11/17/2016 Premature Rupture of Membranes: Overview, Premature Rupture of Membranes (at Term), Premature Preterm Rupture of Membranes

Thissiteisintendedforhealthcareprofessionals

PrematureRuptureofMembranes
Updated:Jun16,2016
Author:AllahyarJazayeri,MD,PhD,FACOG,DACOG,FSMFMChiefEditor:CarlVSmith,
MDmore...

OVERVIEW

Overview
Prematureruptureofmembranes(PROM)referstoapatientwhoisbeyond37weeks'
gestationandhaspresentedwithruptureofmembranes(ROM)priortotheonsetoflabor.
Pretermprematureruptureofmembranes(PPROM)isROMpriorto37weeks'gestation.
Spontaneouspretermruptureofthemembranes(SPROM)isROMafterorwiththeonsetof
laboroccurringpriorto37weeks.ProlongedROMisanyROMthatpersistsformorethan24
hoursandpriortotheonsetoflabor.

Atterm,programmedcelldeathandactivationofcatabolicenzymes,suchascollagenase
andmechanicalforces,resultinrupturedmembranes.PretermPROMoccursprobablydue
tothesamemechanismsandprematureactivationofthesepathways.However,early
PROMalsoappearstobelinkedtounderlyingpathologicprocesses,mostlikelydueto
inflammationand/orinfectionofthemembranes.Clinicalfactorsassociatedwithpreterm
PROMincludelowsocioeconomicstatus,lowbodymassindex,tobaccouse,pretermlabor
history,urinarytractinfection,vaginalbleedingatanytimeinpregnancy,cerclage,and
amniocentesis.[1]

Eightyfivepercentofneonatalmorbidityandmortalityisaresultofprematurity.PPROMis
associatedwith3040%ofpretermdeliveriesandistheleadingidentifiablecauseofpreterm
delivery.PPROMcomplicates3%ofallpregnanciesandoccursinapproximately150,000
pregnanciesyearlyintheUnitedStates.[2]WhenPPROMoccursremotefromterm,
significantrisksofmorbidityandmortalityarepresentforboththefetusandthemother.
Thus,thephysiciancaringforthepregnantwomanwhosepregnancyhasbeencomplicated
withPPROMplaysanimportantroleinmanagementandneedstobefamiliarwithpotential
complicationsandpossibleinterventionstominimizerisksandmaximizetheprobabilityof
thedesiredoutcome.Thisarticlefocusesoninformationthephysicianneedstoachieve
thesegoals.[1,3,4]

Forpatienteducationresources,seethePregnancyCenterandLaborSigns.

PrematureRuptureofMembranes(atTerm)
Prematureruptureofmembranes(PROM)attermisruptureofmembranespriortotheonset
oflaboratorbeyond37weeks'gestation.PROMoccursinapproximately10%of
pregnancies.PatientswithPROMpresentwithleakageoffluid,vaginaldischarge,vaginal
bleeding,andpelvicpressure,buttheyarenothavingcontractions.

ROMisdiagnosedbyspeculumvaginalexaminationofthecervixandvaginalcavity.Pooling
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offluidinthevaginaorleakageoffluidfromthecervix,ferningofthedriedfluidunder
microscopicexamination,andalkalinityofthefluidasdeterminedbyNitrazinepaperconfirm
thediagnosis.

BloodcontaminationoftheNitrazinepaperandferningofcervicalmucusmayproducefalse
positiveresults.PoolingoffluidisbyfarthemostaccuratefordiagnosisofROM.Ifallfluid
hasleakedoutasinearlyPROM,anultrasonographicexaminationmaythenshowabsence
oforverylowamountsofamnioticfluidintheuterinecavity.

NewevidencesuggeststhattheuseofbiochemicalmarkerstodiagnoseROMinuncertain
casesmaybeappropriateandcosteffective.Echebirietalreportedcosteffectiveness
comparedtostandardmethodsofdiagnosesbetween34and37weeks.[5]

Ngetalreportedplacentalalphamicroglobulin1levelshavea95.7%sensitivity,100%
specificity,100%positivepredictivevalue,and75%negativepredictivevalue.[6]Inselect
caseswhenthediagnosesorROMisnotclear,placentalalphamicroglobulin1shouldbe
usedtoprovideadditionalinformationforappropriatemanagement.

