"I think my water broke." I told my husband one chilly morning early in my third trimester.
I knew the signs because I had grown up hearing stories about how my mother's water broke a few weeks early when she had me. Baby Me made a dramatic entry in to the world, and everyone was fine. But here I was, approaching the tail end of a completely uneventful pregnancy with a baby that was going to show up early two months early--too early. I called my OB and explained the situation. He told me to come to the hospital, adding, "Sounds like we are going to have a baby today!"
Let me give away the ending here: Billable Baby turned out okay. I was, perhaps, a bit traumatized (wait until you see the hospital bill!). On the bright side, I managed to walk away with a ton of knowledge about early water-breaking, known as Preterm Premature Rupture of Membranes (PPROM). And since I spent so much time reading about PPROM, I wanted to gather in one place the useful resources I found and share them with you.
Disclaimer: I'm not a doctor, and this is not medical advice. Please consult your doctor if you have any questions about PPROM.
What is PPROM
PPROM is a pregnancy complication. In this condition, the sac (amniotic membrane) surrounding the baby breaks (ruptures) before week 37 of pregnancy. Once the sac breaks, the mother is at an increased risk for infection and has a higher chance of having the baby early. In most cases of PPROM, the cause is not known. (Source)
Statistics about PPROM in the U.S.
- For context, preterm birth (before 37 weeks) occurs in approximately 10% of all births in the U.S.
- For term babies, prelabor rupture of membranes (PROM) occurs in approximately 8% of pregnancies.
- In a large randomized trial, one half of patients with term PROM delivered within 33 hours of membrane rupture, and 95% gave birth within 94–107 hours.
- PPROM occurs in approximately 2–3% of pregnancies.
- One half of patients with PPROM delivered within 1 week of membrane rupture.
Guidance for Handling PPROM
The American College of Obstetricians and Gynecologists (ACOG) issues clinical management guidelines through "practice bulletins." The chart below, from ACOG Bulletin 217 on Prelabor Rupture of Membranes, describes the management of PPROM based on gestational age.
To put this into plain English: For ruptures that occur before week 34 of the pregnancy, the guidance recommends keeping the baby inside as long as there are no signs of infection or other issues.
For ruptures that occur on or after week 34, the current guidance allows the patient to decide whether to deliver right away or wait (until 37 weeks). This is a recent development. Before ACOG Bulletin 217 was published in March 2020, the previous guidance recommended delivering right away for patients who had PPROM on or after 34 weeks.
PPROMT Clinical Trial
As the ACOG Bulletin 217 noted, a recent large randomized trial of 1,839 women suggests benefits to "expectant management" at 34 through 37 weeks of gestation (monitoring the patient as opposed to delivering right away).
Either expectant management or immediate delivery in patients with PROM between 34 0/7 weeks of gestation and 36 6/7 weeks of gestation is a reasonable option, although the balance between benefit and risk, from both maternal and neonatal perspectives, should be carefully considered, and patients should be counseled clearly. Care should be individualized through shared decision making, and expectant management should not extend beyond 37 0/7 weeks of gestation.ACOG Bulletin 217 (emphasis added).
The clinical trial in question was known as PPROMT, or "Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term." The study took place at 65 healthcare centers in 11 countries (Australia, New Zealand, Argentina, South Africa, Brazil, UK, Norway, Egypt, Uruguay, Poland, and Romania) between May 28, 2004, and June 30, 2013. As you can see, U.S. patient populations were not part of the study. The PPROMT study results are published in The Lancet.
The following chart summarizes the infant and maternal outcomes in the PPROMT:
The takeaway: "[F]or women with ruptured membranes between 34 weeks and 36 weeks and 6 days of gestation who were carrying a single fetus and who had no contraindication for expectant management, immediate delivery increased neonatal complications with no clinically significant decrease in neonatal sepsis. Therefore, in contrast to recent guideline recommendations, we advocate that expectant management is preferred to immediate delivery in women with ruptured membranes close to term."
Older clinical trials: The PPROMT study team identified "nine studies that compared immediate planned birth with expectant management in women with ruptured membranes between 34 and 37 weeks." Seven of the nine studies were published 20-30 years ago, when medical practices were different. The PPROMT team noted that the two more recent studies have "limited applicability" because they were not "adequately powered," meaning it is harder to draw conclusions about the broader population based on the sample population in the study (at least that's my interpretation--med friends, please correct me if I'm wrong). By contrast, PPROMT is the largest study to date that sheds light on managing PPROM between 34 and 37 weeks. This means the PPROMT infant and maternal outcomes (in table 3 above) are useful reference points for patients who need to make an induction decision between 34 and 37 weeks.
How We Approached PPROM
I had PPROM at 32 weeks. As we approach week 34, my OBs and maternal fetal medicine doctors encouraged me to create a plan. We scheduled induction at 35 weeks 5 days, but labor spontaneously began before that. Billable Baby ended up spending half a week in the NICU.
My husband and I had different risk tolerances for the induction decision. He wanted to induce at 34 weeks because he was worried about me getting an infection and having severely negative health outcomes (for both myself and the baby). I wanted to go past 34 weeks to give the baby more time to develop her lungs. I was focused on avoiding negative health implications and complications associated with preterm delivery. At the same time, I was not willing to wait until 37 weeks because I thought the risk of infection for a 3-week wait was too high. We ended up "splitting the baby" (terrible expression, I know) and went past week 34, with the goal of inducing during week 35. The exact day for the induction came down to my OB's call schedule. Of course, our strong-willed daughter had ideas of her own!
My experience with PPROM really hit home for me how hard it is to make decisions as a parent and how much is out of your control. Looking back, the most important thing for us was reaching a decision that we were both comfortable with, even assuming the worst case scenario occurred. I was happy with the decision-making framework we used and the path we selected.
For those of you who faced difficult decisions during your pregnancy or childbirth, I would love to hear from you!