Given the recent overturn of Roe v Wade and the frightening headlines that have followed, now more than ever, American women are questioning the medical care and information they receive during pregnancy. Many pregnant women have heard or read that they won’t be able to receive proper medical care if they have a miscarriage (we addressed this misconception here), or an ectopic pregnancy, or if they develop an infection if their water breaks too early. Today, we are going to discuss premature rupture of the fetal amniotic sac of membranes (commonly known as having your water break too early), and the truth about whether pregnant women can still receive the treatment they need if this happens, even in a post-Roe America.
Normally, a woman’s water breaks during labor
Most of the time, a pregnant woman’s bag of water will break during labor. The American College of Obstetricians and Gynecologists (ACOG) notes that about 8% of the time, women who are 37 weeks pregnant or beyond will have their water break before they go into labor, and this is known as premature or prelabor rupture of membranes (PROM). In these circumstances, labor usually starts on its own within 24 hours. A woman whose water breaks but then does not go into labor spontaneously within 24 hours may be recommended for induction by her doctor, due to the risk of developing an infection when the baby’s infection-prevention “bubble” has essentially popped.
But some women will experience their water breaking before (even long before) 37 weeks (which is when the baby is considered “early term,” and ready to be born). This situation is called preterm premature rupture of membranes (PPROM), and it affects thousands of women each year. PPROM is a concern primarily because, like I wrote above, labor typically soon follows. In fact, more than half of women experiencing PPROM will go into labor within one week of the event. This is a medically challenging situation because a baby born too early has a higher risk of death, and is prone to potentially life-long health problems. Fortunately, thanks to modern advancements in medicine, even extremely premature babies have a chance at life, and many can lead healthy lives despite very rocky beginnings [1].
How long after PPROM will labor start?
While old studies with small sample sizes consistently found that more than half of women went into labor within one week of PPROM, the length of time between membrane rupture and labor is inversely correlated with how early membrane rupture occurred, according to ACOG’s guidelines [2]. This means that the earlier a woman’s water breaks, the longer it may be before she goes into labor. The further along she is in her pregnancy, the shorter the time frame may be between her water breaking and labor beginning.
Sometimes women whose waters break before 24 weeks may carry their babies for an additional two to five weeks, and others may go even longer. One study of 174 babies found that half of women who had membrane rupture before 24 weeks carried their babies for at least 6 additional weeks, with one woman staying pregnant for an additional 17 weeks and her baby surviving until hospital discharge (the end of the study timeframe) [2]. The PPROM Foundation notes that gestational age at birth, not at the time that PPROM occurred, is “the key predictor of survival.”
What are your treatment options with PPROM?
The American College of Obstetricians and Gynecologists has a set of clinical guidelines that physicians can follow when this complication arises. The two options for treatment are expectant management or labor induction (early birth). The type of medical care ACOG recommends depends largely on gestational age, though other complications must be considered too. Generally, the later PPROM happens during pregnancy, the better the outcome, because the unborn baby has had more time to develop in the womb.
Expectant management involves monitoring the health of the mother and her unborn baby at home or, as is often the case, in a hospital setting. There, she may receive medications such as antibiotics to ward off infection, or corticosteroid injections to help her preborn baby’s lungs mature more quickly. The goal with expectant management is to allow babies more time in the womb, while balancing any risks (like life-threatening infection) posed to mothers. If any additional complications arise, induction is typically recommended to preserve the life of the mother.
Expectant management often a superior option for PPROM between 24 and 37 weeks gestation, study finds
For pregnant women who experience PPROM between 24 and 37 weeks without any additional complications, expectant management was linked to better outcomes for mother and baby compared with immediately inducing labor, as found by a 2017 meta-analysis [3]. This type of study combines data from multiple studies to detect an effect (which can be tricky to identify in individual research studies if you’re studying a rare complication) and is considered the strongest level of scientific evidence. The results were published in Cochrane Database of Systematic Reviews, a prestigious and respected journal.
The researchers reached this conclusion by analyzing the outcomes for mothers and babies from 12 clinical trials, 7 of which were done in the United States. The trials collectively included 3,617 pregnant women who had membrane rupture between 24 weeks and 37 weeks gestation. Women were randomly assigned treatment with either early birth by inducing labor, or expectant management.
24 weeks was the gestational age cutoff for the studies because babies have long been considered viable, or able to survive outside of the womb, starting at 24 weeks. Some consider viability to start sooner, around 22 or 23 weeks, given that babies born at that age have survived (the world’s most premature baby was born in 2020 at just 21 weeks and 1 day).
