Dr. Shari Gelber returns to Healthful Woman to explain PPROM, or preterm premature rupture of membranes, meaning that the water breaks early. PPROM occurs in just 2-3% of pregnancies but can cause complications including premature birth or infection. Dr. Gelber explains causes for PPROM and more.
“PPROM: Preterm Premature Rupture of Membranes” – with Dr. Shari Gelber
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Dr. Fox: Welcome to today’s episode of “Healthful Woman”, a podcast designed to explore topics on women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Dr. Gelber, welcome back to “Healthful Woman.” So nice to have you.
Dr. Gelber: It’s great to be here.
Dr. Fox: We’re talking about PPROM today, which is an acronym that is used so often in OB that we almost never actually say the words anymore, but it does stand for preterm premature rupture of membranes where your water breaks early. And you came in all wet from the rain in honor of the occasion.
Dr. Gelber. Yes.
Dr. Fox: Excellent. You do have some control over the weather, as you said. You only come when it rains.
Dr. Gelber: I only come when it rains. The good thing is I came in rain, the fluid, the PPROM urine.
Dr. Fox: Fetal urine. Excellent. So in terms of a definition just so everyone knows what we’re talking about, it’s such a long acronym because the first P means it’s preterm, so prior to 37 weeks, the second P is premature, which can mean under 37 weeks, but in this instance, it means your water is breaking before labor, and then R-O-M, rupture of membranes, meaning your water breaking. So we have something called PROM, P-R-O-M, which is where your water breaks before labor, and then PPROM, that happens in your preterm. A lot of letters in there.
Dr. Gelber: Lots of Ps.
Dr. Fox: Why do we care? Like why is this a topic in obstetrics?
Dr. Gelber: Well, because it happens to a lot of people. I mean, 2% to 3% of people, so not like a crazy number, but enough where we see it all the time, and it’s associated with some bad pregnancy outcomes, premature birth, infection of the newborn, infection of the mother. It often requires prolonged hospitalizations for patients. So it’s like a life stress.
Dr. Fox: Yeah. I think when people think of preterm birth, right, conceptually people think that, “Okay. I’m pregnant. I’m rolling along and then, boom, I go into labor. I’m contracting, I’m having pain.” And the things that you would expect at the end of pregnancy just happen early. And that is, you know, one of the main ways preterm birth happens. But about a third of the time it’s this, where everything is fine and then, you know, let’s say you’re 32 weeks or whatever, and your water breaks. You’re not contracting, you’re not in labor, but your water’s broken. And then so that’s how we view it, and it’s a big risk for preterm birth. The third way is everything’s fine and we tell you, you need to be born early. Like, you know, it’s the doctor’s fault because there’s something going on with the baby. But PPROM is, it’s a thing. It happens. I mean, people have this and they don’t realize it’s a possibility. And as you said, one of the interesting things about it is sometimes people get parked in the hospital for a very long time with this because they don’t deliver. Their water’s broken, but they don’t go into labor, which is a good thing, but then they’re sort of stuck frequently in the hospital. So if we’re gonna have someone in the hospital for like a month, this is one of the big reasons why that might happen. Like why would someone’s water break at 28 weeks, or 30 weeks, or 32 weeks out of nowhere?
Dr. Gelber: For any individual patient, we never know the reason, but there are lots of possible reasons. So infection, like a significant number of cases of PPROM are associated with infection, and that doesn’t mean that the mom is sick, or that if we do testing of the mother, we’re gonna find anything, or even that we could do testing in early pregnancy and figure out who’s at risk. There are these sort of what they call atypical organisms that are associated with rupture of membranes, things like mycoplasma, ureaplasma, and then the more common things like E. coli and GBS, and if they get into the uterus, they can cause weakening of the membranes. Sometimes people have some contractions that can, I don’t know, cause stress on the membranes that can cause the membranes to rupture because you can have contractions without being in labor. Any kind of bleeding, not usually in the first trimester, but bleeding that happens in the second trimester, whether the woman has the experience of bleeding or we see a hematoma in the uterus, can cause membranes to weaken presumably because cytokines, you know, hormones in the blood that act on the membranes and make them weaker.
Dr. Fox: Right. They sort of inflame them in a sense.
Dr. Gelber: Yes.
