PPROM 23–34 Weeks — Inpatient Order Set (Example)

1. Location, Team & Initial Notifications

• Admit to: ☐ Labor & Delivery   ☐ Antepartum / high-acuity OB unit   ☐ ICU if maternal instability
• Nursing level of care: ☐ Standard high-risk OB   ☐ Step-down / continuous monitoring.
• OB/MFM: ☐ Primary team   ☐ MFM consultation requested.
• Notify: ☐ NICU/Neonatology   ☐ Anesthesia   ☐ Social work / case management.

2. Diagnosis, Counseling & Initial Evaluation

• Confirm PPROM:
  • History of fluid leakage; sterile speculum exam (pooling, nitrazine, ferning), visible membrane defect, or positive amniotic fluid test per local protocol.
  • Avoid digital vaginal exams unless in active labor or delivery imminent.
• Document gestational age and viability threshold at local institution; provide individualized counseling regarding neonatal survival and morbidity, especially at 23–25 weeks.
• Review contraindications to expectant management:
  • Suspected or confirmed chorioamnionitis, significant abruption, non-reassuring fetal status, fetal demise, severe preeclampsia/eclampsia, maternal sepsis/instability.
• Vital signs q 4 hours (or per acuity): HR, BP, RR, SpO₂, temperature.
• Maternal symptom review at least daily: uterine tenderness, foul discharge, decreased fetal movement, contractions, bleeding.

3. Maternal Labs, Cultures & GBS Screen

4. Fetal Assessment & Ultrasound

• Admission ultrasound:
  • Confirm presentation, estimated fetal weight, amniotic fluid volume, placental location, and fetal anatomy if not previously completed.
• Fetal heart rate surveillance:
  • Viable fetus: daily NST or continuous monitoring based on gestational age, symptomatology, and unit policy.
  • Consider biophysical profile (BPP) 1–2 times per week during expectant management.

5. Antenatal Corticosteroids (23–34 Weeks)

• Candidates:
  • PPROM between 23 0/7 and 33 6/7 weeks when neonatal resuscitation is planned.
• Regimen (choose one):
  • Betamethasone 12 mg IM every 24 hours × 2 doses
  • OR dexamethasone 6 mg IM every 12 hours × 4 doses
• Consider a single “rescue” course before 34 weeks if:
  • At risk of delivery within 7 days, and prior course ≥ 7–14 days ago, and no contraindication per institutional policy.

6. Magnesium Sulfate for Fetal Neuroprotection

• Indications:
  • PPROM with anticipated delivery within 24 hours between 23 0/7 and 31 6/7 weeks (per institutional neuroprotection protocol).
• Common regimen (adjust per local protocol):
  • Magnesium sulfate 4–6 g IV loading dose over 20–30 minutes, then 1–2 g/hour continuous infusion until birth or for up to 24 hours.
• Monitor maternal reflexes, respiratory rate, urine output, and serum magnesium levels per protocol; have calcium gluconate available as antidote.

7. Latency Antibiotics (23–34 Weeks)

Standard latency regimen is based on the Mercer trial (ampicillin + erythromycin IV for 48 hours, followed by oral amoxicillin + erythromycin for 5 days). In patients with penicillin allergy, select alternatives below according to anaphylaxis risk and local resistance patterns.

7A. No Penicillin Allergy (Standard Latency Regimen)

• Start as soon as PPROM confirmed and expectant management chosen:
  • Ampicillin 2 g IV q 6 hours for 48 hours
  • Erythromycin 250 mg IV q 6 hours for 48 hours
• Then for 5 additional days (oral):
  • Amoxicillin 250 mg PO q 8 hours
  • Erythromycin 333 mg PO q 8 hours
• Avoid amoxicillin–clavulanate in PPROM (possible association with increased NEC in some studies).

7B. Alternative Macrolide if Erythromycin Not Tolerated or Unavailable

• Consider azithromycin as a macrolide alternative to erythromycin:
  • Example regimen (institutional protocols vary):
    • Azithromycin 1 g PO once (single loading dose) given at initiation of IV beta-lactam therapy
    • OR azithromycin 500 mg IV/PO once, then 250 mg PO daily for 4 days (per local protocol).
  • Continue ampicillin/amoxicillin component as in standard Mercer regimen unless β-lactam allergy is present.
• Document rationale for azithromycin substitution (e.g., intolerance to erythromycin, local guideline, formulary limitations).

7C. Penicillin Allergy — Low Risk for Anaphylaxis

Examples: remote rash, vague history, or non–IgE-mediated reaction. Cephalosporins are generally acceptable in this group.

• Replace ampicillin/amoxicillin with a first-generation cephalosporin:
  • Cefazolin 1–2 g IV q 8 hours for 48 hours (dose per weight/local protocol)
  • Then cephalexin 500 mg PO q 6 hours for 5 days
• Macrolide component:
  • Use erythromycin as above, OR azithromycin regimen as in 7B if erythromycin poorly tolerated or unavailable.

7D. Penicillin Allergy — High Risk for Anaphylaxis

Examples: anaphylaxis, angioedema, respiratory distress, urticaria to penicillins or cephalosporins. Avoid β-lactams; use clindamycin or vancomycin for GBS, plus macrolide for latency as per institutional guidance.

