Preterm Prelabour Rupture of Membranes

The following information has been produced with parents who have also experienced this to help you understand your care and choices.

This leaflet has been developed for patients alongside the NHS Northwest regional guideline for Preterm Prelabour Rupture of Membranes (PPROM). The regional guideline is to guide healthcare professionals. This leaflet aims to empower women experiencing PPROM in their pregnancy and provide a guide for them, their partners, and families about the condition. This leaflet was created on behalf of the Northwest Neonatal Operational Delivery Network, Cheshire & Merseyside and Greater Manchester & Eastern Cheshire Local Maternity and Neonatal Systems

What is PPROM before 24 weeks of pregnancy?

PPROM is the medical word for Preterm Prelabour Rupture of Membranes. This is when your waters break early in pregnancy. This leaflet covers when the waters break before 24 weeks of pregnancy. This is a rare situation. It is estimated to happen in less than 1 in 1000 pregnancies. In a lot of cases the cause is unknown.

What are membranes?

A baby in the womb is surrounded by amniotic fluid, called ‘the waters’ , these are contained within the amniotic sac. When the waters break, a hole occurs in the amniotic sac and the fluid leaks through the neck of the womb (cervix) and into the vagina. The pregnant woman may be aware of a ‘pop’ or ‘gush’ followed by passing of fluid out of the vagina.

Once the protective membrane around the baby is broken there is an increased chance of complications. This is why it is important we monitor women with this condition closely. The concerns with PPROM are:

• You may go into labour early. Labour might start before your baby can survive, or when your baby is very preterm.
• You, or the baby, may develop an infection in the womb. This may lead to sepsis.
• The umbilical cord may come through the vagina before the baby. This is called ‘cord prolapse’ and is an emergency for the baby.
• The placenta may come away from the wall of the womb before your baby is born. This is called ‘placental abruption’. This may lead to an emergency for you and your baby and you may need to give birth early because of this.

What can I expect to happen in hospital?

At present, there is uncertainty about the best way to care for women after PPROM under 24 weeks of pregnancy. The North West regional guidelines have been developed to recommend things that the team looking after you can do to help you and your baby.

If you are well in yourself and are showing no signs of infection or labour, you can continue your pregnancy. Due to the risks of complications to both mother and baby you will also be offered a termination of pregnancy for medical reasons (TFMR).

Some women with PPROM feel unwell, or have blood tests or heart rate, temperature or blood pressure showing an infection is developing. If this happens then you will be offered antibiotics. The option of delivering your baby by the quickest and safest way will be discussed to help you get better.

Care - if you continue your pregnancy

You will be looked after by obstetricians (doctors who care for pregnant women) and midwives. You will be offered monitoring in hospital, because we know that the most likely time to go into early labour is the first few days after your waters break.

If you are well within yourself - You will be given the opportunity to talk with the neonatologists (doctors who care for premature babies) if you are 22 weeks or over. You may have to be moved to another hospital with a neonatal intensive care unit. This is the best place for your baby to be looked after if they are born very early. This website explains more about how neonatal care works.

How does neonatal care work? | Bliss

If you become unwell - The team looking after you might explain that delivering your baby by the quickest and safest method may be necessary in order to help you recover. You will be offered support throughout these difficult discussions by your midwife.

Why am I offered monitoring?

You will be offered tests and monitoring to minimise the risks associated with PPROM, these are:

Infection - You will be offered vaginal swabs for vaginal or womb infections. Your team will consider offering a urine test for a water works infection (urinary tract infection, UTI) and offer antibiotics if needed.

Sepsis - This is the immune system’s overreaction to an infection. Sepsis can be very serious and sometimes life-threatening. So that the team can act quickly you will be offered regular temperature, heart rate and blood pressure checks, and blood tests for infection.

Cord Prolapse - This happens when the umbilical cord slips down in front of the baby into the vagina. It is an emergency for the baby. You will be offered an internal examination if there is a concern about cord prolapse.