Dr. Fox: It’s like inflammation without an infection. The interesting thing about the infection is there’s lots of bacteria in people’s bodies and in the vagina, there’s a lot of bacteria, and that that’s normal. They’re supposed to be there, but for the vast majority of women who are pregnant, that’s where they stay. They don’t make it into the uterus and past the membrane. But for some women, and we don’t understand why, and it’s not in every pregnancy, some women in some pregnancies, those bacteria find their way up there and they get into the uterus and then she could have like you said, a sub-clinical infection. I mean, she doesn’t know she’s infected, there’s no pain, no fever, but the water breaks. And what happens clinically which is interesting, is when women come with PPROM, you know, ruptured membranes in there early, there’s a group of them that are already infected, and that was the cause of it, and those people tend, within a day or two, it’s pretty obvious, they have a fever, they’re in labor, the fetus is like, not happy, and they’re going to deliver. But then there’s another group where they’re clearly not infected because nothing happens, they just sit there, and we wait and wait. But the issue with them is that they can therefore get infected because the barrier is broken, because their water has broken. So it’s almost a matter of time, whether a week or two or whatever, before they become infected.
Dr. Gelber: Absolutely. And a significant number of women will get what we call clinical chorioamnionitis, which is a reason why they have to be delivered. But there’s another chunk of women who they look fine, the babies look fine, but afterwards you send the placenta to the pathology and it’s all full of signs of infection. And, you know, when that happens, I always feel like we dodged a bullet.
Dr. Fox: Right. You mean like the placenta is infected but it didn’t really spread to the rest of the uterus, to the rest of the body or whatever. And it’s a really interesting thing because when, you know, women come in, they almost divide themselves into two groups. There’s the first group, and you don’t know when they first show up, but… And I tell women, you know, in terms of when are you gonna deliver, it’s not a bell-shaped curve, it’s two bell-shaped curves. The first one is the group of women who are gonna deliver within two to four days. And we don’t know who you are right now, but it’s possible that a day or two you’re in labor. And probably if that’s the case, you are already infected, the placenta’s gonna be infected, the membranes are gonna be infected, and you may end up with a fever and whatnot. But if you sort make it past those first two to four days, you probably were not infected when you showed up, and then it could be two, three, four weeks from now when that happens and you go into labor or we deliver you before then potentially. But usually, the placentas do look infected no matter what you do. It’s interesting. It was also part of the reason why we had to know what to do with placental pathologies moving forward. They’re interesting from a scientific standpoint, but clinically, hard to know what to do with it.
Dr. Gelber: Absolutely. Years ago, they took women who had a history of preterm birth or PPROM and they gave them what they called interconception antibiotics with the idea that you could sort of sterilize the uterus and prevent bad outcomes. And I was 100% sure that was gonna work, and that accomplished absolutely nothing.
Dr. Fox: Like many things, we were 100% wrong. Yeah, antibiotics, we’ll talk about antibiotics are part of the management of women who have PPROM, but almost never do they prevent it. I mean, there’s some studies in some very unique situations, it might be helpful to lower the risk, but for the vast majority of people, giving antibiotics at the very beginning of pregnancy, later in pregnancy, if they happen to have certain vaginal infections, does not seem to help because it’s a much more complicated process because you can’t eradicate the bacteria in the body. You’re just sort of reducing some and increasing others and it doesn’t seem to work unbalanced for preventing this or preterm labor or pretty much anything in pregnancy.
Dr. Gelber: Anything.
Dr. Fox: Yeah. Unfortunately. So how do we evaluate women who either clearly have or might have PPROM? What do we do?
Dr. Gelber: So the first step is every woman’s least favorite thing. We do a speculum exam and we look for what’s called pooling, which is just a pool of amniotic fluid in the vagina. And when you have pooling, that’s pretty much because your membranes have ruptured, but sometimes there’s just a little bit of fluid. You don’t know what it is. Maybe it’s ruptured membranes. Maybe it’s just normal vaginal discharge because vaginal discharge, common in pregnancy. So I always ask a patient to do what, in medical terms, we call Valsalva. In the rest of the world, I just tell them to cough. And you see fluid comes out of the cervix and hits you in the face or not, you know, their membranes are almost certainly ruptured. We can also take a Q-tip, take a sample of that fluid. We look at the pH of the fluid. Normally vaginal secretions are acidic, but amniotic fluid should be sort of neutral like your blood. And so we look at the pH of the fluid, we can do what’s called burning, which is you take the fluid, you put it on a slide, and if it’s amniotic fluid, it’s supposed to make this beautiful pattern that looks like a fern.
