PRETERM PRELABOUR RUPTURE OF MEMBRANES (PPROM)

CLINICAL GUIDELINE FOR DIAGNOSIS AND MANAGEMENT

1. Aim/Purpose of this Guideline
1.1. This guideline gives guidance to obstetricians and midwives on the diagnosis and
management of preterm prelabour rupture of membranes (PPROM).

2. The Guidance
2.1. Preterm prelabour rupture of the membranes (PPROM) is the rupture of the
membranes prior to labour, occurring before 37+0 weeks gestation.
If fetal infection is present spontaneous delivery usually occurs within days of PPROM.
In the absence of infection the pregnancy may continue for weeks or months.1
Definitive diagnosis of intrauterine infection after preterm rupture of membranes is only
possible by culture of amniotic fluid or fetal blood because the majority of cases are
subclinical.
Normal maternal observations (temp, pulse, leucocyte count, C - reactive protein
(CRP) do not exclude intrauterine infection and vaginal swab cultures yield a high false
positive rate.
In addition, as intrauterine infection does not affect placental perfusion and fetal
oxygenation, non-invasive fetal monitoring cardiotocographs (CTG) and biophysical
profiles) may be normal in the presence of infection. 2
2.2. Diagnosis and initial inpatient management
Diagnosis is best made on history of a gush of fluid per vaginum (PV) and clinical
findings. A liquor pool in the upper vagina is the most reliable sign.
All patients should have a sterile speculum examination after 30 minutes bed
rest. The cervix must be visualised and a high vaginal swab (HVS) obtained.
Maternal coughing or straining may assist identification of liquor from the cervix.
Digital examination should be avoided.
Ultrasound may be useful where fetal presentation, size or well-being is in doubt.
Normal amniotic fluid volume on scan, whilst making the diagnosis less likely, does
not preclude PPROM. Conversely, reduced amniotic fluid on ultrasound may have
other causes.
A routine full blood count (FBC), CRP and a full set of maternal observations should
be performed and recorded on a MEOWS chart.

2.3. Prophylactic antibiotics

Administer prophylactic Erythromycin 250mg orally four times daily for 10 days
from diagnosis. This has been shown to be of potential modest benefit for the

neonate in PPROM3. Erythromycin should not be prescribed based upon a

possible diagnosis from history alone.
Co-amoxiclav should not be used because of the association with necrotising
enterocolitis.
Appropriate antibiotics should be given in suspected intrauterine infection,
either intrapartum or to cover caesarean section.
2.4. Uncertain Diagnosis
Where diagnosis is uncertain e.g. a strong history but negative speculum and delay in
confirmation of PPROM is deemed to be clinically important after consultant input,
Actiprom may be used.

2.5. Corticosteroids
Maternal corticosteroids given prophylactically to cases of preterm labour with or
without intact membranes at gestational ages 24-34+6 weeks have demonstrated a
50% reduction in neonatal death, respiratory distress and intraventricular
haemorrhage. In cases of PPROM, steroids do not increase the risk of neonatal
sepsis or chorioamnionitis but do increase the risk of endometritis.3
Two doses of Betamethasone 12mg are to be given, 24 hours apart.

Tocolysis in women with PPROM is not recommended because this treatment does
not significantly improve perinatal outcome. However, it may be used to allow inutero
transfer.4
The tocolytic of first choice is Atosiban. Prophylactic tocolysis to women with PPROM
who are not contracting should not be given.
The risk of infection is highest in the first few days after diagnosis and the length of
inpatient management should be individualised, taking into account the gestation,
other obstetric risk factors, where the woman lives and her social circumstances.
Women should be advised admission for at least 48 hours in view of the increased risk
of infection during this time.
2.6. Outpatient Management
Expectant management at home is safe after initial observation in hospital.5
The woman should be advised of the following:
Check her temperature 4 to 8 hourly
Avoid intercourse
If expectant management is appropriate, the woman should attend the Day
Assessment Unit (DAU) weekly for clinical evaluation and CTG. It is not necessary to
carry out weekly maternal FBC or C-reactive protein because the sensitivity of these
tests in the detection of intrauterine infection is low. Any additional assessments, in
the community or DAU, will be at the discretion of the obstetric team. If liquor drainage
stops, the accuracy of the diagnosis should be re-evaluated.
The woman should be instructed to contact DAU or Delivery Suite out of hours if:
Contractions establish
Preterm Prerupture PPROM

