SUMMARY:

ACOG has released a guidance update on Prelabor Rupture of Membranes

(PROM). The use of ‘prelabor’ is in keeping with reVITALize terminology
(see ‘Related ObG Topics’ below) and is defined as the ‘spontaneous
rupture of membranes that occurs before the onset of labor’.

Diagnosis
o Most cases can be diagnosed based on history and physical
examination
o Avoid digital examination due to infection risk, unless delivery
appears to be immediate
o Speculum examination
 Visualization of amniotic fluid (AF) leaking through the
cervix
 Vaginal pooling
 pH testing
 Normal: 4.5-6.0
 AF: 7.1-7.3
 False positives: Blood or semen, alkaline
antiseptics or BV
 False negatives: Minimal remaining AF following
rupture
o If above inconclusive consider
 Ultrasound for AFV may be helpful but not diagnostic
 Fetal fibronectin is sensitive with high negative predictive
value but positive result is not diagnostic
 Conclusive test: Ultrasound guided dye with passage into
the vagina and detected with tampon or pad stain
 Maternal urine may turn blue following instillation of
indigo carmine

PROM at < 24 Weeks

Clinical Considerations
 o Survival with PROM ≥ 22 weeks is significantly higher (57.7%)
than <22 weeks (14.4%)
 Survival rates are likely overestimated
 Combination of birthweight, gestational age and sex will
impact morbidity/mortality
 Individualize risks
o Maternal complications: infection | endometritis | abruption |
retained placenta
 Maternal sepsis risk of 1%
o Latency
 40-50% will deliver within 1 week and 70-80% will deliver
within 2-5 weeks
o Pulmonary hypoplasia
 Will occur in approximately 10-20% of cases
 Insufficient data to recommend ultrasound for
determination of lung volumes or function
o Oligohydramnios can result in Potter’s deformation sequence
 Low-set ears | recessed chin | prominent bilateral
epicanthal folds
 Limb contractures
 Skeletal malformations

Management

o Counsel regarding risks and benefits of expectant management

vs immediate delivery
 Immediate delivery should be offered as an option
o If patient chooses expectant management and no infection
 Outpatient surveillance is an option
 Give information to return to hospital immediately if
signs or symptoms of bleeding, labor or infection
(self-monitor temperature)
 Advise return to hospital at time of viability
o Corticosteroids and latency antibiotics: Data currently limited at
<24 weeks
 Offering antibiotics as early as 20w0d is an option
 Consider offering a single course of corticosteroids as
early as 23w0d of gestation due to risk of delivery within
7 days
 o Antenatal corticosteroids and latency antibiotics (see below for
Preterm PROM) are recommended upon reaching viability

Preterm PROM at 24w0d-33w6d

o Expectant management in a hospital setting is recommended
 If there are maternal and/or fetal contraindications to
expectant management, delivery is recommended
 Proceed to delivery at 34w0d
o If a patient opts for expectant management beyond 34w0d,
discuss risks benefits
 Expectant management should not extend beyond
37w0d
o Antenatal (single course) corticosteroids are recommended
o Latency antibiotics are recommended
 Eunice Kennedy Shriver NICHD MFMU Network trial
regimen
 IV ampicillin [2 g every 6 hours] and erythromycin
[250 mg every 6 hours] for 48 hours followed by
oral amoxicillin [250 mg every 8 hours] and
erythromycin base [333 mg every 8 hours]
 Amoxicillin–clavulanic acid
 Not recommended due to increased risk for
necrotizing enterocolitis
 Allergy to β-lactam antibiotics
 Not well studied but erythromycin alone may be an
alternative
 Unclear as to whether cerclage should be removed or
retained but if retained, antibiotic therapy should not be
extended beyond 7 days
o Patients with PROM before 32w0d and imminent delivery are
candidates for fetal neuroprotective treatment with magnesium
sulfate (MgS04)
o HSV infection and Preterm PROM
 Risk of vertical transmission is 30-50% with primary HSV
and 3% with recurrent HSV
 Recurrent active HSV
 Expectant management is recommended
 Initiate HSV therapy
  Cesarean section is indicated if active disease or
prodromal symptoms are present at time of
delivery
 Primary HSV
 Management less clear due to high risk of vertical
transmission
 HSV therapy is recommended
 Cesarean delivery recommended if active lesions
are present
o HIV infection and Preterm PROM
 Optimal management is uncertain due to concern of
vertical transmission with PROM
 Management should include a physician with expertise in
the management of HIV in pregnancy and standard HIV
guidelines should be followed
 Most recent data suggest that vertical transmission risk
my not be increased if the patient is on highly active
antiretroviral therapy with a low viral load and has
received antepartum and intrapartum zidovudine
 Management should be individualized
 If gestational age is early, but patient is on
appropriate therapy with a low viral load expectant
management may be appropriate