Dr. Fox: It’s also a lot of women…I mean we know immediately when they tell us just because someone’s story is frequently classic and just someone says, you know, “I’m walking along and suddenly, boom, like there’s water coming out of me, my pants are wet. It’s dripping down my legs. It’s on my socks.” Like, yeah, your water’s broken. We’ll verify it, but it’s pretty clear. But other times it’s really hard to diagnose these stories because sometimes, “There’s a little bit of trickle. I’m not sure.” And we do the exam and it’s equivocal, we’re not so sure. And then, you know, we’re doing an ultrasound and measuring the amniotic fluid volume. And not everyone whose water breaks has low fluid in the uterus because the baby continues to pee, so there’s replenishing of the fluid. And then there’s a test, the commercial name’s called an AmniSure, which is…checks for certain proteins that are really only found in the amniotic fluid. It’s like an antibody test, almost like…the concept is like a pregnancy test, but you do it for amniotic fluid, so the line turns blue and it’s bad news, blue, not good news. And these are the things we do, but ultimately we have to diagnose what’s going on. And if someone is diagnosed that they have PPROM, there’s a lot of factors we need to know. So, for example, the most…I would say the most important one is do we think she’s infected right now? Like is there an infection going on, and why is that so important in terms of what we’re gonna do?
Dr. Gelber: Because unlike with other things, we can’t treat an intrauterine infection. And so if we think the baby is infected, the smartest course of action is to deliver the patient, hand the baby to the pediatricians, and let them give the baby antibiotics, and treat the baby. There’s a very high rate of fetal death if you just have an infected fetus that you don’t treat, that you don’t deliver, or you can end up with significant brain injuries. Fetuses that are infected are more likely to bleed into their brains, which can cause permanent neurologic injury. And so if we think there’s an infection, delivery is really the best thing, both for the fetus and for the mother, because a mother can get really sick from an intrauterine infection.
Dr. Fox: Right. And so if she’s infected, giving antibiotics, let’s say, you know, whether it’s pills or intravenously, it won’t cure the mother, right? It may hold off some of the bacteria that are there, but ultimately the only cure is to get the placenta and membranes and baby, of course, as well, out, and for the baby, it’s not gonna help and there’s not gonna be enough treatment by giving a mother antibiotics. So it doesn’t mean we have to like deliver the baby within five minutes, so it’s not a reason we have to do like a cesarean, but we say, “All right. If you’re infected, it’s time to go into labor. If you’re not in labor, we’re gonna induce your labor and give you antibiotics while you’re in labor to hold off.” But yeah, there’s really no role for what we call expected management for waiting if we think the mother is infected. So one of the parts for evaluation is we feel her belly, is it painful? Is it tender? Does she have a fever? You know, what’s her pulse? What’s the baby’s heart rate, whether the fluid looks infected or purulent or not. And these are things that we need to know. Another big one is how far pregnant is she. And why is that important?
Dr. Gelber: Because what happens with PPROM can depend in part on the gestational age. So people who rupture very early before what we call viability have a decreased likelihood of delivering a healthy baby. So if someone ruptures their membranes at 16 weeks, it’s not impossible that they would be able to deliver a healthy baby, but statistically, the likelihood is very low.
Dr. Fox: Right. Because they have to get eight weeks before really the baby can survive potentially.
Dr. Gelber: Whereas if someone ruptures their membranes at 36 weeks, they’re practically term, and regardless of whether they’re infected, or they’re not affected, there are diminishing benefits of staying pregnant. So most people would say, let’s just have a baby because there’s risk of infection and really minimal benefit to the mother or the baby in continuing the pregnancy. And then between those two extremes, you know, statistically, there are different likelihoods of people staying pregnant, getting to viability, having healthy babies. And so how we counsel patients depends a lot on what their gestational age is.
