EBB 281 – Mini Q & A on the Evidence on Preterm PROM

For Preterm Premature Rupture of Membranes (PPROM):

Dr. Rebecca Dekker:

Hi everyone. On today’s episode of the Evidence Based Birth® Podcast, I’m going to talk with you about the evidence on preterm premature rupture of membranes.

Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice, ebbirth.com/disclaimer for more details.

Hi everyone and welcome to today’s mini episode of the Evidence Based Birth® Podcast. My name is Dr. Rebecca Dekker, pronouns she/her and I’ll be your teacher for today’s episode. Today is a mini episode where I’m going to answer some questions and explain the evidence on PPROM, also known as preterm premature rupture of membranes. But before I get started, I have a special announcement for you. Next week is Labor Day and we have an amazing opportunity for you to get your hands on a limited number of physical copies of our EBB pocket guides and our EBB podcast listening guide. If you want to be one of the first to be notified when the pocket guides and the podcast listening guide are released, make sure you go to ebbirth.com and get on our newsletter on the homepage today. The available copies will sell out quickly, so you’ll want to be on our email list to get the notification as soon as it comes out.

As a content note, I want to let you know that today’s podcast episode will discuss viability, complications with preterm birth, causes of preterm birth and racism. I also want to give thanks and acknowledgement to Sara Ailshire, MA, who’s a research fellow here at EBB for compiling this information. You can find a text version of this at the bottom of our article on PROM available ebbirth.com/PROM, as well as all of the scientific references and resources that I mentioned. And now, let’s get started with answering some of your questions about preterm premature rupture of membranes.

What is PPROM? Preterm PROM happens when your water breaks before 37 weeks. This is different than term PROM, which happens at 37 weeks or later. We covered term PROM in depth in episode two 277 of the Evidence Based Birth® Podcast. Today, I’m going to focus on preterm PROM or PPROM, which occurs in about 3% of pregnancies and is the cause of about one third of preterm births. I do want to acknowledge before I go further that it can be frightening to have your water break before pregnancy reaches term. Whether PPROM will result in preterm labor, depends on a variety of factors specific to your unique situation, and your medical provider can help you understand the specifics of your circumstances and what options you have moving forward if you have preterm PROM.

So, what can cause PPROM? PPROM is associated with a variety of factors, including inflammation from an infection, having a previous history of preterm labor, smoking, vascular disease, uterine distension from a multiples pregnancy. So your uterus is larger because there’s more than one baby in there, or your uterus might be larger from polyhydramnios, which is a condition where there’s too much amniotic fluid. There could be a decrease in collagen. Collagen is the most common protein in your body and it serves as the primary building block for skin, muscle, bone, tendons, ligaments, and other tissues including the membranes that are surrounding your baby. Also, if you’ve had a cervical cerclage, that could also put you at higher risk for preterm PROM. There’s also some evidence that a disruption of the microbiome can increase the risk of PPROM, a decrease in lactobacillus that is a beneficial bacteria. If you have less of the beneficial bacteria, that’s associated with a higher risk of having preterm PROM. And then there’s also bacterial vaginosis that is a bacterial infection of the vagina that’s associated with miscarriage and PPROM.

Similarly, group B strep is a type of bacteria, sometimes we call it GBS that can cause preterm birth and PROM, both PPROM and sometimes term PROM. And we cover GBS in another podcast about that topic, which I’ll link to in the show notes. Other types of bacteria that can lead to PPROM include gardnerella vaginalis, mycoplasma, and ureaplasma. There’s also evidence that is emerging evidence that being exposed to very hot weather, such as heat wave or heat dome or very extreme cold weather or air pollution can increase the risk of both term PROM and preterm PROM. If you live somewhere that has decreased access to green space or air conditioning, that can make it harder on your body and also raise the risk of PPROM if you’re exposed to a heat wave.

Living within two miles of a petrochemical park, also known as a PIP can impact rates of PPROM. So petrochemical industrial products are things like plastics, natural gas, and other consumables made from petroleum. So there’s evidence that living near one of those kinds of factories or plants can increase the risk of PPROM. But in general, it’s really hard to predict who PPROM is going to happen to. In most cases, the ultimate cause is never understood. It’s likely that there are multiple factors interacting with each other, which is why the membranes might weaken early. And I want to let you know that PPROM can happen when none of these risk factors are present, and it’s not likely that we can prevent or treat all of these potential risk factors. A lot of them we don’t have any control over. So instead it’s recommended that we focus on treating each case as it occurs on an individual basis. I also want to affirm that if you have PPROM, it is not your fault.