All but one measured health outcome was better in expectant management vs. early birth group
The researchers found that, compared with immediate birth via induction, when mothers with PPROM were expectantly managed:
- Incidence of respiratory distress syndrome (difficulty breathing) for infants dropped from 10.9% to 8.4%
- Incidence of infants needing ventilators to breathe dropped from 11% to 8.6%
- Incidence of admission to neonatal intensive care during the first 28 days of life dropped from 49.7% to 42.8%
- Incidence of Cesarean sections for women dropped from 21.7% to 17.2%
- Incidence of endometritis (infection of the uterus) dropped from 0.26% to 0.16%
- Incidence of chorioamnionitis for moms rose from 0.51 to 1.03%*
The biggest risk of expectant management is chorioamnionitis
Chorioamnionitis, also known as intrauterine infection, is a relatively common complication of PPROM in which the amniotic fluid, placenta, fetus, fetal membranes, or decidua (membrane that lines the uterus during pregnancy) becomes infected. While women who were induced and had an early birth had lower risk of chorioamnionitis in the meta-analysis, this was seen only when birth occurred within 24 hours of PPROM. Just how common is chorioamnionitis? According to ACOG’s guidelines, other studies have reported chorioamnionitis after PPROM to occur much more frequently, between 15% and 35% of the time.
Chorioamnionitis after PPROM can lead to sepsis
Chorioamnionitis is a concern because it can lead to sepsis (bloodstream infection) for mom and/or baby. Approximately 1 to 5 percent of mothers with chorioamnionitis after PPROM develop sepsis, which can be life-threatening. Oftentimes, the treatment is to initiate labor to expel the infected fluid and tissue along with a hopefully healthy baby. Very rarely have there been reported instances of mothers dying from sepsis after PPROM.
Sepsis can also occur in infants and is the leading cause of death for them. The rate of infant sepsis was similar between the groups of mothers in the analysis: 3.7% for expectant management compared with 3.4% for immediate birth.
Survival rates in both expectant management and early birth groups were very high
The analysis revealed that while some of these babies sadly died in the womb or shortly after birth, approximately 97% survived when born early by inducing labor, and nearly 99% when expectant management was used. As other studies have also shown, most babies born after 24 weeks will survive when given the necessary medical care.
Rare complications occurred equally in both groups
Placental abruption (placental detachment from the uterine wall before birth), umbilical cord prolapse (umbilical cord exits the birth canal before the baby), periventricular leukomalacia (damage to a certain area of brain tissue), intraventricular hemorrhage (bleeding in areas of the brain filled with cerebrospinal fluid), and necrotizing enterocolitis (intestinal tissue lining becomes inflamed or dies) occurred very rarely and equally in both the expectant management group and the early birth group.
Women and babies with PPROM can thrive with proper, evidence-based care
Certainly, having your water break too early is stressful and frightening for moms. Fortunately, evidence-based guidelines exist to guide pregnant women and their healthcare providers in deciding whether to induce labor for an early birth or to continue the pregnancy with closely-supervised (and potentially inpatient) expectant management. Thanks to advances in medical technology, babies born after 24 weeks have excellent survival rates, and even younger babies are surviving at greater rates. No one wants to go into labor early, or otherwise not have their labor and delivery go according to plan, but women and their babies tend to do well even in cases of PPROM after 24 weeks.
Author’s note: In a separate article, I address the thornier issue of PPROM before viability (24 weeks), and whether abortion is an appropriate or necessary treatment for pre-viability PPROM. Read it here.
References:
[1] Crump C, Winkleby MA, Sundquist J, Sundquist K. Prevalence of Survival Without Major Comorbidities Among Adults Born Prematurely. JAMA. 2019;322(16):1580–1588. doi:10.1001/jama.2019.15040 [2] Brumbaugh, Jane E et al. “Neonatal survival after prolonged preterm premature rupture of membranes before 24 weeks of gestation.” Obstetrics and gynecology vol. 124,5 (2014): 992-998. doi:10.1097/AOG.0000000000000511 [3] Bond, Diana M et al. “Planned early birth versus expectant management for women with preterm prelabour rupture of membranes prior to 37 weeks’ gestation for improving pregnancy outcome.” The Cochrane database of systematic reviews vol. 3,3 CD004735. 3 Mar. 2017, doi:10.1002/14651858.CD004735.pub4