Dr. Fox: Right. Exactly. I mean, the earlier they are, clearly the worse the prognosis because there’s always a chance they’re gonna go into labor soon or we need to deliver them soon. And the earlier you are, then the baby’s gonna be born early. If it’s before viability, it’s basically a miscarriage and won’t survive. And once you get past the point where the baby could survive, there is an increased risk of babies, again, having issues from prematurity itself or being infected and being premature at the same time, which is like a double problem for the baby. And so, yes, the later it is, the better it is. Mm-hmm.
Dr. Gelber: And it’s counterintuitive, but actually the earlier it is, the more, what we call latency.
Dr. Fox: Right. Yeah. They’ll stay pregnant longer the earlier their water breaks. Yeah. That makes sense. And then we also, we do an ultrasound typically, not just for diagnosis, right? It sometimes helps us make the diagnosis that the water is broken, like if someone has a story and there’s no amniotic fluid in the uterus, we assume they broke their water. But frequently we’re doing it not for a diagnosis, but just to get a sense, like what’s the position of the baby, right? If it’s head up versus head down, meaning if we’re gonna end up delivering, are we gonna do a C-section or an induction of labor. Number two is, you know, the baby look healthy, there’s a movement, how much fluid is left is another thing, what’s the size of the baby. Is it gonna be growth-restricted. And these are important parts of the evaluation as well as frequently, we’ll do something called like a non-stress test to look for the baby’s heart rate and patterns. And why is that an important part of PPROM?
Dr. Gelber: Well, because one of the things is that when a woman is pregnant, the baby is floating around in all of this fluid. It’s like in a pool. And then when that amount of fluid is decreased, you increase the likelihood of the baby leaning on the umbilical cord, not being able to get off the umbilical cord. And so sometimes when people have ruptured membranes, you see patterns of fetal heart tracing that make you think that the baby could be leaning on the cord and that it would really be safer to be delivered because you’re at risk of a cord accident. The other piece of fetal monitoring is looking at the baby’s heart rate. So babies that have a very high heart rate and for, you know, heart rate in a fetus is more than 160, you’re more worried about infection.
Dr. Fox: Right. So I mean, just like with children and adults, when people get fevers or get infected, their heart rate goes up, so fetuses are the same. So if you’re seeing someone with PPROM and it’s pretty clear their water broke and mom doesn’t seem to be infected but the baby’s heart rate is persistently 180 beats per minute, we’re concerned that, yeah, the baby’s infected and the mom’s gonna have a fever since that’s part of our evaluation. And so let’s say someone does have PPROM and let’s just say she’s 28 weeks, so it’s early enough that we’re certainly not gonna plan to deliver right now and it’s late enough that we do expect the baby to be born and survive, what do we do? How do we manage these patients?
Dr. Gelber: So they get admitted to the hospital.
Dr. Fox: And why is that?
Dr. Gelber: Because things can happen that become emergency, so you wanna be somewhere where it can be managed. Like the worst-case scenario with PPROM is that the cord could come out. So you don’t want that happening at home. And people need frequent assessments. We take their temperature more frequently, we’re looking at their heart rate more frequently, we’re looking at the baby more frequently, and there’s just so much involved that you could plausibly do it at home. And sometimes it’s really not uncommon at all for people with PPROM to get emergently delivered. And it doesn’t mean, you know, one minute they’re fine, and the next minute they’re in the OR, but something happens and we’re like, “Let’s get you delivered,” or start a delivery process in the next hour or two.
Dr. Fox: Yeah. I mean, I think there are people who do manage some of these patients as outpatients. Not where we are and not so much locally. I guess you’d have to live real close to the hospital or you’d have to be able to be seen almost daily by somebody, which is hard to do logistically and all these things you have to do at home. And so it’s pretty unusual around these parts that someone’s gonna go home with their water broken, you know, in the third trimester. They’re almost always gonna be sitting in the hospital. It’s not like the hospital keeps them pregnant, right? It’s just that they need to be evaluated and if you want a NICU team readily available, you want your obstetricians readily available, and nurses readily available, blood products, antibiotics, fluids, blood tests, all these things you would need to do quickly.
Dr. Gelber: Right. I mean, I’ve had a couple of patients in my career who we had admitted to our antepartum service and they’re fine. And then suddenly they deliver in the bed, right? Their water’s broken, the baby is small, and suddenly there’s the baby, and it is much better for that baby if peds is down the hall than somewhere far away.
