PPROM: “Expectant management” may still be possible, even if your water breaks before baby is viable

In a separate article, I covered treatment options for pregnant women whose waters break pre-term, between 24 weeks and 37 weeks gestation. But what about the <0.5% of pregnant women whose water breaks even earlier, before the widely accepted lower limit of “viability” (when the baby can survive outside the womb)? [1] For example, what can you do if your water breaks when you’re just 20 weeks pregnant? 

I wrote previously that expectant management (rather than labor induction/early birth) is generally a reasonable option for both mom and baby when preterm premature rupture of membranes (PPROM) occurs between 24 and 37 weeks. It also may be worth a shot for women whose bag of water breaks much sooner. 

Some may wonder whether pursuing expectant management is even reasonable given the known complications that can follow for mothers and the potentially dire outcomes for babies. However, thanks to medical advances like the administration of antibiotics to prevent infection and steroids to help babies’ lungs mature, plus the capability for mechanical ventilation and other advanced life support measures even for very tiny babies, expectant management is always worth at least discussing with one’s medical team. 

Survival of babies younger than 24 weeks gestation is increasingly common

Babies born at 22 or 23 weeks have increasingly higher survival rates when given the necessary medical care [2]. Corticosteroids can be given to speed up lung development in unborn babies, and a synthetic form of lung surfactant can help prevent the airways from collapsing upon exhalation [3]. (Surfactant is a liquid substance that naturally coats the inside of the lungs but is often absent in extremely premature babies.)  

Encouragingly, a few research studies conducted in the early 2000s in Australia, Germany, and Belgium found that up to 70% of babies may be expected to survive when membrane rupture happens before viability and mothers receive expectant management with expert medical care [4][5][6].   

Iowa research study looks at survival rates for babies with PPROM at 20 weeks or sooner

More recently, in 2014, one group of researchers in Iowa reported incredible survival rates of 90% among infants when membranes ruptured before 24 weeks and babies were carried for at least one additional week [7]. Incredibly, they also found that 15 of 18 babies born when membrane rupture occurred before 20 weeks survived to discharge, including one baby whose mother had membrane rupture at 13 weeks. The researchers wrote:  

“These data suggest that neonatal survival is possible after second-trimester preterm PROM in a center offering expectant maternal management, routine administration of antenatal corticosteroids, and a neonatal team prepared to aggressively manage the ensuing neonatal lung disease.”

The study in Iowa was small, including only 58 pregnant women who were expectantly managed, and all patients were treated at the same institution, making it difficult to discern whether such high survival rates are common at other institutions. Additionally, the endpoint of the study was whether the babies survived until hospital discharge, without examining what serious, perhaps long-term or permanent, medical conditions these babies experienced. Still, the study illustrates how far the field of obstetrics has come, and that all hope is not lost should one experience pre-viability PPROM, especially if mothers receive expert care and monitoring.  

What short- and long-term complications commonly arise in very premature babies? 

The Iowa study also provided insight into what parents might expect of their babies in the short-term. All babies had some degree of initial lung problems, such as respiratory distress syndrome, and most babies required time on a ventilator and a lengthy hospital stay. More than half of the babies stayed in the hospital for at least 3 months.

After discharge, babies commonly required supplemental oxygen and medications for their lungs. More severe complications were seen, too, but less frequently: intraventricular hemorrhage was seen in 15% of babies, and less than 10% had periventricular leukomalacia, which can lead to long-term disability. (However, it should be noted that even babies with disabilities may go on to lead full lives, often contributing to the happiness of their families.)  

For parents worried about the long-term effects of premature birth, consider the following: A large study of more than 2.5 million babies born in Sweden between 1973 and 1997 found that 22% of those born between 22 and 27 weeks and 55% of those born before 37 weeks survived to adulthood with no major comorbidities [8]. For comparison, only 63% of babies born full-term (39 to 41 weeks) had no major comorbidities as adults. 

Complications for moms from PPROM

Complications among mothers with PPROM before 24 weeks are similar to those seen with PPROM after 24 weeks, including chorioamnionitis, endometritis, placental abruption, and retained placenta (placenta not delivered within 30 minutes of birth), but they occur more frequently. However, the evidence is mixed as to whether these complications can be avoided by immediately inducing labor.  

While one study found that women who had expectant management had nearly twice the risk of having poor overall health as women who ended their pregnancies by immediately inducing labor or having a dilation and evacuation (D&E) procedure, the researchers in Iowa found no such difference when they compared women expectantly managed to those immediately induced [9].   

Another study found that one in seven women whose membranes rupture before viability have significant complications, including sepsis, blood transfusion, hemorrhage, and sudden kidney failure. However, this was not linked to whether babies were born immediately or carried longer [10]. Instead, the women most at risk for these complications following membrane rupture before viability were those over the age of 35, and those carrying twins.  

A brief note about PPROM due to amniocentesis

Although the cause of membrane rupture is often unknown, when amniocentesis during the second trimester is the cause (as is the case for approximately 1% of pregnancies), membranes usually reseal on their own and good outcomes are expected for mothers and babies.  

Explaining the options offered to women experiencing serious complications from pre-viability PPROM

While expectant management is generally a reasonable option to pursue for moms with very early PPROM, maternal complications like infection do indeed arise, and may be serious. In circumstances where expectant management is contraindicated or becomes untenable, women may be offered the options of a dilation and curettage (D&C) abortion procedure, a D&E abortion procedure, an induction abortion, labor induction, or (for truly emergent situations, where minutes count) Cesarean section to end their pregnancies. Of these four options, labor induction and C-section do not cause the direct death of the fetus, and therefore do not constitute a direct abortion.

