UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Midtrimester preterm premature rupture of membranes

Author
Thomas McElrath, MD, PhD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG

INTRODUCTION

Midtrimester preterm premature rupture of the fetal membranes (PPROM) refers to rupture of membranes before or at the limit of viability. This is an arbitrary definition, which varies slightly among investigators. Because many of these pregnancies deliver remote from term, midtrimester PROM is associated with substantial serious pediatric morbidity and mortality.

The etiology, diagnosis, and complications of midtrimester PPROM, primarily PPROM <23 weeks of gestation, will be reviewed here. The management of PPROM ≥23 weeks of gestation is discussed separately. (See "Preterm premature (prelabor) rupture of membranes".)

INCIDENCE

Midtrimester PPROM complicates 0.4 to 0.7 percent of pregnancies [1,2].

CAUSES AND RISK FACTORS

Midtrimester PPROM may occur spontaneously or during/after an invasive procedure that breaches the fetal membranes.

Spontaneous — The pathogenesis of spontaneous PPROM is not well understood. Multiple etiologies are probably involved and operate along various pathways involving both mechanical and nonmechanical factors. It is likely these pathways lead to a final common pathway that culminates in membrane rupture. (See "Pathogenesis of spontaneous preterm birth".)

                             

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu Nov 17 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Waters TP, Mercer BM. The management of preterm premature rupture of the membranes near the limit of fetal viability. Am J Obstet Gynecol 2009; 201:230.
  2. Manuck TA, Varner MW. Neonatal and early childhood outcomes following early vs later preterm premature rupture of membranes. Am J Obstet Gynecol 2014; 211:308.e1.
  3. McElrath TF, Hecht JL, Dammann O, et al. Pregnancy disorders that lead to delivery before the 28th week of gestation: an epidemiologic approach to classification. Am J Epidemiol 2008; 168:980.
  4. Gold RB, Goyert GL, Schwartz DB, et al. Conservative management of second-trimester post-amniocentesis fluid leakage. Obstet Gynecol 1989; 74:745.
  5. Borgida AF, Mills AA, Feldman DM, et al. Outcome of pregnancies complicated by ruptured membranes after genetic amniocentesis. Am J Obstet Gynecol 2000; 183:937.
  6. Gratacós E, Deprest J. Current experience with fetoscopy and the Eurofoetus registry for fetoscopic procedures. Eur J Obstet Gynecol Reprod Biol 2000; 92:151.
  7. Beck V, Lewi P, Gucciardo L, Devlieger R. Preterm prelabor rupture of membranes and fetal survival after minimally invasive fetal surgery: a systematic review of the literature. Fetal Diagn Ther 2012; 31:1.
  8. Owen J, Hankins G, Iams JD, et al. Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length. Am J Obstet Gynecol 2009; 201:375.e1.
  9. Moretti M, Sibai BM. Maternal and perinatal outcome of expectant management of premature rupture of membranes in the midtrimester. Am J Obstet Gynecol 1988; 159:390.
  10. Taylor J, Garite TJ. Premature rupture of membranes before fetal viability. Obstet Gynecol 1984; 64:615.
  11. Beydoun SN, Yasin SY. Premature rupture of the membranes before 28 weeks: conservative management. Am J Obstet Gynecol 1986; 155:471.
  12. Dowd J, Permezel M. Pregnancy outcome following preterm premature rupture of the membranes at less than 26 weeks' gestation. Aust N Z J Obstet Gynaecol 1992; 32:120.
  13. Bengtson JM, VanMarter LJ, Barss VA, et al. Pregnancy outcome after premature rupture of the membranes at or before 26 weeks' gestation. Obstet Gynecol 1989; 73:921.
  14. Major CA, Kitzmiller JL. Perinatal survival with expectant management of midtrimester rupture of membranes. Am J Obstet Gynecol 1990; 163:838.