Late Preterm, Early Term and Term

PROM (≥ 34w0d)
o Delivery is recommended
 If no spontaneous labor, induce labor with oxytocin
 Allow adequate time (12-18 hours) for latent phase
to progress before performing a cesarean section
for failed induction of labor
 Induction with prostaglandins equally as effective as
oxytocin but may have higher rates of chorioamnionitis
 Insufficient data to recommend for or against cervical
ripening with mechanical methods such as a Foley
balloon
 Insufficient evidence to recommend antibiotic prophylaxis
beyond GBS indications
 o If a patient declines delivery and requests expectant
management, counsel regarding risks and benefits
 If fetal and maternal status are reassuring, expectant
management ‘may be acceptable’
o Late preterm (34w0d-36w6d)
 Management is similar to early term and term, except
that if no previous steroids were administered, a single
course of betamethasone may be considered between
34w0d-36w6d

Key Points:
PROM-Related Risks
o Preterm birth
 50% of patients will deliver within 1 week
 Risks associate with prematurity include RDS,
sepsis, IVH and NEC
o Infection
 Preterm PROM and intrauterine inflammation are
associated with increased risk of neurologic injury
 Intraamniotic infection (15-25%)
 Postpartum infection (15-20%)
o Abruption (2-5%)
o Infection and umbilical cord accidents are associated with a 1
to 2% chance for fetal demise

Additional Clinical Considerations

o Membranes may reseal spontaneously leading to good
outcomes
o Hospital admission is recommended if the fetus is viable to
monitor for signs of infection, abruption and fetal compromise
 Acceptable strategy includes periodic ultrasound for fetal
growth and FH monitoring (precise timing not
established)
 No clinical utility evidence for the use of serial WBC
counts or other infectious markers
o Use of tocolysis
 Therapeutic tocolysis is not recommended

o GBS as per standard protocol
 GBS prophylaxis should be given based on prior culture
results or intrapartum risk factors if cultures not
performed or unavailable

PROM Following Amniocentesis

o Risk of PROM following amniocentesis is 1%
o Outpatient, expectant management
o Monitor regularly with ultrasound and counsel patients to watch
for signs of infection, bleeding and/or miscarriage
o Contrary to spontaneous PROM, good outcomes have been
reported
 AF fluid reaccumulated within 1 month in 72% of
patients
 Perinatal survival rate was 91%

Preterm PROM and Future Pregnancies

o Increased risk of recurrent PROM and preterm birth
o Offer progesterone supplementation starting at 16-24 weeks
o Consider cervical length screening
o Consider cerclage for women with the following:
 Current singleton pregnancy
 Prior spontaneous preterm birth < 34 weeks
 Cervical length < 25 mm prior to 24 weeks

Apecguidelines.org. (2018). APEC Guidelines Premature Rupture of Membranes. [online] Available

at: http://apecguidelines.org/wp-content/uploads/2016/07/Premature-Rupture-of-Membranes-9-6-
2016.pdf [Accessed 20 May 2018].

The ObG Project. (2018). ACOG Guidance Update: Diagnosis and Management of PROM (Prelabor
Rupture of Membranes) - The ObG Project. [online] Available at:
https://www.obgproject.com/2017/12/29/acog-guidance-update-diagnosis-management-prom-
prelabor-rupture-membranes/ [Accessed 20 May 2018].