D&C and D&E procedures

In both D&C and D&E surgical procedures, fetal demise via lethal injection may or may not be performed prior to surgery. Whether fetal demise is induced prior to the procedure or not, both D&C and D&E procedures directly end the life of the fetus (sometimes via dismemberment and/or crushing of the skull), and are therefore considered induced abortions.

Labor induction versus induction abortion

The difference between labor induction and induction abortion has to do with what medications are used and with intent. Induction abortion involves off-label (not FDA-approved) administration of the drugs Mifepristone and Misoprostol. Mifepristone blocks the pregnancy hormone progesterone’s action in the uterus, and Misoprostol causes uterine contractions. Even before Mifepristone and Misoprostol are given, a lethal injection may also be administered into the fetal heart to ensure death prior to delivery.

Labor induction, in contrast, never involves a lethal injection, and is accomplished typically with Misoprostol or intravenous synthetic oxytocin (many women who have been induced will be familiar with this medication as Pitocin) to stimulate labor. Under these circumstances, a fetus will still be delivered whole and intact, and perhaps alive (albeit very briefly, depending on gestational age).

When PPROM leads to a life-threatening complication for mom, induction of labor before viability—when it will likely result in the baby’s death—is not an elective abortion (also known as an induced abortion). Although a baby born too early would not be expected to survive long after birth (or may be stillborn) induction of labor is a legitimate medical procedure used to save a woman’s life when a life-threatening complication arises, with the desire that the baby will survive too, but with the foreseen and unavoidable outcome that the baby will die soon after birth [11].* 

Induced abortion isn’t necessary even when saving mom’s life requires that the pregnancy end

Survival is possible at increasingly younger gestational ages thanks to medical advances, and this is good news for moms who experience pre-viability PPROM—and for their babies. This is not to say that babies born very prematurely will not encounter serious short-term or long-term, even permanent, problems.

Sometimes, a woman whose pregnancy is being expectantly managed due to PPROM or another medical reason will experience a complication that necessitates early delivery of her baby. When this happens, labor induction to save her life may tragically lead to the death of her child due to being too young to survive outside the womb. But it is important to underscore that labor induction, in these tragic but sometimes unavoidable cases, is not the same as abortion. 

*Editor’s note: This reasoning is consistent with the Principle of Double Effect (PDE), a method of discerning the moral permissibility of a proposed action. We covered PDE in depth in our discussion of ectopic pregnancy treatments, which can be found here.

References: 

[1] Waters, T and Mercer, B. “The management of preterm premature rupture of the membranes near the limit of fetal viability.” AJOG, vol. 201, issue 3 (2009): pp. 230-40. :https://doi.org/10.1016/j.ajog.2009.06.049

[2] Mehler K, Oberthuer A, Keller T, et al. “Survival Among Infants Born at 22 or 23 Weeks’ Gestation Following Active Prenatal and Postnatal Care.” JAMA Pediatr. Vol. 170, no. 7 (2016): pp. 671–77. doi:10.1001/jamapediatrics.2016.0207

[3] Soll R. “Synthetic surfactant for respiratory distress syndrome in preterm infants.” Cochrane Database of Systematic Reviews (1998), Issue 3. DOI: 10.1002/14651858.CD001149. 

[4] Everest, N J et al. “Outcomes following prolonged preterm premature rupture of the membranes.” Archives of disease in childhood. Fetal and neonatal edition. Vol. 93,no. 3 (2008): pp. F207-11. doi:10.1136/adc.2007.118711

[5] Lindner, Wolfgang et al. “Acute respiratory failure and short-term outcome after premature rupture of the membranes and oligohydramnios before 20 weeks of gestation.” The Journal of pediatrics. Vol. 140, no. 2 (2002): pp. 177-82. doi:10.1067/mpd.2002.121697

[6] Williams, O et al. “Contemporary neonatal outcome following rupture of membranes prior to 25 weeks with prolonged oligohydramnios.” Early human development. Vol. 85,no. 5 (2009): pp. 273-7. doi:10.1016/j.earlhumdev.2008.11.003

[7] Brumbaugh, Jane E et al. “Neonatal survival after prolonged preterm premature rupture of membranes before 24 weeks of gestation.” Obstetrics and gynecology. Vol. 124, no. 5 (2014): pp. 992-98. doi:10.1097/AOG.0000000000000511

[8] Crump C, Winkleby MA, Sundquist J, Sundquist K. “Prevalence of Survival Without Major Comorbidities Among Adults Born Prematurely.” JAMA.Vol. 322, no.16 (2019): pp. 1580–88. doi:10.1001/jama.2019.15040

[9] Sklar, Ariel et al. “Maternal morbidity after preterm premature rupture of membranes at <24 weeks’ gestation.” American journal of obstetrics and gynecology. Vol. 226, no. 4 (2022): pp. 558.e1-558.e11. doi:10.1016/j.ajog.2021.10.036

[10] Dotters-Katz, Sarah K et al. “Maternal Morbidity After Previable Prelabor Rupture of Membranes.” Obstetrics and gynecology. Vol. 129,no. 1 (2017): pp. 101-06. doi:10.1097/AOG.0000000000001803

[11] Seeds JW. “Direct Abortion or Legitimate Medical Procedure Double Effect?” Linacre Q. Vol. 79, no. 1(2012):pp. 81-87. doi: 10.1179/002436312803571546. Epub 2012 Feb 1. PMID: 30082962; PMCID: PMC6027086.