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There is vaginal bleeding

The liquor is green or offensive
She feels unwell or has a raised temperature above 37.4oC
Fetal movements are reduced
2.7. Timing of delivery
Many studies have demonstrated benefits in conservative management <34 weeks
gestation but management from 34-37 weeks is contentious.
In the absence of spontaneous preterm labour or complications such as infection that
require intervention <34 weeks, induction of labour > 34 weeks should be discussed.
RCOG Guidance suggests that delivery should be considered at 34 weeks in the
knowledge that there is little evidence that intentional delivery after 34 weeks
adversely affects neonatal outcome.
For expectant management after 34 weeks women should be counselled about the
increased risk of chorioamnionitis and its consequences versus the decreased risk of
serious respiratory problems in the neonate, admission for neonatal intensive care and
caesarean section.
Care should be individualised after careful discussion with the woman.
Counselling should bear in mind that it is self-evident that the risk of infection will be
higher with expectant management but the quoted risk in studies is small with no
longer term neonatal sequelae.
For induction of labour at 34 weeks, the issues of impaired bonding/breastfeeding,
prolonged hospitalisation and neonatal unit workload are not considered in the RCOG
guidance.
If expectant management is selected by the woman, there is no evidence to guide
practice after >37 weeks. Induction of labour will usually be offered at 37 weeks
because the maternal and neonatal morbidity associated with term induction for this
indication is low. However, a Consultant may, in discussion with the woman, opt for
on-going expectant management.
Irrespective of the gestational age, care must be made to ensure that the diagnosis of
PPROM remains accurate before starting induction of labour in order to minimise the
risk of failed induction.
2.8. Spontaneous preterm labour
If labour establishes preterm then Group B streptococcal (GBS) antibiotic prophylaxis
should be offered as per the preterm labour guideline7, 8.
2.9. PPROM and asymptomatic Group B streptococcus9
There is no good evidence base to guide management of PPROM in the presence of
GBS. Women will receive Erythromycin (section 2.3. Prophylactic antibiotics)
but there is no evidence that IV antibiotics are indicated until labour is established.
There is no evidence that the timing of delivery should be influenced by the
asymptomatic carriage of GBS.
Preterm Prerupture PPROM

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3. Monitoring compliance and effectiveness

Element to be
monitored

Counselling: active management versus expectant

management
Did the woman receive GBS antibiotic prophylaxis if required?

Lead

Maternity Risk Manager.

Tool

Compliance Monitoring Tool.

Frequency

This audit will be added to the rolling audit programme and will take
place every three years.

Reporting
arrangements

Perinatal Audit Forum

Maternity Risk Management Forum

Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to be
shared

Maternity Risk Manager

Any lessons learnt will be fed back through the Maternity Risk
Management Forum and shared via the monthly Risk Management
Newsletter

4. Equality and Diversity

4.1.
This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement which can be found in the 'Equality,
Diversity & Human Rights Policy' or the Equality and Diversity website.
4.2.
Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.

Preterm Prerupture PPROM

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Appendix 1. Governance Information

Document Title

PRETERN PRELABOUR RUPTURE OF

MEMEBRANES (PPROM) CLINICAL
GUIDELINE FOR DIAGNOSIS AND
MANAGEMENT

Date Issued/Approved:

9th January 2014

Date Valid From:

9th January 2014

Date Valid To:

9th January 2017

Directorate / Department responsible

(author/owner):

Dr Rob Holmes
Consultant Obstetrician
Obs and Gynae Directorate

Contact details:

01872 252727
This guideline gives guidance to
obstetricians and midwives on the diagnosis
and management of preterm prelabour
rupture of membranes (PPROM).

Brief summary of contents

Rupture, membranes, PPROM, PROM,

SROM, ruptured, membranes, prolonged,
speculum, Erythromycin, steroids,
premature, Betamethasone
RCHT
PCH
CFT
KCCG

Suggested Keywords:

Target Audience
Executive Director responsible for
Policy:

Medical Director

Date revised:

9th January 2014

This document replaces (exact title of

previous version):

Guideline for the management of pre term pre

labour rupture of membranes

Approval route (names of

committees)/consultation:

Maternity Guideline Group

Obs & Gynae Directorate
Divisional Board

Divisional Manager confirming

approval processes

Head of Midwifery

Name and Post Title of additional

signatories

Not Required

Signature of Executive Director giving

approval
Publication Location (refer to Policy
on Policies Approvals and
Ratification):
Preterm Prerupture PPROM

Internet & Intranet

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Intranet Only

Document Library Folder/Sub Folder

Clinical/Midwifery and Obstetrics

Links to key external standards

None
1. Carroll SG, Ville Y, Greenough A,
Gamsu H, Patel B, Philpott-Howard J
and
Nicolaides
KH.
Preterm
Prelabour amniorrhexis: Intrauterine
infection and interval between
membrane rupture and delivery.
Arch Dis Child 1995;72:F43-46
2. Carroll SG, Papaioannou S, and
Nicolaides KH. Assessment of fetal
activity and amniotic fluid volume in
pregnancies complicated by preterm
prelabour amniorrhexis. Am J Obstet
Gynecol 1995;172:1472-1435
3. RCOG Clinical guideline No. 44
2010. Preterm prelabour rupture of
membranes

