What PPROM is

The RCOG's definition: "Preterm prelabour rupture of membranes (PPROM) is when your waters break before 37 completed weeks of pregnancy but you haven't gone into labour yet."

It is not rare. The RCOG says this "can happen in up to 3 out of every 100 pregnant women", and that PPROM is associated with 3 to 4 out of every 10 preterm births. On cause it says the reason "is not always known, but may be because of infections, placental problems or other causes." Nothing you did caused your membranes to rupture.

The RCOG's own leaflet covers 24 to 37 weeks and notes that if waters break before 24 weeks, that needs an individual discussion with your team, because the considerations are different.

How to tell, and what to do

The RCOG is realistic about the ambiguity: "You may notice a 'gush' of fluid or you may feel damp. The amount of fluid you lose may vary from a trickle to a gush." Leaking urine is common in pregnancy, so people talk themselves out of calling.

What to do, per the RCOG:

wear a pad, not a tampon
note the colour and the amount of fluid
contact your healthcare professional and go to hospital for a check-up straight away

Go even if you are unsure. The check is quick and the alternative — an undetected rupture with infection developing — is the thing everyone is trying to avoid.

What happens at the hospital

The RCOG says the check-up should include a discussion of what happened, a check of your general health including temperature, pulse and blood pressure, and a check of your baby's heartbeat.

Diagnosis is by speculum examination. NICE's preterm guideline sets out the sequence: offer a speculum examination to look for pooling of amniotic fluid, and if pooling is seen, do not perform any diagnostic test — just provide PPROM care. If no pooling is seen, NICE says to perform an insulin-like growth factor binding protein-1 test or a placental alpha-microglobulin-1 test on vaginal fluid. NICE also says not to use nitrazine testing.

If those tests are negative and no fluid is seen, NICE says antibiotics should not be given, and you should be told it is unlikely you have PPROM but to come back if symptoms recur. The RCOG makes the same point from the patient side: "If you continue to leak fluid at home, you should return to the hospital for a further check-up."

What PPROM changes

The RCOG names three things that follow from the membranes no longer being intact.

Infection. "The membranes form a protective barrier around the baby, and after these have broken, there is a risk of infection getting into your uterus." That infection — chorioamnionitis — can trigger early labour or cause sepsis in you or your baby.

Preterm birth. "About 50% of women with PPROM will go into labour within the first week after their waters break," and the RCOG notes that the further along you are, the more likely labour is within that week.

Less common complications. The RCOG lists cord prolapse, which is an emergency though uncommon; pulmonary hypoplasia, where the baby's lungs fail to develop properly because of lack of fluid, which is more likely if waters break before 24 weeks; and placental abruption. It also says plainly that sometimes a baby does not survive, and that this risk is greater the earlier the waters break.

Treatment

The RCOG starts with what is not possible: "It is not possible to replace the fluid or repair the hole in the membranes around your baby. You may carry on leaking fluid for the rest of your pregnancy as amniotic fluid continues to be made."

Antibiotics. NICE recommends oral erythromycin 250 mg four times a day for a maximum of 10 days or until established labour, whichever is sooner. If erythromycin cannot be tolerated or is contraindicated, NICE says to consider an oral penicillin on the same schedule. NICE specifically says not to offer co-amoxiclav. The RCOG explains the dual purpose: reducing infection risk, and helping to delay labour.

Steroids. A course of corticosteroids is offered to help the baby's lungs, on the same gestational thresholds as for preterm labour generally.

Magnesium sulfate. Offered where the baby is at risk of being born very prematurely, to reduce the risk of cerebral palsy.

Intrapartum antibiotics if you go into preterm labour, to reduce the risk of early-onset group B streptococcal infection in the baby.

Monitoring for infection is not a single test. NICE says to use a combination of clinical assessment, C-reactive protein, white blood cell count and cardiotocography, and explicitly says not to use any one of those in isolation to confirm or exclude intrauterine infection.

Going home, and when to come straight back

The RCOG says you will usually be advised to stay in hospital for a few days, and that going home afterwards may be an option if you are well and not considered high risk. Follow-up is then usually one or two check-ups a week, with your temperature, pulse and blood pressure checked, blood tests for infection, and monitoring of the baby's heart rate.

The RCOG says to contact your healthcare professional and return to hospital immediately if you have:

a raised temperature
flu-like symptoms — feeling hot and shivery
vaginal bleeding
leaking fluid that becomes greenish or smelly
contractions or cramping pain
abdominal pain or back pain
any worry that the baby is not moving as normal

The NHS gives the same list for people sent home after P-PROM. None of these is a wait-until- morning symptom.

When the baby is born

The RCOG says that if you and the baby are both well with no signs of infection, you may be advised to wait until 37 weeks, "because carrying on with the pregnancy reduces the risk to your baby that are related to being born preterm." If you are known to carry group B strep, birth may be advised from 34 weeks. The NHS adds that immediate induction or caesarean is offered if you have P-PROM between 34 and 37 weeks and group B strep has been found in your urine or vagina.

If there are signs of infection in either of you, the RCOG says the baby may need to be born straight away.

Vaginal birth is often possible. The RCOG says it depends on when labour starts, the baby's position and your circumstances and choices. Detailed clinical management in the UK follows the RCOG's Green-top Guideline No. 73.

Support, and future pregnancies

The RCOG says PPROM "can be a very stressful time for both you and your family" and that you should be offered emotional support during pregnancy and after the birth. It points people to Little Heartbeats, a UK charity set up specifically for PPROM, alongside Group B Strep Support, Sands, the UK Sepsis Trust and the Birth Trauma Association. Tommy's also has a PPROM section and a midwife line.

For next time: the RCOG says PPROM or a preterm birth increases the chance of preterm birth in future pregnancies, and that you should be under a specialist team who will plan your care from early on. Ask for that referral rather than waiting to be offered it.

Waters Breaking Early (PPROM)