Placental abruption - This is when some, or all, of the placenta separates from the wall of the womb before the baby is born. You will be offered monitoring and might be offered early birth if this happens.

Tests after PPROM

You will be offered monitoring of your baby’s heartbeat and your observations. These are your pulse rate, breathing rate, temperature and blood pressure. Other tests that are done after a diagnosis of PPROM are explained here:

Blood tests - Full blood count (FBC) - to look at your white blood cell count (this can be raised in infection) CRP (C-reactive protein)- this is a marker of inflammation in the body (can also be raised in infection).

Swabs and cultures - High vaginal swab - to look for the an infection in the vagina Low vaginal and rectal swab - to look for a bacteria called Group B Streptococcus. This bacteria can cause infections after birth in the baby. Some women prefer to take these swabs themselves, some prefer the healthcare team to do them. Urine sample - to look for bacteria in the urine that may cause infection.

Scans - Abdominal ultrasound - this is a scan of your tummy to look at the baby. It can show the way the baby is lying (head down or breech), the baby’s weight, where the placenta is implanted and how much water is around baby. It can also show the blood flow through the umbilical cord.

Reasons to go back into hospital

If you remain well during your stay in hospital, a senior doctor may offer you the opportunity to be discharged. If this happens you will be offered regular hospital visits for the rest of the pregnancy. We recommend that you attend your maternity unit urgently if you experience any of these problems:

• Feeling hot and shivery or a high temperature (over 37.5 degrees C)
• Abdominal (tummy) tenderness, pain or cramping
• Feeling generally unwell, concerned about baby’s movements or sensation of something in vagina (see next page)
• An unusual vaginal discharge or vaginal bleeding

Umbilical cord prolapse

This is a rare complication of pregnancy, but a bit more common if you have PPROM. You would notice the sensation of something in the vagina. If you think this is happening when you are at home then you should call 999 for an ambulance. In the hospital alert healthcare team immediately. Do not try to push the cord back up into the vagina. Place yourself into a face-down, bum in the air, knees to chest position. In the ambulance, it is safer for you to lie down on your side.

Umbilical cord prolapse in late pregnancy | RCOG

Care - if you end your pregnancy

This is called TFMR- termination for medical reasons. You will be looked after by a specialist team in a maternity or gynaecology unit. You should have a private room with access to bereavement and psychological support services.

If you are well in yourself - Most women opt for medications to end the pregnancy. Some hospitals might be able to offer an operation to end the pregnancy. This is less common and might have more risks for your health. We recommend you discuss this with your doctor if it is being considered.

If you become unwell - If you are showing signs of infection, you will be recommended to start antibiotics through a drip. The team looking after you are likely to recommend medications to end the pregnancy as soon as possible.

What are the statistics?

This information is available if you feel that it would be helpful for you. These are chances of outcomes and do not mean that an outcome will definitely happen to you or your baby. You can discuss your situation with your healthcare team.

Information for women and families | Institute of Life Course and Medical Sciences | University of Liverpool

A UK wide study assessed the pregnancy outcomes of all women affected by PPROM between 16 and 23 weeks’ of pregnancy over 18 months from September 2019 to March 2021. This included 364 women. The study was carried out when no guidelines were available for care.

The health outcomes for women and babies included in the study are available by following the link above. This information is available about babies:

• Chance of being born alive
• Chance of leaving hospital alive
• Chance of leaving hospital without severe illness

This information is available about women:

• Chance of developing sepsis
• Chance of becoming very ill

Women’s health - what are the concerns?

Sepsis - Some women with PPROM before 24 weeks’ of pregnancy develop sepsis

Retained placenta - Some women need to go to theatre for a procedure to help the placenta be delivered after birth

Haemorrhage - this is when you bleed a lot. This is more likely if the placenta needs to be surgically removed. Rarely women bleed so heavily they need an operation to remove their womb to stop the bleeding (hysterectomy). This is only done very rarely, to save the woman’s life

Psychological wellbeing and mental health - this is an incredibly stressful time. You should be offered psychological support.