  15. Rib DM, Sherer DM, Woods JR Jr. Maternal and neonatal outcome associated with prolonged premature rupture of membranes below 26 weeks' gestation. Am J Perinatol 1993; 10:369.
  16. Hibbard JU, Hibbard MC, Ismail M, Arendt E. Pregnancy outcome after expectant management of premature rupture of the membranes in the second trimester. J Reprod Med 1993; 38:945.
  17. Hadi HA, Hodson CA, Strickland D. Premature rupture of the membranes between 20 and 25 weeks' gestation: role of amniotic fluid volume in perinatal outcome. Am J Obstet Gynecol 1994; 170:1139.
  18. Fortunato SJ, Welt SI, Eggleston MK Jr, Bryant EC. Active expectant management in very early gestations complicated by premature rupture of the fetal membranes. J Reprod Med 1994; 39:13.
  19. Farooqi A, Holmgren PA, Engberg S, Serenius F. Survival and 2-year outcome with expectant management of second-trimester rupture of membranes. Obstet Gynecol 1998; 92:895.
  20. Kurkinen-Räty M, Koivisto M, Jouppila P. Perinatal and neonatal outcome and late pulmonary sequelae in infants born after preterm premature rupture of membranes. Obstet Gynecol 1998; 92:408.
  21. Shumway JB, Al-Malt A, Amon E, et al. Impact of oligohydramnios on maternal and perinatal outcomes of spontaneous premature rupture of the membranes at 18-28 weeks. J Matern Fetal Med 1999; 8:20.
  22. Falk SJ, Campbell LJ, Lee-Parritz A, et al. Expectant management in spontaneous preterm premature rupture of membranes between 14 and 24 weeks' gestation. J Perinatol 2004; 24:611.
  23. Nimrod C, Varela-Gittings F, Machin G, et al. The effect of very prolonged membrane rupture on fetal development. Am J Obstet Gynecol 1984; 148:540.
  24. Arias F, Victoria A, Cho K, Kraus F. Placental histology and clinical characteristics of patients with preterm premature rupture of membranes. Obstet Gynecol 1997; 89:265.
  25. Hillier SL, Martius J, Krohn M, et al. A case-control study of chorioamnionic infection and histologic chorioamnionitis in prematurity. N Engl J Med 1988; 319:972.
  26. Morales WJ. The effect of chorioamnionitis on the developmental outcome of preterm infants at one year. Obstet Gynecol 1987; 70:183.
  27. Kibel M, Asztalos E, Barrett J, et al. Outcomes of Pregnancies Complicated by Preterm Premature Rupture of Membranes Between 20 and 24 Weeks of Gestation. Obstet Gynecol 2016; 128:313.
  28. McElrath TF, Allred EN, Leviton A, Development Epidemiology Network Investigators. Prolonged latency after preterm premature rupture of membranes: an evaluation of histologic condition and intracranial ultrasonic abnormality in the neonate born at <28 weeks of gestation. Am J Obstet Gynecol 2003; 189:794.
  29. Blott M, Greenough A. Neonatal outcome after prolonged rupture of the membranes starting in the second trimester. Arch Dis Child 1988; 63:1146.
  30. Morales WJ, Talley T. Premature rupture of membranes at < 25 weeks: a management dilemma. Am J Obstet Gynecol 1993; 168:503.
  31. Alexander JM, Mercer BM, Miodovnik M, et al. The impact of digital cervical examination on expectantly managed preterm rupture of membranes. Am J Obstet Gynecol 2000; 183:1003.
  32. Mabie WC, Barton JR, Sibai B. Septic shock in pregnancy. Obstet Gynecol 1997; 90:553.
  33. Holmgren PA, Olofsson JI. Preterm premature rupture of membranes and the associated risk for placental abruption. Inverse correlation to gestational length. Acta Obstet Gynecol Scand 1997; 76:743.
  34. Lockwood CJ, Toti P, Arcuri F, et al. Mechanisms of abruption-induced premature rupture of the fetal membranes: thrombin-enhanced interleukin-8 expression in term decidua. Am J Pathol 2005; 167:1443.
  35. Cakmak H, Schatz F, Huang ST, et al. Progestin suppresses thrombin- and interleukin-1beta-induced interleukin-11 production in term decidual cells: implications for preterm delivery. J Clin Endocrinol Metab 2005; 90:5279.
