Care Process Model

december 2012

MANAGEMENT OF

Premature Rupture of Membranes (PROM)

This care process model (CPM) was developed by Intermountain Healthcares OB Development Team under the guidance of the
Women and Newborns Clinical Program. It recommends an evidence-based approach for assessing and managing pregnancies
affected by premature (prelabor) rupture of membranes (PROM). The model provides guidance for cases of very preterm PROM (in
the second trimester or earlier) through term PROM (occurring at 37 weeks completed gestation or later).

Why Focus on PROM?

Premature rupture of membranes (PROM) warrants our attention for Whats iNside
several reasons.
Algorithm: management
Its common and increasing. PROM occurs in approximately 8% to 10% of PROM. . . . . . . . . . . . . . . . . . . . . 2
of term pregnancies, and preterm PROM (PPROM, defined as PROM prior
Notes on the algorithm . . . . . . 3
to 37 weeks completed gestation) occurs in 2% to 4% of all singleton and 7%
to 20% of twin pregnancies.1 PPROM is a complication in about one-third of References and resources . . . . 4
all preterm births, which have increased by 38% since 1981.2 Every obstetric
provider will see and need to manage many cases of PROM in the course of
his or her career.
PPROM in particular is associated with increased morbidity and Goals of this cpm
mortality. About one-third of women with PPROM develop potentially serious The overarching goal of this model is to
infections, and the fetus/neonate is at even greater risk of PPROM-related promote evidence-based practice and
morbidity and mortality than the mother.3 Premature delivery and its attendant clinical consistency in the management of
PROM within the Intermountain Healthcare
potential problems, perinatal infection, and in utero cord compression are
system. Specific goals include:
common complications.2 PPROM accounts for approximately 18% to 20%
of perinatal deaths in the United States.1 Optimize use of resources applied to the
assessment and treatment of PROM
Practice varies widely. Management hinges on knowledge of gestational age
and assessing the relative risks of preterm birth versus expectant management.2 Help clinicians navigate the risks
of preterm labor and expectant
As our understanding of these risks and the factors affecting them evolves, we
management
expect to reduce variability of practices such as the timing of delivery, the use of
medications, and the preferred surveillance practices of expectant management. Establish a shared approach that can
serve as a baseline for measurement
A systematic and evidence- and consensus-based approach may and ongoing improvement
improve outcomes. See Goals of this CPM at right to see how we hope to
benefit from implementing this model.
 M a n ag e m e n t o f P r e m at u r e r u p t u r e o f m e m b r a n e s ( P r o m ) d ec e m b e r 2 012

A lg o r i t h m : m a n ag e m e n t o f P ROM

Patient presents with

suspected PROM

assess for PROM

Medical history and physical exam; other tests as needed.
See Assessment Notes on page 3.

confirm PROM
transfer to L&D
As needed, give tocolytic only to allow transport
of preterm PROM patients having labor contractions.

Evident
intrauterine infection,
placental abruption, or fetal yes DELIVER expeditiously
compromise?

no
manage per gestational age
as outlined below

~24 weeks or less ~25 weeks 31 weeks 6 days ~32 weeks 33 weeks 6 days ~ 34 weeks or more
PROVIDE counseling to MANAGE EXPECTANTLY (INPATIENT) If fetus is 32 or 33 weeks WITH documented give Antibiotic for
patient and family. as described in steps below. lung maturity, CONSIDER Induction GBS prophylaxis
Gestational age at delivery provides otherwise... as needed; following
best estimate of chance of survival. If Intermountains Prevention
22-24 weeks gestation, consultation with
give Magnesium if delivery MANAGE EXPECTANTLY
expected <24 hrs. of Perinatal GBS algorithm.
Neonatology to discuss resuscitation issues is (INPATIENT) as described in steps below.
recommended. See page 3 Notes on PPROM. See Medication Table page 3.

