Population: Pregnant women with rupture of membranes prior to onset of labor.
Organizations
ACOG 2020, Cochrane Database of Systematic Reviews 2013, NICE 2021
Recommendations
–Diagnose PROM based on history and physical exam. Avoid digital examinations unless patient appears to be in active labor or delivery seems imminent (ACOG). Sterile speculum exam is preferred.
–In all patients with PROM, initial period of electronic fetal heart monitoring and uterine activity monitoring should be done. Non-reassuring fetal status and clinical chorioamnionitis are indications for delivery.
–<23–24 wk of gestation at risk for imminent delivery:
• Expectant management or induction of labor.
• Consider antibiotics as early as 20-0/7 wk of gestation.
• Do not use GBS prophylaxis before viability.
• Do not use corticosteroids, tocolysis, or magnesium sulfate before viability; consider as early as 23-0/7 wk of gestation.
–24-0/7 to 33-6/7 wk of gestation at risk for imminent delivery:
• Use IV magnesium sulfate for its fetal neuroprotective effect <32-0/7 wk of gestation, if there are no contraindications.
• Consider trial of expectant management.
• Use antibiotics to prolong latency if there are no contraindications.
• Give a single course of corticosteroids. Consider at 23-0/7 wk gestation if risk of preterm birth within 7 d.
• Treat intra-amniotic infection if present (and proceed to delivery).
• GBS screening and prophylaxis as indicated.
–34-0/7 to 36-6/7 wk of gestation:
• Expectant management (NICE) or proceed toward delivery.
• Consider single course of corticosteroid. Do not delay delivery for steroids.
• GBS screening and prophylaxis as indicated. If positive, proceed toward delivery.
• Treat intra-amniotic infection if present (and proceed toward delivery).
–≥37-0/7 wk of gestation:
• GBS screening and prophylaxis as indicated.
• Treat intra-amniotic infection if present.
• Proceed toward delivery.
–Not enough evidence to show that removal of cerclage after preterm PROM diagnosis has been made. If cerclage remains in place with preterm PROM, prolonged antibiotics prophylaxis beyond 7 d is not recommended.
–Outpatient management of preterm PROM is not recommended.
Practice Pearls
• Twenty-two studies involving over 6800 pregnant women with PROM prior to 37 gestational weeks were analyzed. Routine antibiotics decreased the incidence of chorioamnionitis (RR 0.66), prolonged pregnancy by at least 7 d (RR 0.79), and decreased neonatal infection (RR 0.67), but had no effect on perinatal mortality compared with placebo.
• Between 34-0/7 and 36-6/7 wk of gestation, NICE recommends expectant management until 37 wk of gestation in the absence of other contraindications. ACOG does not make an explicit recommendation. Either expectant management (with close monitoring) or delivery is reasonable.
Sources
–Obstet Gynecol. 2020;135(3):e80-e97.
–NICE. Inducing labour (NG207). 2021.
–http://www.cochrane.org/CD001058/PREG_antibiotics-for-preterm-rupture-of-membranes