  36. Mackenzie AP, Schatz F, Krikun G, et al. Mechanisms of abruption-induced premature rupture of the fetal membranes: Thrombin enhanced decidual matrix metalloproteinase-3 (stromelysin-1) expression. Am J Obstet Gynecol 2004; 191:1996.
  37. Rosen T, Schatz F, Kuczynski E, et al. Thrombin-enhanced matrix metalloproteinase-1 expression: a mechanism linking placental abruption with premature rupture of the membranes. J Matern Fetal Neonatal Med 2002; 11:11.
  38. Stephenson CD, Lockwood CJ, Ma Y, Guller S. Thrombin-dependent regulation of matrix metalloproteinase (MMP)-9 levels in human fetal membranes. J Matern Fetal Neonatal Med 2005; 18:17.
  39. Lockwood CJ, Kayisli UA, Stocco C, et al. Abruption-induced preterm delivery is associated with thrombin-mediated functional progesterone withdrawal in decidual cells. Am J Pathol 2012; 181:2138.
  40. Schucker JL, Mercer BM. Midtrimester premature rupture of the membranes. Semin Perinatol 1996; 20:389.
  41. Rotschild A, Ling EW, Puterman ML, Farquharson D. Neonatal outcome after prolonged preterm rupture of the membranes. Am J Obstet Gynecol 1990; 162:46.
  42. Kilbride HW, Yeast J, Thibeault DW. Defining limits of survival: lethal pulmonary hypoplasia after midtrimester premature rupture of membranes. Am J Obstet Gynecol 1996; 175:675.
  43. Dewan H, Morris JM. A systematic review of pregnancy outcome following preterm premature rupture of membranes at a previable gestational age. Aust N Z J Obstet Gynaecol 2001; 41:389.
  44. Vergani P, Ghidini A, Locatelli A, et al. Risk factors for pulmonary hypoplasia in second-trimester premature rupture of membranes. Am J Obstet Gynecol 1994; 170:1359.
  45. Wong LF, Holmgren CM, Silver RM, et al. Outcomes of expectantly managed pregnancies with multiple gestations and preterm premature rupture of membranes prior to 26 weeks. Am J Obstet Gynecol 2015; 212:215.e1.
  46. Pristauz G, Bauer M, Maurer-Fellbaum U, et al. Neonatal outcome and two-year follow-up after expectant management of second trimester rupture of membranes. Int J Gynaecol Obstet 2008; 101:264.
  47. Locatelli A, Ghidini A, Paterlini G, et al. Gestational age at preterm premature rupture of membranes: a risk factor for neonatal white matter damage. Am J Obstet Gynecol 2005; 193:947.
  48. Hoekstra JH, de Boer R. Very early prolonged premature rupture of membranes and survival. Eur J Pediatr 1990; 149:585.
  49. Dinsmoor MJ, Bachman R, Haney EI, et al. Outcomes after expectant management of extremely preterm premature rupture of the membranes. Am J Obstet Gynecol 2004; 190:183.
  50. Grisaru-Granovsky S, Eitan R, Kaplan M, Samueloff A. Expectant management of midtrimester premature rupture of membranes: a plea for limits. J Perinatol 2003; 23:235.
  51. Manuck TA, Eller AG, Esplin MS, et al. Outcomes of expectantly managed preterm premature rupture of membranes occurring before 24 weeks of gestation. Obstet Gynecol 2009; 114:29.
  52. Shenker L, Reed KL, Anderson CF, Borjon NA. Significance of oligohydramnios complicating pregnancy. Am J Obstet Gynecol 1991; 164:1597.
  53. McElrath TF, Robinson JN, Ecker JL, et al. Neonatal outcome of infants born at 23 weeks' gestation. Obstet Gynecol 2001; 97:49.
  54. Brumbaugh JE, Colaizy TT, Nuangchamnong N, et al. Neonatal survival after prolonged preterm premature rupture of membranes before 24 weeks of gestation. Obstet Gynecol 2014; 124:992.
  55. Chauleur C, Rochigneux S, Seffert P, et al. Neonatal outcomes and four-year follow-up after spontaneous or iatrogenic preterm prelabor rupture of membranes before 24 weeks. Acta Obstet Gynecol Scand 2009; 88:801.
  56. de Waal K, Kluckow M. Prolonged rupture of membranes and pulmonary hypoplasia in very preterm infants: pathophysiology and guided treatment. J Pediatr 2015; 166:1113.