Per patient choice, either: Give Corticosteroid. consider Corticosteroid. DELIVER

INDUCE LABOR (refer to See Medication Table page 3. See Medication Table page 3. (usually by induction of labor)
Intermountains Pregnancy
Termination Procedure)
Procedure)..
MANAGE EXPECTANTLY / give Antibiotic to prolong latency.
DECISION TO RESUSCITATE See Medication Table page 3.
(Inpatient) as described at right.
MANAGE EXPECTANTLY /
consult MFM If HSV, HIV, or hepatitis C.
DECISION NOT TO RESUSCITATE
(OUTPATIENT) as described below. If cerclage: leave in place, unless patient has intrauterine infection or
unexplained vaginal bleeding.
Consider inpatient evaluation
for 24 to 48 hours and administration provide surveillance:
of latency antibiotics. See page 3 Daily nonstress test to monitor fetal health.
Medication Table.
Periodic (not daily) ultrasound to assess amniotic fluid; if patient no
Discharge to home with instructions longer reports leakage of fluid, do u/s to check for reaccumulation of fluid
to monitor temperature daily (call if
suggesting resealing of the rupture. (If resealed, the patient may be
temperature > 100.4F / 38C).
discharged home.)
Perform weekly fetal ultrasound
Note that corticosteroids are NOT
recommended. assess fetal lung maturity via lamellar body count of amniotic
fluid from vaginal pool specimen: attempt to obtain specimen at 32 weeks
If fetus reaches viability and patient and proceed to delivery if lung maturity can be documented;
and Neonatology care team decide to
otherwise deliver at 34 weeks.
resuscitate infant upon delivery,
admit as inpatient and...

2 2012 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .

M a n ag e m e n t o f P r e m at u r e r u p t u r e o f m e m b r a n e s ( P r o m ) d ec e m b e r 2 012

Assessment Notes
PROM is a clinical diagnosis usually based on patient history and visualization of amniotic fluid during physical exam.
In some cases, lab tests are needed to exclude other possible causes of vaginal or perineal wetness.
Medical history: Timing and quantity of leaking or wetness, weeks gestation/EDD, pregnancy history of PROM, etc.
Physical exam: Avoid digital exam unless active labor or imminent delivery is expected. Use sterile speculum examination to:
Visually inspect for cervicitis, umbilical Obtain cultures as needed
cord prolapse, or fetal prolapse Visually confirm PROM diagnosis
Assess cervical dilation and effacement
Test: if diagnosis of PROM cant be visually confirmed:
Test pH of fluid from posterior vaginal fornix (amniotic fluid usually ~ 7.1-7.3, versus vaginal secretions ~ 4.5 - 6)
Look for arborization of fluid from posterior vaginal fornix
Consider ultrasound to check amniotic fluid volume; to assess fetal weight, gestational age, and presentation; to check for fetal
anatomic abnormality; or to confirm diagnosis of PROM by guiding transabdominal instillation of indigo carmine dye.
Consider AmniSure if diagnosis of PROM remains uncertain after physical examination, nitrazine, and fern tests. (AmniSure is a rapid
slide test that uses immunochromatographic methods to detect trace amounts of placental alpha microglobulin-1 protein in vaginal fluid.)4

Notes on PPROM at <24 weeks Gestation

Advances in neonatal care and in management of PPROM at the limits of viability may continue to impact survival; nevertheless,
for PPROM at <24 weeks gestation, fetal and neonatal morbidity remain high. Counseling for patients evaluating their choice for
termination (induction of labor) or expectant management should include discussion of both maternal and fetal outcomes and, if gestation
is 22 to 24 weeks, should also include a consultation with Neonatology.5 Note that multiple studies on outcomes are complicated by their
small size or other limitations.4,6 This CPM strongly recommends:
For counseling patients at 22 to 25 weeks, use the Neonatal Research Network Extremely Preterm Birth Outcome Data7
If induction of labor before viability is considered, refer to Intermountains Pregnancy Termination Procedure for guidance
in conforming to current Utah law