Babies’ health - what are the concerns?

Preterm birth - if a baby is born early, there may be short and long term problems with many organs in the body. Some are severe enough to cause death. This figure has more details about survival rates for babies born from 22 to 26 weeks of pregnancy.

outcome-of-births-infographic-201909111005-colour

For babies born from 27 weeks of pregnancy onwards the chance of survival is higher, and improves the further through pregnancy you are. Your medical team will be able to discuss this further. Please do still seek care if your condition changes even if you are now in more advanced pregnancy, because later pregnancies with PPROM can still have complications.

Pregnancy loss - this can happen if you go into labour before the baby is mature enough to survive. Sometimes the baby passes away in the womb before birth, after birth or in the neonatal unit. It can be hard know which babies will survive or not. Your doctors, supported by the information on page 13, can give you further information about the chance of this.

Disability - this is hard to predict and mostly related to prematurity.

Infection - during labour and after birth. Wherever possible doctors will try to treat with antibiotics, but severe infections can make babies so sick that they can die or have disabilities.

Breathing problems - due to the lower amount of water around the baby, the lungs might not develop as well as they should. This can lead to long lasting breathing problems.

Limb contractures - This is like ‘club foot’ (or hand). Low levels of fluid inside the womb reduce the movement of the baby’s arms and legs and affects their development. Contractures are often treatable with physiotherapy.

Special circumstances

If you are under the care of a specialist preterm birth prevention clinic, you may be using vaginal progesterone or have a cervical cerclage (stitch) in place - After PPROM anything in the vagina can increase the risk of infection tracking upwards into the womb. This can cause women and babies to get very sick. You are recommended to stop vaginal progesterone pessaries and your doctor will discuss taking out your stitch.

If you are pregnant with more than one baby, waters breaking early is more common - Your options and how you will be looked after in pregnancy are similar to women carrying one baby. Mothers with multiple pregnancies may be more likely to get sepsis.

If my baby is going to be born preterm (before 37 weeks), how will they be looked after?

See Preterm birth page for more information.

Bed rest is not normally recommended because it hasn’t been shown to improve outcomes for women or babies, but some women do choose to reduce their activities. If your activities are reduced a lot consider with your healthcare team whether you need medications to reduce the chance of blood clots.

Timing of Birth

Who do I contact if I am worried when I am at home?

If you have any concerns when you are at home, contact Maternity Triage on 01270 273116.

What can I do to help?

Very little research has been done on practical steps that women can do to improve the outlook after PPROM.

Steps for general pregnancy good health are still likely to be of benefit after early PPROM:

• Avoid going to sleep on your back. Try to go to sleep on your side, either left or right
• Eat a healthy diet. Follow the advice of ‘Start for Life’ , healthy eating in pregnancy: www.nhs.uk/start-for-life/pregnancy/healthy-eating-in-pregnancy
• Reduce, and ideally stop, smoking or vaping Limit your caffeine intake to less than 200mg a day. This is about 2 cups of instant coffee.

Steps that might help reduce the chance of infection after PPROM:

• Feminine hygiene - wear clean cotton underwear, change pads every 4 hours (whilst awake), avoid perfumed intimate soap
• Do not place anything into the vagina, for example tampons
• We recommend no sex
• No swimming
• Opinions are mixed about whether women should have baths after PPROM. There is a concern that the bath water could enter the vagina and the womb, but this hasn’t been shown in research studies. Showers are considered safe.

Having a pregnancy complicated by PPROM before 24 weeks’ of pregnancy is a difficult time. Everyone has other pressures in life too, before PPROM. If there are other areas of your life where you can reduce your commitments, so that you can focus on yourself, this may help.

How can I contact other women who have experienced PPROM?

The patient support and advocacy group, Little Heartbeats, support women and their families who experience PPROM. They have 24/7 help available and have a global reach helping women all over the world who experience PPROM.

They have a closed Facebook group and website with real life stories.

They also provide care packs to help you through PPROM, regardless of choices and outcomes www.little-heartbeats.org.uk