  57. Lauria MR, Gonik B, Romero R. Pulmonary hypoplasia: pathogenesis, diagnosis, and antenatal prediction. Obstet Gynecol 1995; 86:466.
  58. Glasser SW, Korfhagen TR, Wert SE, Whitsett JA. Transgenic models for study of pulmonary development and disease. Am J Physiol 1994; 267:L489.
  59. van Teeffelen AS, Van Der Heijden J, Oei SG, et al. Accuracy of imaging parameters in the prediction of lethal pulmonary hypoplasia secondary to mid-trimester prelabor rupture of fetal membranes: a systematic review and meta-analysis. Ultrasound Obstet Gynecol 2012; 39:495.
  60. Orthopedic Problems, Chapter 48. In: Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant, 5, Mosby Year Book, St Louis 1996.
  61. Seeds AE, Hellegers AE. Acid-base determinations in human amniotic fluid throughout pregnancy. Am J Obstet Gynecol 1968; 101:257.
  62. Devlieger R, Millar LK, Bryant-Greenwood G, et al. Fetal membrane healing after spontaneous and iatrogenic membrane rupture: a review of current evidence. Am J Obstet Gynecol 2006; 195:1512.
  63. Crowley AE, Grivell RM, Dodd JM. Sealing procedures for preterm prelabour rupture of membranes. Cochrane Database Syst Rev 2016; 7:CD010218.
  64. O'Sullivan CJ, Allen NM, O'Loughlin AJ, et al. Thrombin and PAR1-activating peptide: effects on human uterine contractility in vitro. Am J Obstet Gynecol 2004; 190:1098.
  65. Quintero RA, Morales WJ, Allen M, et al. Treatment of iatrogenic previable premature rupture of membranes with intra-amniotic injection of platelets and cryoprecipitate (amniopatch): preliminary experience. Am J Obstet Gynecol 1999; 181:744.
  66. Contino B, Armellino F, Brokaj L, Patroncini S. Amniopatch, a repairing technique for premature rupture of amniotic membranes in second trimester. Acta Biomed 2004; 75 Suppl 1:27.
  67. Cobo T, Borrell A, Fortuny A, et al. Treatment with amniopatch of premature rupture of membranes after first-trimester chorionic villus sampling. Prenat Diagn 2007; 27:1024.
  68. Richter J, Henry A, Ryan G, et al. Amniopatch procedure after previable iatrogenic rupture of the membranes: a two-center review. Prenat Diagn 2013; 33:391.
  69. American College of Obstetricians and Gynecologists. Practice Bulletin No. 160: Premature Rupture of Membranes. Obstet Gynecol 2016; 127:e39.
  70. Raju TN, Mercer BM, Burchfield DJ, Joseph GF Jr. Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. Am J Obstet Gynecol 2014; 210:406.
  71. Xiao ZH, André P, Lacaze-Masmonteil T, et al. Outcome of premature infants delivered after prolonged premature rupture of membranes before 25 weeks of gestation. Eur J Obstet Gynecol Reprod Biol 2000; 90:67.
  72. Porat S, Amsalem H, Shah PS, Murphy KE. Transabdominal amnioinfusion for preterm premature rupture of membranes: a systematic review and metaanalysis of randomized and observational studies. Am J Obstet Gynecol 2012; 207:393.e1.
  73. Roberts D, Vause S, Martin W, et al. Amnioinfusion in very early preterm prelabor rupture of membranes (AMIPROM): pregnancy, neonatal and maternal outcomes in a randomized controlled pilot study. Ultrasound Obstet Gynecol 2014; 43:490.
  74. Mercer BM, Goldenberg RL, Moawad AH, et al. The preterm prediction study: effect of gestational age and cause of preterm birth on subsequent obstetric outcome. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Am J Obstet Gynecol 1999; 181:1216.
  75. Monson MA, Gibbons KJ, Esplin MS, et al. Pregnancy Outcomes in Women With a History of Previable, Preterm Prelabor Rupture of Membranes. Obstet Gynecol 2016; 128:976.
  76. van der Heyden JL, van Kuijk SM, van der Ham DP, et al. Subsequent Pregnancy after Preterm Prelabor Rupture of Membranes before 27 Weeks' Gestation. AJP Rep 2013; 3:113.