Medication table
Medication type, use in PROM Recommended

Magnesium magnesium sulfate, IV: Bolus 6 grams over 40 minutes, then infuse 2 grams/hour maintenance
for neuroprotection in preterm dose from premixed 20 gram/500mL bag until delivery or until 12 hours of therapy. (If preterm delivery
PROM <31 weeks when delivery seems unlikely after 12 hours of therapy, discontinue therapy).
is expected within 24 hours

Corticosteroid to lower risk betamethasone: 12 mg IM every 24 hours x 2 doses.

of RDS If betamethasone isnt available, may use dexamethasone: 6 mg IM every 12 hours X 4 doses.

Antibiotics ampicillin 2 grams IV every 6 hours and erythromycin 250 mg IV every 6 hours x 48 hours
to prolong latency followed by: amoxicillin 250 mg PO every 8 hours for 5 days
and erythromycin 333 mg PO every 8 hours for 5 days.
If penicillin allergy, low risk (e.g., isolated macupapular rash without urticaria or pruritis):

(Options listed at right will cefazolin 1 gram IV every 8 hours x 48 hours

provide GBS coverage for
48 hours. If delivery is expected
after 48 hours and before
completion of antibiotics used
to prolong latency, follow
Intermountains Prevention of
Perinatal GBS algorithm.)
and erythromycin 250 mg IV every 6 hours x 48 hours
followed by: cephalexin 500 mg PO every 6 hours x 5 days
and erythromycin 333 mg PO every 8 hours x 5 days
If penicillin allergy, high risk (e.g., anaphylaxis, angioedema, respiratory distress, urticaria):
vancomycin 1 gram IV every 12 hours x 48 hours
and erythromycin 250 mg IV every 6 hours x 48 hours
followed by: clindamycin 300 mg PO every 8 hours x 5 days
and erythromycin base 333 mg PO every 8 hours x 5 days

2012 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 3

m a n ag e m e n t o f p r e m at u r e r u p t u r e o f m e m b r a n e s d ec e m b e r 2 012

References
1. Caughey AB, Robinson JN, Norwitz ER. Contemporary diagnosis and management of
preterm ruptures of membranes. Rev Obstet Gynecol. 2008;1(1):11-22.
2. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 80.
Premature rupture of membranes. Obstet Gynecol. 2007;109:10071019.
3. Duff P. Preterm premature rupture of membranes. UpToDate website. http://www.
uptodate.com/contents/preterm-premature-rupture-of-membranes. Updated June 13,
2012. Accessed September 18, 2012.
4. McElrath T. Midtrimester preterm premature rupture of membranes. UpToDate website.
http://www.uptodate.com/contents/midtrimester-preterm-premature-rupture-of-
membranes. Updated August 6, 2012. Accessed September 18, 2012.
5. Batton DG, Committee on Fetus and Newborn. Antenatal counseling regarding
resuscitation at an extremely low gestational age. Pediatrics. 2009;124:422-427.
6. Dinsmoor MJ, Bachman R, Haney EI, Goldstein M, Mackendrick W. Outcomes after
expectant management of extremely preterm premature rupture of the membranes.
Am J Obstet Gynecol. 2004;190(1):183-187.
7. National Institute of Child Health and Human Development. Extremely Preterm Birth
Outcome Data. http://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/epbo_case.
RESOURCES cfm. Updated July 30, 2010. Accessed November 13, 2012.
Patient and provider tools relating
to management of this condition are
available on the Clinical Programs
website at: intermountain.net/
clinicalprograms. Select the
Preterm Labor topic page to
access the following tools:
This CPM
PPROM order set
Documents providing guidance re:
other preterm labor and PROM
concerns: GBS prophylaxis,
magnesium sulfate for
neuroprotection, etc.
See all of the Women and Newborns
provider tools by choosing the
Clinical Guidelines and CPMs link
under the Women & Newborns
heading in the lefthand navigation.

4 2012 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. Patient and Provider Publications 801-442-2963 CPM052 - 12/12