Dr. Fox: Right. The other side of town.
Dr. Gelber: You know, the other thing is that having ruptured membranes is an increased risk for what’s called a placental abruption where a placenta separates and so sometimes patients have very heavy bleeding, and you really don’t want that to happen at home.
Dr. Fox: Right. So we admit them to the hospitals, so that’s number one. And then what else do we do?
Dr. Gelber: You know, ultrasound, fetal monitor, and things like that. Pretty much universally people get antibiotics. Antibiotics have been shown to increase latency, so the time to deliver, and certainly decrease adverse outcomes for the mother and mostly decrease adverse outcomes for the baby.
Dr. Fox: Right. Just by staying pregnant…on average, you stay pregnant a week longer if you get antibiotics versus if you don’t. But we only give them for a week. Usually, it’s about a week because afterwards, again, there’s diminishing returns. You start causing more problems than you fix by giving antibiotics for longer than that. So that’s pretty typical, is someone’s gonna get admitted, they’re gonna get antibiotics for about a week. The regimen we use is two days of intravenous followed by five days of oral. There’s a ton of, you know, protocols out there, but that’s the most common one in the U.S. What else might they get besides antibiotics?
Dr. Gelber: People get steroids which help the baby’s lungs mature. And it means that when they deliver preterm, the baby is less likely to have lung disease, less likely to need supplementary oxygen, less likely to long-term have pulmonary problems.
Dr. Fox: Right. And those are given typically as injections, usually 2 injections, 24 hours apart. Okay. So antibiotics and steroids, and nowadays we’re typically giving magnesium.
Dr. Gelber: Right. So we give magnesium up until 32 weeks. Ideally, like we give it to people when they come in with ruptured membranes because we think there’s a good likelihood they’re gonna deliver within 24 hours, and then usually if they’re still pregnant, or if they’re going to deliver before 32 weeks, we give them more magnesium. And the idea behind magnesium is it actually protects the brain.
Dr. Fox: Right. The baby’s brain.
Dr. Gelber: Yes. Not the mother’s brain.
Dr. Fox: Although if she has preeclampsia, it can protect her brain as well. But that’s a separate story.
Dr. Gelber: Babies that are born prematurely, and especially infected are at increased risk for brain injury. And the idea behind magnesium is that it quiets the brain. Like you have all these neurons in your brain and like when you’re being born, they’re like all screaming at each other and magnesium slows that whole process down.
Dr. Fox: Yeah. And it’s interesting because that was found almost by accident because magnesium used to be given all the time for preterm labor to stop contractions and it was learned to not work that well. It’s given for women who have very severe preeclampsia to prevent seizures, again, same concept of, you know, sort of calming down the brain. And then sort of secondarily said, “You know what? It seems like the babies of the moms who got magnesium versus something else seemed to do better.” And then they designed a very large trial where they took women who were gonna deliver preterm or they thought were gonna deliver preterm and the ones who got magnesium, the babies did better than the ones who didn’t. So that’s become pretty much standard of care. And like you said, since PPROM, we don’t know when they’re gonna deliver, we give it to them when they come in, and then we don’t give forever, you know, about, you know, 6, 12 hours. And then we can give it later if it seems like they’re gonna deliver and it’s given intravenously and it’s unpleasant to receive magnesium.
Dr. Gelber: Yes. Everyone hates being on magnesium. It makes you really, really tired.
Dr. Fox: Right. Someone else said, “Flu in a bag,” I think is what they said. Not everyone has bad side effects, but many people do. And so we try to sort of keep it to a limited time period. The steroids and antibiotics really have almost no side effects because the steroids, of course, is short enough that you don’t get that typical steroid side effect like if you’re on it for a week or two. And then what about giving medications to either stop or prevent contractions, what we call tocolysis or tocolytics? How do you feel about those?
Dr. Gelber: I feel bad about those. But this is like a matter of debate in the medical community. There is no answer. The idea is that you might wanna stop contractions to keep the baby in for longer. Some of those medications have been shown to delay delivery by 48 hours. And that’s the time you need to get that steroid effect. And so I think it’s pretty popular to give people tocolytic agents to try and keep the baby in at least to get steroids on board. The downside is I think if there is some kind of underlying infection and the baby wants out, I don’t know that you want to delay that process.