• If GBS isolate known and clindamycin-susceptible:
  • Clindamycin 900 mg IV q 8 hours for 48 hours
  • Then clindamycin 300 mg PO q 8 hours for 5 days
• If GBS clindamycin-resistant or susceptibility unknown:
  • Vancomycin IV dosed per weight and renal function (e.g., 15–20 mg/kg q 8–12 hours) for the IV portion of the course; transition to an oral agent per infectious disease/pharmacy guidance.
• Add macrolide:
  • Azithromycin 1 g PO once, OR azithromycin 500 mg once then 250 mg PO daily × 4 days, OR erythromycin oral regimen per local protocol.
• Consider allergy testing/penicillin challenge post-partum for future pregnancies if history unclear.

8. GBS Intrapartum Prophylaxis Planning

• Ensure GBS status documented (culture or bacteriuria). In PPROM < 37 weeks, GBS prophylaxis is generally indicated when in active labor or at time of delivery.
• Standard:
  • Ampicillin 2 g IV loading, then 1 g IV q 4 hours until birth, OR penicillin G per institutional protocol.
• Penicillin allergy — low risk for anaphylaxis:
  • Cefazolin 2 g IV loading, then 1 g IV q 8 hours until birth.
• Penicillin allergy — high risk for anaphylaxis:
  • If GBS isolate clindamycin-susceptible: clindamycin 900 mg IV q 8 hours until birth.
  • If clindamycin-resistant/unknown: vancomycin IV dosed per weight/renal function.

9. Tocolysis, Contractions & Activity Restrictions

• Routine prolonged tocolysis is not recommended in PPROM; short-term tocolysis (e.g., 48 hours) may be considered in selected patients to allow completion of antenatal corticosteroids if no signs of infection, abruption, or fetal compromise.
• Avoid digital cervical exams; monitor uterine activity with toco (or palpation) and symptoms.
• Activity:
  • Generally no strict bed rest; encourage mobility with precautions, per institutional policy.
  • Pelvic rest and avoidance of intercourse or intravaginal products.

10. Ongoing Expectant Management (Maternal & Fetal)

• Daily assessment for chorioamnionitis:
  • Maternal temperature, uterine tenderness, maternal/fetal tachycardia, foul fluid, maternal leukocytosis.
• Fetal surveillance:
  • At least daily NST or continuous EFM if indicated by gestational age or maternal/fetal status.
• Ultrasound:
  • Amniotic fluid volume and growth every 2–4 weeks (or more often if concern for growth restriction or oligohydramnios).
• DVT prophylaxis per institutional protocol for reduced mobility.

11. Timing & Indications for Delivery

• Deliver immediately (regardless of gestational age) if:
  • Clinical chorioamnionitis
  • Non-reassuring fetal status
  • Severe placental abruption
  • Maternal sepsis or hemodynamic instability
• In the absence of complications, plan delivery at:
  • 34 0/7 weeks (or per updated guideline/local protocol) after counseling regarding maternal/neonatal risks and benefits.
• Route of delivery based on standard obstetric indications (presentation, prior uterine scar, fetal status), not PPROM alone.

12. Counseling, Documentation & Discharge Planning

• Document counseling regarding neonatal survival, morbidity, and parental preferences, especially at 23–25 weeks and again at major gestational milestones.
• Ensure NICU consultation documented prior to viability/at threshold for active resuscitation.
• Most patients will remain inpatient until delivery; if your institution allows outpatient management in very selected cases, follow local criteria and provide clear return precautions.
• Debrief after delivery and review recurrence risk and strategies for future pregnancies (e.g., progesterone, cervical length surveillance) per current guidelines.

References (Selected)

1. American College of Obstetricians and Gynecologists. Practice Bulletin No. 217: Prelabor Rupture of Membranes. Obstet Gynecol. 2020;135(3):e80–e97.
2. Society for Maternal-Fetal Medicine (SMFM). Consult Series documents on previable/periviable PPROM and periviable birth, 2020–2024.
3. Mercer BM, et al. Antibiotic therapy for reduction of infant morbidity after preterm premature rupture of the membranes. JAMA. 1997;278(12):989–995.
4. Seaman RD, et al. Erythromycin vs azithromycin for treatment of preterm prelabor rupture of membranes: a systematic review and meta-analysis. Am J Obstet Gynecol. 2022;226(3):391–403.e4.
5. UIC Drug Information Group. What evidence supports the use of azithromycin for ruptured membranes in preterm prelabor? FAQ, Jan 2024.
6. Merck Manual Professional Edition. Prelabor Rupture of Membranes (PROM) — Management and antibiotic regimens, updated 2023.
7. ACOG Committee Opinion No. 797. Prevention of Group B Streptococcal Early-Onset Disease in Newborns. Obstet Gynecol. 2020;135(2):e51–e72.
8. Recent JOGC/other national guideline updates describing cephalosporin + macrolide combinations as options for penicillin allergy without anaphylaxis in PPROM latency regimens.

Disclaimer

This OBPharm order set is an educational template for instructional purposes only. It does not replace institutional PPROM protocols, ACOG/SMFM guidance, or consultation with MFM, neonatology, anesthesia, and infectious disease.

Antibiotic regimens, dosages, and timing of delivery must be verified against current guidelines, local microbiology patterns, pharmacy recommendations, and patient-specific factors (e.g., renal/hepatic function, gestational age, GBS status, allergy history). For EHR implementation, each bullet should be mapped to local orderables and named exactly as they appear in your system.