Giventheimportanceofmakingthecorrectdiagnoses,theassociatedmorbiditywith
hospitalizationanddeliverypriortoterminPROMreaching34weeksandbeyond,andthe
potentialneonatalmorbidityresultingfromprematurityincasesofincorrectdiagnosesof
PROM,itismandatorytoconfirmthediagnosisofPROMwithpoolingofamnioticfluidwith
someevidenceofdecreasedorabsenceofamnioticfluidinallcasesofsuspectedPROM.

Mostpatients(90%)enterspontaneouslaborwithin24hourswhentheyexperienceROMat
term.Themajorquestionregardingmanagementofthesepatientsiswhethertoallowthem
toenterlaborspontaneouslyortoinducelabor.Inlargepart,themanagementofthese
patientsdependsontheirdesireshowever,themajormaternalriskatthisgestationalageis
intrauterineinfection.TheriskofintrauterineinfectionincreaseswiththedurationofROM.
Evidencesupportstheideathatinductionoflabor,asopposedtoexpectantmanagement,
decreasestheriskofchorioamnionitiswithoutincreasingthecesareandeliveryrate.[7,8]

Hannahetalstudied5041womenwithPROMwhowererandomlyassignedtoinductionof
laborwithintravenousoxytocinorvaginalprostaglandinE2gelversusexpectant
managementforasmanyas4dayswithinductionoflaborforcomplications.[9]They
concludedthat,inwomenwithPROM,inductionoflaborandexpectantmanagement
resultedinsimilarratesofcesareandeliveryandneonatalinfection.However,inductionwith
oxytocinresultedinalowerriskofmaternalinfection(endometritis)whencomparedwith
expectantmanagement.Additionally,thewomeninthestudyviewedinductionoflabormore
favorablythanexpectantmanagement.

Othersmallerstudieshaveshownresultswithhighercesareanand/oroperativedelivery
rateswhenthecervixwasunfavorable.

Atterm,infectionremainsthemostseriouscomplicationassociatedwithPROMforthe
motherandtheneonate.TheriskofchorioamnionitiswithtermPROMhasbeenreportedto
belessthan10%andtoincreaseto40%after24hoursofPROM.[10]Thispointsoutthe
importanceofappropriatemanagementstrategiesforPROMatterm.

SinceriskofinfectionattermwithROMissmallduringthefirst24hours,expectant
managementandwaitingforspontaneouslabormaybeconsideredinselectedpatientsfor
thefirst1224hoursifapatientdesiresexpectantmanagement.Theuseofexpectant
managementafterthefirst24hoursisquestionable.

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Digitalvaginalexaminationsshouldbeavoideduntillaborisinitiatedhowever,fetal
presentationshouldbedocumentedtoavoiddiscoveringmalpresentationofthefetuslong
afteradmissionforROM.AllpatientswithROMshouldbeaskedtocometothehospitalto
ensurefetalwellbeing.

TheneonatalrisksofexpectantmanagementofPROMincludeinfection,placental
abruption,fetaldistress,fetalrestrictiondeformitiesandpulmonaryhypoplasia,and
fetal/neonataldeath.Fetaldeathdoesoccurinapproximately1%ofpatientswithPROM
afterviabilitywhohavebeenexpectantlymanaged[1]andinabout1:1000termPROM.[11]

Theprimarydeterminantofneonatalmorbidityandmortalityisgestationalageatdelivery,
againstressingtheimportanceofconservativemanagementwhenpossible.(Seethe
GestationalAgefromEstimatedDateofDeliverycalculator.)

Ingeneral,prognosisisgoodafter32weeks'gestationaslongasnoothercomplicating
factor,suchascongenitalmalformationorpulmonaryhypoplasia,exists.

PrematurePretermRuptureofMembranes
Prematurepretermruptureofmembranes(PPROM)occurringfrom2437weeks'gestation
isfarmoredifficulttomanagethanprematureruptureofmembranes(PROM)atterm.
Severalissuesneedtobeconsideredinformulatingaplanofmanagement.Prematurityis
theprincipalrisktothefetus,whileinfectionmorbidityanditscomplicationsaretheprimary
maternalrisks.AllplansformanagementofPPROMremotefromtermshouldincludethe
familyandthemedicalteamcaringforthepregnancy,includingtheneonatalandmaternal
medicalteam.Remotefromterm,PPROMshouldonlybecaredforinfacilitieswherea
NICUisavailableandcapableofcaringfortheneonate.BecausemostPPROM
pregnanciesdeliverwithinaweekofROM,transferofthepregnantmothertoaqualified
facilityisurgentandshouldbefacilitatedimmediatelyupondiagnoses.