Dr. Fox: Right. I think, fortunately, that is sort of the academic debate, is it better to try to keep the baby in, or better to try to let the baby come out in that circumstance? But I think, fortunately, it’s usually moot because they don’t work. I tends to be that if it’s bad enough that the babies are coming out, it’s not gonna work. And even if it’s not so bad, they frequently don’t work that well. That’s what a lot of the data shows. So people debate it a lot, “Do I give it? Do I not give it? Do I give it? Do I not give it?” People argue which one, how long, how much. And it probably matters very little most of the time because usually if it’s time for the baby to come out, she’s gonna go into labor and they’re not gonna work.
Dr. Gelber: Right. And all of those medications have side effects and that’s one of the reasons I’m not enthusiastic. They don’t work and they can cause problems.
Dr. Fox: Yeah. It’s…it is one of those plus-minus things. And it could be patient-specific. Some people you’ll try it and see if she responds. And again, it depends how symptomatic, what’s the medication. There’s a lot of variables, but that is something that is an area of debate and controversy. And the way I sort of think about it is when someone’s getting admitted to the hospital for PPROM, there’s sort of three things we’re doing. The first is we assume this baby’s coming out prematurely, right? That’s gonna happen. And so we prepare for a premature birth. And so that’s your magnesium, that’s your steroids, that’s being admitted to the hospital. That’s like, because the baby’s coming out early, we’re doing these things. The second thing is the things we do to try to keep her pregnant longer, which would be the antibiotics and then plus, minus these medications for the contractions. And that’s about it. And the third decision is watching to decide when to deliver, right? We have to make a decision, when are we gonna deliver? And what are the things that would make you decide, “All right. Even though you’re premature, it’s time for the baby to come out?” So we mentioned infection. So that was one of them. If it’s clear the mom or baby has an infection, that’d be one reason. What else?
Dr. Gelber: Bleeding. Like if you think you’re having a placental eruption, you want to deliver the baby before that happens. And not spotting, like lots of people will have a little bit of bleeding, but any kind of heavy bleeding, we monitor the fetus. So any sign that the fetus isn’t doing well. So we expect certain things on fetal monitoring and it shows us that the baby is well oxygenated, things like that. So if you walk in and the fetal monitoring strip is totally flat, which is not a good sign, or the heart rate is too high or too low, I might move toward delivery.
Dr. Fox: Right. And obviously, if she goes into labor we’ll tell her she needs to be delivered although basically, she’s telling us she needs to be delivered if she goes into labor. Let’s say none of those things happen. You’re watching her, she has no fever, the baby looks fine, everything’s okay. Do we wait indefinitely till she goes into labor or is there a point at which you would say, “All right. It’s time to be delivered” just because you’re certain at a gestational age? And when would that be? Because that’s definitely an area of controversy.
Dr. Gelber: Right. So our sort of standard is we deliver people at 34 weeks. But there is debate about whether it would be better to deliver them earlier, like as early as 32 weeks, and also debate about whether we should let them go later, like up until 36 weeks.
Dr. Fox: Why would someone think earlier and why would someone think later? I mean, what are the competing interests in terms of this debate?
Dr. Gelber: From the point of view of the mother, it’s always better to not be pregnant. So the longer you’re pregnant, the more likely you are to have, I mean, in this case, an infection, and people can get bad uterine infections that could cause them to bleed at the time of delivery, that could cause scar tissue in their uterus, that could cause a mother to get septic and need to go into an ICU. And that’s very, very rare, but it happens. From the point of view of the baby, you’re balancing infection with gestational age. The older the baby is, the less likely it is to have issues with its lungs, issues with its brain. But being infected will counteract all of that. So you really want every baby to get as far along as possible without having an infection. And this is the place where in medicine, we need the crystal ball.
