected management and the beginning, you're going to get a course of magnesium sulfate for neuroprotection that's through the IV, it helps to protect the brain. It helps reduce the risk of cerebral palsy. We like to give it around the 12 hours of delivery that we anticipate delivery is gonna happen.

Nicole: So at some point, if you deliver before 32 weeks, you're gonna get that magnesium sulfate. You may get it a couple times. So if you come in, we give it during that initial course. And then later when you go into labor, if it's before 32 weeks, we'll restart it again. But that magnesium helps to protect the baby's brain. Lots of studies have shown that. And then we're also just gonna monitor the baby while you're in the hospital. And I'm gonna talk about why you need to be in the hospital when your water breaks in just a minute. But while you're in the hospital, we do non-stress tests daily. Non-stress tests is when you get put on the monitor and we check out the baby's heart rate, make sure the baby looks okay. Non-stress tests are not good at predicting infection, but they are good at looking at the baby and see if seeing if the baby's healthy.

Nicole: If the NST looks good, then we know that the baby is in good shape. Okay. We also check for fetal growth periodically every two to three weeks. And we monitor moms for any signs of infection. So elevated temperature, tenderness pressing on the uterus. That can be a sign of chorioamnionitis. We look at mom's heart rate, baby's heart rate. If those are very high, those can be signs of infection. If there are a lot of contractions, those are, those are signs of infection. So those are the things that we look at. And of course we also screen for any infection as well. When you come in, we would look for gonorrhea, chlamydia, syphilis. We look for HIV, bacterial vaginosis, tricomonis um, just to make sure that we treat any of those things that are there. All right. So I talked about hospital management and almost all physicians will recommend that once your water is broken, if you are over 23 weeks, you stay in the hospital until delivery.

Nicole: So it's a potential that you could be in the hospital for quite some time. There have only been two randomized trials that evaluated the safety of outpatient versus inpatient management for women with PPROM, they were small trials, less than a hundred between them. And although they didn't find a big difference in outcomes, except that the home group had lower cost. And that makes sense because they're at home, the trials just weren't big enough to look for any meaningful differences. Also of note in those trials, I believe four or five people delivered outside of the hospital. Actually I take that back. It was three, three women delivered outside of the hospital unexpectedly, which could be problematic for a preterm baby. You really wanna be in the hospital and in a hospital with an appropriate level of care. If you have a preterm baby. Now in another study, a retrospective study where they looked back, the first two studies were randomized trial and a retrospective study of about 200 women with PPROM, who were managed as outpatients.

Nicole: Um, 12 had severe complications of fetal death, placenta abruption, umbilical chord prolapse, delivery outside of the hospital, neonatal death, which is death within the first 28 days of life. So really looking at the available evidence that we have, we really recommend inpatient stay in the hospital management for PPROM. I know that I have seen things turn so quickly for women who have PPROM round on them. Go see them, Hey, how's it doing? How how's it going? Everything's good. And within an hour or two, full blown labor. Okay. So you really wanna be in the hospital, especially if your baby is early. If you have PPROM under rare circumstances where we do home management, you would have to live very close to the hospital. Um, you know, be able to get in quickly, all of those things so expect if your water breaks early, the safer place is going to be in hospital management.

Nicole: Okay. So that is expected management. It's in the hospital, steroids, antibiotics, monitoring. And I'm gonna talk about the timing of delivery in just a second. I wanna quickly touch upon some things that we know don't work. There have been in cases of extremely preterm, like not viable pregnancies, some experimental treatments of something called tissue sealants, where we try to use special glues to stop the fluid from leaking, like try to seal over the amniotic fluid. Um, that has only been seen in a couple of case reports. I could not find a lot on that at all. So we don't know the safety or efficacy of that. And it was always in pregnancies that were very early, like 19, 20 weeks. So that is something that we don't do also something called Amnio infusion. Amnio infusion is something we do in labor is essentially after the water breaks, sometimes it can cause compression of the cord and that can cause changes in the heart rate.

Nicole: We essentially put the water back into or fluid back into the uterus. Usually it's saline, just normal saline and it can help reduce those changes in the heart rate. It's not something we do in the setting of PPROM. There are a couple of small studies that have shown that amnio infusion has helped. And this was amnio infusion through the belly, not through the vagina. In labor, we do it through the vagina. So this is trans abdominal amnio infusion has shown to help in some small studies, very small studies, but it's not something that's done commonly. Okay.

Nicole: So let's talk about timing of delivery. As I said, this has changed and is a little bit, I don't wanna say controversial, but you'll see like differing opinions on timing of delivery. Typically for years and years and years in my career, it was 34 weeks. If your water broke and you were preterm, if you, once you got to 34 weeks, then we induced your labor. Okay. Um, so anybody after 34 weeks, if your la water broke, then we induced your labor. However, there has been, there have been some studies that have come out that have shown that outcomes can be improved if we wait a little bit longer, and that is wait of to 37 weeks. So in one study, which compared expected management with 37 weeks to a planned early birth, there was an increased risk of, um, several outcomes in the planned early birth group.

Nicole: So in the planned early birth group, there was an increased risk of respiratory distress syndrome, increased need for mechanical ventilation, increased need for admission to NICU, increased neonatal death. And you can expect that in a way because the baby is born early. And as I said, we just don't have the same environment on the outside as the uterus in terms of supporting a baby that is early and for the mother planned early birth resulted in a lower rate of chorioamnionitis, it also resulted in a shorter length of hospital stay. That makes sense. If you induce earlier, not gonna be in the hospital as long, it did result though, in a higher Cesarean delivery rate and as a result, a higher frequency of endometritis, which is an infection of the uterus, um, infection of the endometrial lining the lining of the uterus, typically related to C-section.