So, when can PROM occur? It’s generally divided into three main categories. There is previable PPROM, which happens before the limit of viability, which is the gestational age that a fetus can survive outside the womb. It depends where you live, but typically in some countries it’s defined as about 23 weeks of gestation. There’s also PPROM remote from term that’s from the age of viability to about 32 weeks gestation. And then there’s PPROM near term or close to term, and that’s between 32 weeks and 36 weeks gestation. Medical care for PPROM really depends on when it occurs in the pregnancy. Also, if you have any complicating factors like infection, whether labor has begun or not, whether the placenta is still appropriately attached to the uterus or if it’s separated from the uterine wall, that’s called placental abruption and the condition of the fetus. About one third or 38% of those with PROM around the limit of viability will give birth within one week, and 69% give birth within five weeks of the onset of PROM.

Let’s talk about the treatment options that are available if someone has PROM. The basic treatment options include waiting to give the fetus time to develop inside the womb when possible. So you’re trying to delay the onset of labor. The other main option is inducing labor in cases where the fetus is viable or if there are other medical complications that mean induction is necessary, or in situations where the fetus would not survive anyways. In some rare cases though, the membranes can reseal themselves where they kind of close back up and the pregnancy can continue as expected. But in general, when you have PPROM, your medical team will work with you to assess your health status, your baby’s health status, and talk with you about what’s the best decision or what are the different paths that you can take, and whether induction is on the table or not.

I wanted to pause here and acknowledge that there have been many news reports published of people who experienced preterm PROM before the limit of viability and required an induction because there was a medical complication where the birthing person’s life was at risk. And because of some of the laws that have been passed after the U.S. Supreme Court Dobbs decision, there have been some very precarious and scary situations where parents have not been able to have the medical induction that they need in a timely manner. This is one thing that a lot of experts were saying would happen if Roe v. Wade was overturned. If you want to learn more about the research evidence on abortion and why sometimes it can be a medical necessity even in a planned pregnancy, you can check out EBB Podcast 240 about our findings from the Evidence Based Birth® Abortion Research Guide. And you can find a link there to all of the research that we’ve compiled on that topic. Now, I’m going to turn back to my discussion about other treatment options for preterm PROM.

Hospitalization is a common treatment so that the medical team can monitor you and your baby status and provide other treatments as needed. One of the major problems with PPROM is that the fetus would be underdeveloped, specifically the baby’s lungs. Often, they give corticosteroids. This is an evidence-based treatment. It’s a medication that’s given to you that then helps the baby’s lungs mature early before a preterm birth. And another common treatment that you might receive is magnesium sulfate. It might be administered by IV to you, and that is supposed to protect the baby’s neurological system. And then also antibiotics may be given to you IV to prevent or treat infection.

There are some other risks of other complications that can happen with preterm PROM, and these include problems with the cord of the baby, so umbilical cord compression or cord prolapse, chorioamnionitis, which is infection or inflammation of the membranes, endometritis, which is infection or inflammation of the endometrial tissue. And very rarely, maternal sepsis, which is like a blood infection in the birthing person. But the good news is that even with cases that are remote from term or around the limit of viability, most infants born at 24 to 26 weeks gestation will survive with aggressive medical care and a neonatal intensive care unit.

Some people want to know maybe you’ve had preterm PROM in the past and you want to prevent it from happening again in the future, is there anything I can do to lower my risk of PPROM? So there was a systematic review of the research that was published in 2022. Researchers reviewed 29 studies looking at a whole bunch of different ways that they were trying to prevent preterm PROM. Unfortunately, out of all of these studies looking at all of these different prevention methods, they only identified one study that researchers were able to successfully lower the rate of PPROM. In this study, participants who were randomly assigned to receive a folic acid, iron and zinc supplement along with 11 other micronutrients did have a reduced risk of PROM compared to those who did not receive a supplement or received other supplements that did not have this full combination.

But the reviewers of the research on this were skeptical about the study. They labeled it as low quality. One of the other main criticisms of the study is that because it took place in rural Nepal where there are a lot of nutritional deficiencies, the researchers were skeptical that this same supplement would work in places where there are not as many nutritional deficiencies.

So because PPROM is a major cause of preterm birth though, you can look at the research on pre-term birth in general and there are a few things that have been shown to lower rates of preterm birth. One of the most important is that there’s evidence that midwifery care lowers rates of preterm birth. There is a Cochrane review of randomized trials where they combined a whole bunch of randomized trials on this topic and they found that midwife-led care, when your care team is led by midwives, they’re the ones in charge, that there’s high quality evidence that being cared for by midwives, a team led by midwives leads to a lower risk of both preterm birth and fetal death before 24 weeks. That’s in comparison to physician-led care and something called the mixed model of care where you have physicians and midwives kind of working together. So that midwife-led care is really important. And we have an EBB podcast all about the evidence on midwifery care. I’ll link to that in the notes below. It’s a good one to check out.

In another Cochran review where they were looking at interventions to prevent preterm birth in general, researchers found clear benefits from screening for lower genital tract infections. In other words, screening for UTIs in pregnancy. One of the reasons why they check your urine at most prenatal appointments, taking zinc supplements, and again, having a midwife as a care provider. But a supportive care provider, particularly if they’re a midwife, eating nutritious food, taking prenatal dietary supplements and stress reduction practices can be beneficial for everyone who’s pregnant. We do hope that in the future we’ll see more research on other ways to lower the risk of PPROM.

