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Management of Premature Rupture of Membranes

November 14, 2013

Management of Premature Rupture of Membranes

  1. Allison Bryant, MD, MPH

ACOG advises induction of labor at term or early term; in the absence of indications for delivery, expectant management is recommended between 24 and 34 weeks' gestation.

  1. Allison Bryant, MD, MPH

Sponsoring Organization: American College of Obstetricians and Gynecologists (ACOG)

Target Population: Obstetric care providers

Background and Objective

Most women with premature rupture of membranes (PROM) at term will deliver within 28 hours; for preterm PROM (PPROM), half of women will deliver within 1 week. ACOG has updated its recommendations for management of PROM.

Key Recommendations

Term and Early Term PROM (>37 0/7 weeks); Late PPROM (34 0/7–36 6/7 weeks)

  • Compared with expectant management, induction of labor is associated with shorter latency to delivery and lower risk for maternal infection without excess risk for cesarean delivery.

  • Candidates for vaginal delivery should be offered immediate induction, generally with oxytocin.

  • For women who decline induction, expectant management with close monitoring and informed consent is reasonable.

  • Intrapartum prophylaxis for group B streptococci (GBS) should be administered to at-risk women.

PPROM (24 0/7–33 6/7 weeks)

  • Expectant management is recommended; indications for delivery include nonreassuring fetal status, chorioamnionitis, and placental abruption.

  • A single course of antenatal glucocorticoids should be given to lower risk for respiratory distress syndrome and other morbidities associated with prematurity.

  • Magnesium sulfate for fetal neuroprotection should be considered if delivery seems imminent before 32 0/7 weeks' gestation.

  • A 7-day course of antibiotics to prolong pregnancy is advised.

  • Intrapartum prophylaxis for GBS should be administered to at-risk women.

Previable PPROM (<24 0/7 weeks)

  • Risk for perinatal death is nearly 60%, and risk for pulmonary hypoplasia approaches 20%.

  • Likelihood of maternal infection and bleeding complications is substantial.

  • Women should be counseled about the risks associated with continuing a pregnancy after previable PPROM; pregnancy termination should be offered.

  • Outpatient expectant management can be considered; latency antibiotics, glucocorticoids, and tocolytics have no role before 24 completed weeks' gestation.

  • Outcomes are remarkably better for amniocentesis-related (vs. spontaneous) second-trimester PPROM.

Comment

Risks for fetal and maternal morbidity and even mortality in the setting of premature rupture of membranes are not trivial. Clinicians with a high index of suspicion for intraamniotic infection must be prepared to act swiftly when faced with this complication, irrespective of fetal gestational age.

  • Disclosures for Allison Bryant, MD, MPH at time of publication Nothing to disclose

Citation(s):

Reader Comments (1)

Tarik Zamzami Physician, Obstetrics/Gynecology, KAUH, Jeddah, SA

PROM at term with unfavorable cervix expectant management vs immediate induction is safer and majority of patients start spontaneous onset of labor during the first 24 hours, not only in case of prior 1 cs and reduce failed induction.

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