What is PPROM?

Normally, your waters break shortly before or during labour. PPROM, or preterm prelabour rupture of membranes is when your amniotic sac or “waters” break before 37 weeks of pregnancy and labour has not started within 1 hour. This happens in around 3% of pregnancies and is associated with 30-40% of preterm births (babies born before 37 weeks).

What causes PPROM in pregnancy?

The cause of PPROM is not always known. Some conditions which can cause PPROM include infection (inside the womb or chorioamnionitis), placental issues such as placental insufficiency (when the placenta is not able to nourish the baby optimally) or a blood clot behind the placenta or membranes.

There are certain factors which increases your chances of having PPROM:

• You have had PPROM before
• You have had a previous preterm delivery (less than 37 weeks)
• You have had vaginal bleeding in pregnancy
• You have had cervical surgery or you are known to have a short cervix
• You are pregnant with more than one baby
• You have previously experienced placental abruption

You should remember that PPROM is not caused by anything you did or didn’t do in pregnancy. There is nothing you can actively do to prevent PPROM.

How long can you stay pregnant with ruptured membranes?

PPROM can trigger early labour; about 50% of women with PPROM will go into labour within 1 week after their waters break. However, if you and your baby are well with no signs of infection, you may be advised to wait until 37 weeks to give birth. This is because the risks for the baby associated with premature delivery are reduced once you reach 37 weeks. The timing of birth will be discussed with you on an individual basis, taking your preferences into consideration. Although the waters have broken, your baby will continue to produce amniotic fluid so there is still fluid around the baby, although this will likely be less than before.

Once the waters have broken, it is not possible to ‘fix’ the membranes. It is also not possible to stop labour from progressing once it happens. Trials have shown that trying to stop labour in women with PPROM causes higher rates of infection and also poorer outcomes (APGAR scores) at delivery for the baby.

How to know if your waters have broken and what to do

When your waters break, it may be really obvious, for example you may experience a large gush of fluid, which may feel like you’ve wet yourself. Or it may also be a slow trickle of fluid. Whatever the case, when your waters break, it does not cause pain.

If you think that your waters have broken and you are not yet 37 weeks pregnant, you should contact your midwife or labour ward and go to the hospital immediately for a check-up. Amniotic fluid leaking out should be clear and water-like. You must inform your healthcare professional if you notice that your waters are smelly or discoloured, or if you are losing blood; this may be a sign that you and your baby need urgent attention.

Wear a pad, not a tampon. It may be worth keeping your pads as it is possible that your midwife or doctor will ask to see them.

How is PPROM diagnosed?

When you arrive in hospital, a healthcare professional will discuss with you what happened, including details on the fluid loss, how you are feeling and how you have been in both this pregnancy and any previous pregnancies.

You will then be assessed to see whether your waters have broken. It might be obvious that amniotic fluid is leaking out. However, if it is less certain, they will perform a speculum examination (looking at the neck of the womb or “cervix”) to confirm that your waters have broken.

During a speculum examination, a small instrument usually covered with gel for lubrication is inserted into the vagina. This allows a healthcare professional to see whether there is amniotic fluid leaking out of the cervix and/or whether there is pooling of fluid in the vagina. It is not always obvious and a repeat speculum examination may need to be performed. Sometimes, a swab test may also be performed to determine whether your waters have broken (although not every hospital will have this swab test available).

What happens if you have premature rupture of membranes?

As there is a risk of infection and labour starting early, you will usually be advised to stay in hospital for 5-7 days to monitor you and your baby’s wellbeing. During your stay, your temperature will be checked regularly and you will likely have some blood tests to check for infection. It may be possible for you to go home after your hospital stay if it is considered safe for you to do so. You will be advised to take antibiotics to prevent infection.

If you are home with PPROM, it is important that you contact your healthcare professional and return to hospital if you experience any of the following:

• Symptoms and signs of possible infection including feeling hot and shivery, having a raised temperature, any leaking of green or smelly amniotic fluid or vaginal discharge.
• Symptoms of early labour including contractions or cramping pain, abdominal or back pain.
• Other symptoms: vaginal bleeding; feeling that your baby’s movements have changed, slowed down or stopped.

Treatments for PPROM

To reduce the risks to you and your baby, you may be offered treatment. This could include:

• A course of oral antibiotics to reduce the risk of infection. This is usually given for ten days or until labour starts.
• A course of steroid injections to help your baby’s development, especially their lungs.
• Magnesium sulphate drip once you are in labour to protect your baby’s brain and to reduce the risk of developing cerebral palsy (this will be offered if you are between 24 weeks and 29+6 weeks).
• Intravenous antibiotics if you do go into premature labour to reduce the risk of group B strep infection in your baby.

Labour after PPROM

When you go into labour after PPROM, the type of birth you will aim for depends on the position of your baby, your own individual circumstances (including pregnancy history) and your preferences.

Can PPROM harm your baby?

PPROM can have several implications for your pregnancy. This includes:

Premature birth

50% of women with PPROM will go into labour within a week of their waters breaking. Premature babies have increased risk of health problems. If possible, you will be encouraged to visit the neonatal unit and speak to a neonatal doctor as your baby may require extra support and may need to spend time in the unit.

Infection

The membranes act as a protective layer around the baby. Once the membranes break, there is a small chance of infection. Infection can lead to early labour or cause your baby to become unwell. Therefore, you will be closely monitored before, during and after labour to ensure that the signs of infection are recognised and that appropriate treatment is given.

Cord prolapse

This is when the umbilical cord slips down in front of the baby through the neck of the womb or “cervix” into the vagina. This is an emergency situation as there is a risk that pressure from the baby’s body is put on the prolapsed cord or that the cord goes into spasm, compromising blood flow.

Placental abruption

This is when the placenta separates from the inner lining of the womb before birth of the baby. When this occurs, the baby can be deprived of oxygen and nutrients and the mother may experience heavy blood loss (postpartum haemorrhage). It requires urgent delivery of the baby, usually via caesarean section.

Pulmonary hypoplasia

Once the membranes break, the baby’s lungs may fail to develop normally because of the lack of fluid around them. If your waters break very early in pregnancy (before 24 weeks) when your baby’s lungs are developing, pulmonary hypoplasia is more common.

Finding support

PPROM can be very stressful for you and your family. Talk to your partner, family and friends or your midwife if you have any anxieties. Little Heartbeats is a UK non-profit organisation that provides support to women going through PPROM.

Future pregnancies

Having PPROM in this pregnancy or giving birth prematurely does increase your risk of having a preterm delivery in future pregnancies. For this reason, you will be under the care of a specialist team in future pregnancies to plan for pregnancy care and delivery.

Main points

• PPROM is preterm (less than 37 weeks) pre-labour rupture of membranes.
• There is nothing you can do to prevent it, but it is likely caused by infection or problems with the placenta.
• It may not always be obvious, but if you suspect your waters have broken it is important to contact your hospital to be assessed.
• Diagnosis of PPROM may involve a speculum examination to check whether fluid is leaking out of the cervix and pooling the vagina.
• If you have PPROM, you will be advised to stay in the hospital for 5-7 days to monitor for signs of infection or preterm labour. You will be given a course of antibiotics and possibly also a course of steroids for the baby’s lungs. If well, you may be able to go home after this.
• As long as you and your baby are well, your baby will be delivered after 37 weeks. The type of delivery will depend on the position of your baby and your preferences.
• There are some risks associated with PPROM: infection, preterm delivery, cord prolapse, placental abruption and pulmonary hypoplasia.