ThevastmajorityofwomenproceedtoactivelaboranddeliversoonafterPPROM.With
appropriatetherapyandconservativemanagement,approximately50%ofallremaining
pregnanciesdelivereachsubsequentweekafterPPROM.Thus,veryfewwomenremain
pregnantmorethan34weeksafterPPROM.Thisisimportantinformationtogivethe
womanconsideringexpectantmanagementremotefromviability.[1]

Spontaneoussealingofthemembranesdoesoccuroccasionally(<10%ofallcases),
mostlyafterPPROMthathasoccurredsubsequenttoamniocentesishowever,thisisthe
exceptionratherthantherule.

Severalareasofcontroversiesexistregardingthebestmedicalapproachormanagementof
PROMremotefromterm.Expectantmanagementandimmediatedeliveryarepotential
optionsinthesepatients,andeachhasitsownadvantagesanddisadvantages.With
appropriatecare,thematernalrisksofexpectantmanagementaregenerallyacceptedtobe
minimalandaclearneonataladvantageexistsbyreducingrisksofprematurity.

Controversiesexistastointerventionssuchassteroidsforaccelerationoflungmaturity,
antibiotics,andtocolytics.SeeMedicalTreatment.

AstudybyEkinetalsuggestedthatmeanplateletvolume(MPV)inthefirsttrimesterof
pregnancycanbeusedtopredictthelikelihoodofPPROM.Inaretrospectiverecordreview
of318womenwithPPROMand384controls,theinvestigatorsfoundthat,comparingvalues
betweenthe7thand14thweeksofgestation,theMPVsweresignificantlylowerandthe

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plateletcountssignificantlyhigherinpatientswhohadexperiencedPPROMthaninpregnant
womenwhohadnot.Usingcutoffvaluesoflessthanorequalto8.6fLforMPVandgreater
thanorequalto216x103/Lforplateletcount,thestudyfoundthatthesemeasurements
hadasensitivityandspecificityforpredictingPPROMof58%and65%,respectively,and
62%and44%,respectively.EkinandcolleaguesconcludedthatMPVismoreefficientthan
plateletcountforpredictingPPROM.[12]

MaternalandFetalSurveillance
Afteraninitialperiodofcontinuousmonitoringoffetalheartrateanduterinecontractions
(2448h),iffindingsaresuggestiveofreassuringsurveillance,thenthepatientwouldbea
candidateforexpectantmanagement.Ingeneral,commonpracticehasbeentoplacethe
patientonbedrestontheobstetricfloor.However,thetheexistingdatashownobenefitto
bedrestforanyobstetriccondition.Becausebedrestinpregnancyisassociatedwithan
increasedchanceofdeepvenousthrombosis,prophylaxistoreducethisriskshouldbe
instituted.

Inaddition,fetalmonitoringshouldbeperformedatleastonceaday.Ifevidenceoffrequent
cordcompressionispresentasdeterminedbymoderatetoseverevariables,continuous
monitoringshouldbereinstituted.Maternalvitalsneedtobemonitoredclosely.Tachycardia
andfeverarebothsuggestiveofchorioamnionitisandrequirecarefulevaluationto
determinethepresenceofintraamnioticinfections,inwhichcasedeliveryandinitiationof
broadspectrumantibioticsshouldbepromptlyfacilitated.

Ultrasonographicexaminationforamnioticfluidindexandfetalgrowthandwellbeingshould
beusedliberallytoensureappropriatenessofcontinuedexpectantmanagement.While
oligohydramnios,definedasanamnioticfluidindexoflessthan2cm,hasbeenassociated
withshortlatencyandchorioamnionitis,italoneisnotanindicationfordeliverywhenother
meansofsurveillancearereassuring.Whitebloodcellcountisnotpredictiveofoutcome
anddoesnotneedtobemonitoredotherthantosupportclinicalsuspicionof
chorioamnionitis.