Related Documents:

4. Kenyon SL, Taylor DJ, TarnowMordi W. ORACLE Group. Broadspectrum antibiotics for preterm,
prelabour rupture of the fetal
membranes:
the
ORACLE
I
randomised
trial.
Lancet
2001;357(9261):979-88
5. RCOG Clinical guideline No. 7 2004.
Antenatal corticosteroids to prevent
respiratory distress syndrome
6. RCOG Clinical guideline No 1 (B)
2002. Tocolytic drugs for women in
preterm labour
7. Carlan SJ et al. Preterm premature
rupture of the membranes: A
randomised study of home versus
hospital
management.
Obstet
Gynecol 1991;81:61-64
8. RCHT The Management of
Threatened and Established Preterm
Labour. Nov 2010
9. RCOG Clinical Guideline No.36:
Prevention of early onset neonatal
group B streptococcal disease

Preterm Prerupture PPROM

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Training Need Identified?

No

Version Control Table

Date

Version
No

Summary of Changes

Changes Made by
(Name and Job Title)

Nov 2008 1.0

Initial issue

Rob Holmes
Obstetric Consultant

Nov 2010

1.1

Updated

Rob Holmes
Obstetric Consultant

9th
January
2014

1.2

Minor changes and updated to new best

evidence

Rob Holmes
Obstetric Consultant

All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.

Preterm Prerupture PPROM

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Appendix 2. Initial Equality Impact Assessment Form

Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter
referred to as policy) (Provide brief description): Preterm Prelabour Rupture Of Membranes
(PPROM) Clinical Guideline For Diagnosis And Management
Directorate and service area:
Is this a new or existing Policy?
Obs & Gynae Directorate
Existing
Name of individual completing
Telephone:
assessment: Elizabeth Anderson
01872 252879
1. Policy Aim*
To give guidance to obstetricians and midwives on the diagnosis and
Who is the strategy /
management of preterm, prelabour rupture of membranes (PPROM).
policy / proposal /
service function
aimed at?
2. Policy Objectives*
To ensure women receive an accurate diagnosis and appropriate
management of preterm prelabour rupture of membranes
3. Policy intended
Outcomes*

To ensure women receive a diagnosis and correct management for

preterm prelabour rupture of membranes according to best evidence.

4. *How will you

measure the
outcome?
5. Who is intended to
benefit from the
policy?
6a) Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around
this policy?

Compliance Monitoring Tool.

b) If yes, have these

*groups been
consulted?

N/A

C). Please list any

groups who have
been consulted about
this procedure.

N/A

All pregnant women.

No

7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands:

Age

Preterm Prerupture PPROM

Yes

No

Rationale for Assessment / Existing Evidence

All pregnant women

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Sex (male, female,

trans-gender / gender
reassignment)

All pregnant women

Race / Ethnic
communities /groups

All pregnant women

Disability learning
disability, physical
disability, sensory
impairment and
mental health
problems
Religion /
other beliefs

All pregnant women

All pregnant women

Marriage and civil

partnership

All pregnant women

Pregnancy and
X
All pregnant women
maternity
Sexual Orientation,
X
All pregnant women
Bisexual, Gay,
heterosexual, Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
You have ticked Yes in any column above and
No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
Major service redesign or development
8. Please indicate if a full equality analysis is recommended.
Yes
No
X
9. If you are not recommending a Full Impact assessment please explain why.
N/A
Signature of policy developer / lead manager / director
Rob Holmes
Obstetric Consultant
Names and signatures of
1. Rob Holmes
members carrying out the
2. Elizabeth Anderson
Screening Assessment

Date of completion and submission

9th January 2014

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD
A summary of the results will be published on the Trusts web site.
Signed: Elizabeth Anderson
Date : 9th January 2014
Preterm Prerupture PPROM

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Appendix 3: Recommended Management of Preterm Prelabour Rupture of

Membranes (PPROM)

No Infection

Infection

Discuss risks and

benefits of induction of
labour versus expectant
management until term
+ 10 DAYS Erythromycin
250mg qds

> 34 weeks

Labour induction
+ broad spectrum intrapartum
antibiotics

Expectant management
+ corticosteroids
+ TEN DAYS
Erythromycin 250mg
qds
+/- tocolysis

24-34 weeks

Careful assessment by an
experienced obstetrician for
consideration of expectant
management
+ antibiotics
+ corticosteroids

Expectant management
or
termination of
pregnancy (TOP)

Preterm Prerupture PPROM

< 24 weeks

Expectant management
+ antibiotics
or
TOP + antibiotics

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