One thing I want to talk about is how PPROM affects different communities differently. Some communities are more impacted by PPROM and preterm birth than other communities. In 2021, for example, in the United States, 10.5% of all babies born in the U.S. were born preterm. However, the rate of preterm birth among Black birthing people was 14.8% compared to 9.5% of white and 10.5% of Hispanic birthing people. The important thing to know is that racism is the cause of this, not any kind of ancestral inheritance of a risk for preterm birth. The reason we know that is because researchers have found that recent African immigrants to the United States have preterm birth rates that are comparable to white U.S. born women. But within two generations, the rates of preterm birth among the descendants of the recent African immigrants to the U.S. are similar to those of U.S. born Black birthing people. This tells us that there is something harmful in the environment in the United States for the health of Black people and researchers have come to the conclusion that that’s something harmful is racism.

For example, Dr. Joia Crear-Perry, who’s an OB/GYN and founder of the National Birth Equity Collaborative, often clarifies with this explanation, “Race isn’t the risk factor, racism is.” You can learn more about the impact of racism on birth outcomes and solutions for combating this in our signature article, The Evidence on Anti-Racism in Birth Work and Health Care. But as a short snippet from that article, racism is a cause of chronic stress and the physiological racial weathering effects on the body are well-documented causes of poor birth outcomes. The stress can wear down the body over time and increase rates of illness and poor health. Both inequality and racism leading to these higher levels of stress can increase levels of stress hormones, such as corticotropin-releasing hormone and cortisol. This can lead to premature weakening of the membranes, premature softening of the cervix and a decreased immune system. These factors can also increase the risk of infection and inflammation, and they can work together to increase the risk of PROM.

Other researchers have suggested that a lack of anti-racist adequate prenatal care from providers contributes to poor Black birth outcomes. This can include the impact of something we call medical apartheid, which there’s a whole book written about this in the United States, higher rates of chronic illness and a lack of adequate healthcare provided prior to conception. We see this all the time at EBB in our work that structural and interpersonal racist encounters results in unequal treatment of people of color in U.S. healthcare settings across the board. You see things like care providers spending less time with Black patients in appointments or paying less attention to what they’re telling them. There are scholars like Dr. Karen A. Scott, who are advocating for more research to better understand the scope of preterm birth and how we can affect or improve chronic inflammation or vascular dysfunction. And importantly, Black researchers have called for us as a society to expand and invest in solutions that have been shown to make a positive impact on health outcomes and experiences for pregnant people who are Black, indigenous or people of color.

These solutions include things like community informed, midwifery-led care, racially concordant care, where you share the same racial or ethnic background with your provider, group prenatal and group postpartum care and wraparound doula support services. Some of the solutions that we’ve seen backed by the research. And these are things that Black and birthing people of color can do to protect themselves if they’re concerned about PPROM. So one of the most important is to seek out midwifery care if you can, listen to our podcast, EBB 174, The Evidence on Midwives and check out the resources there. You might particularly benefit from Afrocentric group prenatal care, such as the Village Circle Approach that is offered at the Ida Mae Patterson Center for Maternal Health in Kansas City, Missouri, which we talk about in EBB podcast 278.

Aside from midwifery care, the second most important thing is doula support. Doula care, especially when it’s provided from full spectrum community-based doulas who share a similar background as you can provide families with additional support, social support, emotional support in a typical pregnancy as well as in a pregnancy that’s complicated with PPROM. Sista Midwife Directory is a great place to search for Black midwives and doulas.

Third, we urge you to speak with your care provider about your concerns if you’re worried about PROM or worried about it happening again, and switch healthcare providers if yours doesn’t listen to you. If they don’t take your concerns seriously, switch providers. If they commit microaggressions against you or the staff in their office does, we would urge you to consider switching providers. You may also want to bring a trusted partner, family member, doula, or friend to prenatal appointments with you to support you or to help advocate for you and your concerns if you have any and you’re worried about talking with your provider about them. If you’ve experienced PPROM in a prior pregnancy, or if PPROM runs in your family, you can speak to your care provider about your concerns and develop a plan of action to take if PPROM happened to you.

Finally, we want to remind you again that if PPROM happens to you, it is not your fault. In the notes, I’m going to put a bunch of resources for you of other really great places you can go for information and support related to PPROM, and we’ll also link to the professional guidelines for PPROM. Sometimes it can be helpful to know, is my care provider giving me care based on the latest guidelines or not? So we’ll put those links below.

That wraps up this episode on PPROM. I hope you found this helpful. Please continue following our work here at Evidence Based Birth® and don’t forget to check out our videos on term PROM as well as group B strep and the evidence on Midwives. See you all next week. Bye.

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