Digitalcervicalexaminationsshouldbeavoided.[13]Inanoncephalicpresentation,
especiallywithadilatedcervix,continuousmonitoringshouldbeconsideredtoavoidmissing
thediagnosisofcordprolapse.

Intraamnioticinfectionshouldinvokepromptdelivery.Practitionersshouldhavealow
thresholdfordiagnosinginfectioninapatientwithPPROMasevidenceclearlyshowspoor
outcomeinaninfectedneonatecomparedwithasimilaruninfectedneonate.

PPROMintheSecondTrimester
Prematurepretermruptureofmembranes(PPROM)priortofetalviabilityisauniqueand
relativelyrareproblemthatisoftendifficulttomanage.Itoccursinlessthan0.4%ofall
pregnancies.[14]Themajormaternalriskisinfection,namelychorioamnionitis,whichoccurs
inabout35%abruption,whichoccursin19%andsepsis,whichisrareandoccursinless
than1%.[14]ThemajormorbidityinthefetuswithmidtrimesterROMislethalpulmonary
hypoplasiafromprolonged,severe,earlyoligohydramnios,whichoccursinabout20%of
cases.OthermorbiditiessuchasRDS(66%),sepsis(19%),gradeIIIIVIVH(5%),and
contractures(3%)alsooccurwithhighfrequency,resultinginintactsurvivalratesofmore
than67%.Fetaldeathiscommonandoccursinmorethan30%.[14]

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Olderstudieshavereportedthatapproximately50%ofallremainingpregnanciesdeliver
eachsubsequentweekafterPPROM.[1]Morerecentstudieshaveshownbetterprognosis
andmaybemorerelevanttotodaysclinicalpractice.Withappropriatetherapyand
conservativemanagement,morerecentstudieshavereportedlessthan40%deliveringina
weekandmorethan30%remainingpregnantafter5weeks.Thisinformationisprobably
bettersuitedtobeusedincounselingpatientsregardingearlyPROM.[15]

TheriskofinfectionincreaseswiththedurationofPPROM.Outpatientmanagementof
PPROMpriortoviabilityisappropriateinthewellinformedandeducatedpatient.The
patientneedstobeinformedofwarningsignsthatindicatetheneedforimmediate
evaluation.Thesesignsincludefever,abdominalpain,vaginalspotting,foulsmelling
discharge,andrapidheartrate.Thewomanshouldmonitorhertemperatureathomeatleast
3timesdailyandreportanyelevationbeyond100.4F(38C).Frequentexaminationsare
necessarytoensurematernalsafety.Patientsmustbeeducatedaboutthewarningsignsof
intraamnioticinfection,andtheymusttaketheirtemperature3timesadayathome.After
viabilityisreached,inpatientmanagementneedstobeconsidered.

Midtrimester(1326wk)PPROMhasapoorprognosis,althoughmorerecentstudieshave
reportedbetteroutcome.Expectantmanagementmaybeappropriateinselectpatientswho
arewellinformedandeducatedabouttherisksandthedismalprognosisfortheneonate.
Deliveryisalsoappropriatewhenthemotherisconcernedaboutherownrisks,especially
whenPPROMhasoccurredpriorto20weeks'gestation.Incompleteabortionmaybethe
appropriatetermforthecondition,asproductsofconception(theamnioticfluid)have
passedthecervicalopeningandintothevaginainthesecases.Otherheroicmeasuressuch
asamnioinfusion,tocolysis,andcervicalplugtosealthemembranesareunprovenand
shouldbeconsideredinresearchprotocols.

Survivalvarieswithgestationalageatdiagnosis(from12%whendiagnosedat1619wk,to
asmuchas60%whendiagnosedat2526wk).[16]Untilviability,maternalsafetyshouldbe
theprimaryconcern.

