Preterm Premature Rupture of Membranes (PPROM)

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Preterm premature rupture of membranes (PPROM) is when the amniotic sac ruptures and amniotic fluid is lost before 37 weeks of pregnancy and before labour starts. In simpler words, it is when the waters break early. When it happens before 24 weeks of pregnancy it is called pre-viable PPROM, because the fetus is still not developed enough to survive outside of the womb.

 

How is PPROM diagnosed?

Women usually notice they have had a premature rupture of membranes by seeing fluid coming out of their vagina without contractions or pain. The fluid is either lost in a sudden gush, or as a steady stream.

A doctor then examines the woman with a sterile speculum and the diagnosis is confirmed if amniotic fluid is found in the vagina. An ultrasound is also performed to see how much fluid remains around the fetus.

How is PPROM treated?

The treatment of PPROM depends on the stage of pregnancy.

In pre-viable PPROM (before 24 weeks), the prognosis for the fetus is usually poor, and survival is extremely rare if the membrane rupture before 21 weeks. Therefore, in countries abroad women are offered a choice of either watchful waiting or a termination of pregnancy (abortion).

If the rupture of membranes happens between 24 and 37 weeks, a watchful waiting approach is usually followed, and the woman is given antibiotics, steroids, and other medicines such as magnesium sulfate that help the fetus develop. 

If the rupture of membranes happens after 37 weeks, the treatment is usually induction of labour.

Why is pre-viable PPROM a problem in Malta?

In Malta abortion is illegal under all circumstances, and there are no exceptions to the law. Therefore, at least in theory, a doctor who terminates a pregnancy before 24 weeks (ie: before a fetus can survive outside the womb), is commiting a crime.

In practice this means that doctors in Malta adopt a watchful waiting approach in cases of pre-viable PPROM, even if the chances of survival for the fetus are slim. Continuing the pregnancy in cases of pre-viable PPROM puts the pregnant woman at risk of infection (sepsis), which can be fatal. Unfortunately, women in Malta with pre-viable PPROM are not given a choice to terminate their risky pregnancy.

The case of Savita Halappanavar in Ireland

Savita was a 31 year old pregnant lady who presented to a hospital in Ireland with pregnancy complications in her 17th week of pregnancy. The membranes ruptured a few hours after she was admitted to hospital. At that stage of pregnancy, there is no reasonable chance of survival for fetus, but because Ireland still banned abortion at that time she was not offered a termination of pregnancy. Savita herself requested to have an abortion because she did not want to continue with her risky pregnancy, but the request was declined because the fetus was still alive at the time. A few days later, Savita developed an infection (sepsis) because of her complicated pregnancy and sadly passed away.

 

Savita's case is widely seen as an example of how restrictive abortion laws can tie the hands of doctors when treating complicated pregnancies, and can put women's health and lives at risk. A few years later, the Irish population voted to legalise abortion in a referendum.

Do you have a pre-viable PPROM and need help?

If you have suffered a rupture of membranes before 24 weeks and want to discuss your options, including the option of abortion, contact our Family Planning Advisory Service for advice on what can be done and what risks are involved.