Nicole: And then in another study, which looks specifically at the group from 34 to 36 weeks. So in that last data that I just told you that was anybody who was less than 37, in another study that looked at 34 to 36 weeks. The two approaches resulted in similar rates of outcomes for, um, babies. So similar rates of infection for baby respiratory distress syndrome, um, stillbirth a little bit higher with immediate delivery, but not statistically significant. And then similar, slightly increased risk of Cesarean birth for mom. Um, it did reduce the risk of bleeding if there was immediate delivery and did reduce the risk of chorioamnionitis infection of the membranes. Okay. So looking at all this data now, between 34 and 37 weeks, we say it's an individual decision and weigh the risk and benefits. Some people have criticized the studies saying that it combines lots of different people, that kind of thing, but in general, it is not unreasonable to wait longer for delivery beyond 34 weeks.

Nicole: What we do in our hospital is we have kind of come to a and I should say, every doctor is still a little bit different, but in general we typically say 35 weeks and we say 35 weeks because 35 weeks is when baby can go home with, with the parents. Under 35 weeks, baby is automatically going to the NICU. That's just the policy at my hospital at a lot of hospitals, but at 35 weeks, baby is eligible to stay with mom in the room as long as baby's big enough and doing well. So typically in our hospital, we say 35 weeks if you've been in the hospital for PPROM.

Nicole: All right. So let's wrap up with speaking of being in the hospital. What is the typical clinical course of someone who has PPROM? Well, first of all, fluid stopping, like the fluid not leaking or cessation of the fluid leaking is rare. You will just continue to leak fluid until the baby is born. The fluid comes from the baby making urine. The baby will continue to make urine. The fluid will continue to come. In rare circumstances, and I mean, rare, the membranes will seal back over. I've probably seen that happen twice that I can think of in my entire, you know, 15 plus years of practice. So the membrane seal on their own is very, very rare. It is associated with the good prognosis if that happens, but it's rare. So typically you're going to continue to leak fluid. Now, how long will you leak fluid?

Nicole: How long will you stay pregnant once your water is broken? All right. Now one study of about 240 folks who had PPROM the median time. So if you line everybody up, the middle time to delivery was about six days. Okay? And in this study, 27% of folks delivered within 48 hours, 56% within seven days, 76% within 14 days and 86% within 21 days. So most people are going to deliver within three weeks and even half will deliver within seven days. Despite all of our interventions, I find that if folks make it to seven days, then after seven days, they tend to go a little bit longer. Um, but don't expect that you're gonna be pregnant for months and months. That's not typical. Most folks are gonna deliver within three weeks at, at the latest or so. The most common thing that happens is chorioamnionitis, which is infection of membranes in the placenta. As you might imagine, that is gonna happen because the bacteria, all of our vaginas have bacteria. That is a normal function of the vagina. The membranes keep that bacteria from infecting things. When the membranes are broken, that pathway is available and eventually chorioamnionitis will, will develop.

Nicole: There is also a higher risk in PPROM of the baby not being in a head down presentation. So if the baby is not head down, when you come to the hospital, very often, they are going to not go into a head down position. So they're gonna stay breach or they're gonna stay transverse. That's how they were when the water broke. And that's because there's gonna be a low amount of fluid and they just don't have enough room. They can't turn. So there's no like space for them in the fluid to turn. So there is a higher risk of PPROM of the baby being in a non head down position.

Nicole: And then finally, as far as how babies do, what is the outcome of babies, uh, who are born as a result of PPROM, it's really related to, to the gestational age at birth and whether or not you got steroids, the neonatologist will go over all of those numbers and risk and all of those things with you when you are admitted to the hospital. Okay. So just to recap, PPROM is preterm, pre-labor rupture of membranes. It is when your water breaks before 37 weeks, it causes about one third of pre-term birth. We diagnose it by a sterile speculum exam, looking to see if we see the fluid, we do the nitrazine test. We do the Amnishore test or a similar test in order to confirm that the fluid is, is broken. For sure. Um, ultrasound is not necessarily terribly helpful, but it can be used.

Nicole: Management involves being in the hospital. Steroids and antibiotics are gonna be the two things that are most important. We're also gonna do that magnesium to protect the baby's brain, as well as tocolysis starting con stopping contractions, definitely at least for 48 hours to get those steroids on board. And then delivery is typically going to be anywhere between 34 to 37 weeks, or before that if infection develops, labor happens, placenta abruption, that type of thing. Now, if your baby is born early, do check out episode 76 of the podcast, where I talk with the neonatologist about questions to ask about a NICU baby. I've had so many people come back to me and say that they appreciated being able to go back to that la that episode when their baby was in the NICU. Okay. So there you have it, do me a solid share the podcast with a friend.

Nicole: If you like it, it helps me to reach more people and just fulfill my passion and purpose of serving as many pregnant folks as possible. So share it with a friend, also subscribe to the podcast in Apple Podcast or wherever you're listening to me right now, and be sure to hop on my email list as drnicolerankins.com/email, I send weekly newsletter with some gems of information. It's a great place to get additional pregnancy and birth, um, stuff, inspiration, all kinds of great stuff and not be on social media. So if you're not like a huge social media person, then my email list is a great place to be. That's drnicolerankins.com/email. I also do special offers to the email list. So do check that out. So that's it for this episode, do come on back next week and remember that you deserve a beautiful pregnancy and birth.