Dr. Fox: Right. I mean, yeah, exactly. If you knew that someone was not gonna get infected until a certain point, you would deliver like the day before that point or two days before that point, pretty much no matter when that is, right? But since we don’t know that, you have to decide, and I think 34 weeks was sort of picked because it’s a nice round number in obstetrics. It used to be the gestational age up until we would give steroids. We have frequently given past that, you know, depending on circumstance and it was thought, all right, at 34 weeks with NICU care, the chance that the baby’s, you know, gonna have a severe complication from being born early is really, really low. And if this baby got septic, it’d be really, really bad. And so the thought is, you know what, it’s just time. There have been studies looking at this. They’re not perfect. As you would expect in the studies where they waited a little bit longer, the babies had fewer complications of prematurity slightly, but slightly higher rates of infections, exactly what you would expect, but it didn’t seem to be really life and death in either direction. They both did fine because most babies are gonna do fine no matter what you do after 34 weeks. But that is something that is tweaked. And it’s also different, you know, someone who let’s say who water broke at 30 weeks and is now 34 weeks might be different from someone who’s 34 weeks and her water breaks today. And those two people would both be in the same study. And so it’s hard to always tease that out. But I agree, we usually do around 34 weeks or thereabouts. Some places like in Europe, they do it earlier.
Dr. Gelber: Yeah. Thirty-two weeks I think is very standard.
Dr. Fox: Yeah. The Europeans, there’s…you know, they roll differently than we do. And in terms of how they’re gonna deliver, again, there’s nothing about this specifically that would make us recommend a cesarean unless there was some other reason, correct?
Dr. Gelber: Correct. Although for patients whose cervix is closed and who are infected, they’re less likely to have a normal labor. Like an infected uterus doesn’t contract as well. And so I always think it makes sense to give someone a try, but your cutoff for recommending a cesarean is very, very different in a patient who’s 32 weeks with a fever than it would be for someone who comes in full term.
Dr. Fox: Right. Right. And also things that we see in labor frequently, like the heart rate dropping, because the core is getting compressed, you know, in a term baby, they have a lot more tolerance for those things. They’re bigger, they have, you know, all this…they’re healthier whereas where if you’re a more premature infected baby, our own willingness to watch that for a long time is decreased again because the babies don’t have the same level of reserves, so to speak. That’s a word we use. It doesn’t mean much. But they just don’t have the same capacity to tolerate stresses that you do when you’re bigger, which makes a lot of sense. And then so someone let’s say has PPROM, what about the next pregnancy? Is it gonna happen again? Is it high chance, low chance? What do we do about that?
Dr. Gelber: They’re certainly at increased risk for it to happen again, but for most patients, it won’t happen again. So the risk is probably about 20%, which to doctors is really, really high, but to patients, you know, 80% of the time it won’t happen. Like I wouldn’t be happy if a patient was super stressed that this was going to happen again. Frequently, we recommend things to decrease the likelihood of it happening. So for a long time, progesterone was all the rage. We’ve dialed that back a little bit, but I am still recommending progesterone for people whose membranes ruptured prior to 34 weeks. We do cervical length monitoring because sometimes people’s membranes rupture because their cervix got short or their cervix dilated. And those are both things that sort of make it easier for bacteria to get in and also can probably cause stress on the membranes. And so if someone’s cervix is short, you know, there are things you can do like more progesterone, stitches in the cervix, a cerclage, lots of things that could be tried to decrease the likelihood of membranes rupturing.
Dr. Fox: Right. There’s some data, and this is also a big area of controversy, whether in the next pregnancy there is value in doing any form of vaginal culture and maybe treating, maybe not. This is again…some studies have shown benefit, some studies have not shown benefit, and so people argue about that. It’s not done routinely, like we said, because in sort of low-risk routine pregnant women, it’s definitely been shown not to be helpful, but in certain subsets, like those with a history of PPROM, maybe. We do it in our practice. We do a culture and we’ll treat if there’s an overgrowth of certain types, but it’s not entirely clear if that’s helpful or not. But I agree, it’s important that women should know that most of the time that this happens, it’s sort of sporadic and random and we don’t know why. And those are the women who probably, next pregnancy, nothing’s gonna happen. Whereas if there is this underlying problem, again, which is probably the exception, then that’s something that would recur. And so we sort of watch for those problems. Most of the time nothing happens. And the progesterone injections, fortunately, it seems that the only downside is that they’re annoying. It doesn’t seem to be particularly harmful to any of them, but…and they might be helpful, I agree, as particularly if their delivery was very early. Dr. Gelber, Shari, this covers PPROM. Great topic. Good stuff.
Dr. Gelber: Thanks for having me.
Dr. Fox: Thanks for coming on. Have a good one.
Dr. Gelber: Okay.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at email@example.com. Have a great day.
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