ManagementofPPROM
Theinitialevaluationofprematurepretermruptureofmembranes(PPROM)shouldincludea
sterilespeculumexaminationtodocumentROM.CervicalculturesincludingChlamydia
trachomatisandNeisseriagonorrhoeaeandanovaginalculturesforStreptococcus
agalactiaeshouldbeobtained.Maternalvitalsignsshouldbedocumentedaswellas
continuousfetalmonitoringinitiallytoestablishfetalstatus.Ultrasonographicdocumentation
ofgestationalage,fetalweight,fetalpresentation,andamnioticfluidindexshouldbe
established.Digitalexaminationshouldbeavoided,butvisualinspectionofthecervixcan
accuratelyestimatecervicaldilatation.DigitalexaminationofthecervixwithPPROMhas
beenshowntoshortenlatencyandincreaseriskofinfectionswithoutprovidingany
additionalusefulclinicalinformation.[13]

Incertaincircumstances,immediatedeliveryofthefetuswithPPROMisindicated.These
circumstancesincludechorioamnionitis,advancedlabor,fetaldistress,andplacental
abruptionwithnonreassuringfetalsurveillance.Iffetallungmaturityhasbeendocumented
byeitheramniocentesisorcollectionofvaginalfluid,deliveryshouldbefacilitated.Ina
noncephalicfetuswithadvancedcervicaldilatation(morethanorequalto3cm),theriskof
cordprolapsemayalsooutweighthebenefitsofexpectantmanagementanddeliveryshould
beconsidered.

Ifafterinitialevaluationofthemotherandfetus,theyarebothdeterminedtobeclinically
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stable,expectantmanagementofPPROMmaybeconsideredtoimprovefetaloutcome.The
primarymaternalriskwithexpectantmanagementofPPROMisinfection.Thisincludes
chorioamnionitis(1360%),endometritis(213%),sepsis(<1%),andmaternaldeath(12
casesper1000).Complicationsrelatedtotheplacentaincludeabruption(412%)and
retainedplacentaorpostpartumhemorrhagerequiringuterinecurettage(12%).[3]

Therisksandpotentialbenefitsofexpectantmanagementshouldbediscussedwiththe
patientandherfamily,andinformedconsentshouldbeobtained.Thematernalandfetal
statusneedtobereevaluateddaily,andthesafetyandpotentialbenefitsofexpectant
managementshouldbereassessed.Iftheconditionremainsstable,theimmaturefetusmay
benefitfromexpectantmanagement,evenifforashortperiod,toallowadministrationof
steroidsandantibiotics.Oncematurityhasbeenreached,thebenefitfromexpectant
managementofPPROMisunclearandtherisksofinfectionoutweighanypotentialbenefits.

Amniocentesiscanprovideinformationaboutlungmaturityaccuracyandcorrectnessofthe
diagnosesofPROMandinfection.However,inmostcasesofPPROM,theamountoffluidis
scantthus,amniocentesisshouldbeperformedonlybyindividualswithexperiencein
performingdifficultamniocentesis,andtheappropriateriskswithpotentialforfetal
complicationsandtheneedforimmediatedeliveryshouldbediscussedwithpatientsbefore
attemptingamniocentesis.

MedicalTreatmentofPPROM
Antibiotics
TheinitialstepinmanagementofPPROMisinformedconsent.Thepatientneedstobe
givenrisksandbenefitsinformationandmustparticipateindecisionmaking.Oncethe
decisiontomanageapatientexpectantlyhasbeenmade,theinstitutionofbroadspectrum
antibioticsshouldbeconsidered.Multipletrialshaveexaminedtheadvantagesand
disadvantagesofusingantibioticsandthechoiceofantibiotics.Inmoststudies,useof
antibioticshasbeenassociatedwithprolongationofpregnancyandreductionininfantand
maternalmorbidity.However,afewstudieshavereportedincreasedneonatalmorbiditywith
certaintypesofantibiotics,asdiscussedbelow.

TwoofthelargeststudiesthathavelookedattheefficacyofantibioticuseinPPROMarethe
NationalInstituteofChildHealthandHumanDevelopmentMaternalFetalMedicineUnits
(NICHDMFMU)studyofPROMandtheORACLEtrial.IntheNICHDstudy,intravenous
antibioticswereusedfor48hoursampicillin2gq6handerythromycin250mgq6h.The
patientswerethenplacedonoralamoxicillin250mgq8handentericcoated,erythromycin
base333mgq8htocompletea7daycourseofantibiotictherapy.Inthisstudy,thecontrol
group,comparedwiththeantibioticgroup,hadasignificantlyshorterdurationoflatency.The
antibioticgroupwastwiceaslikelytoremainundeliveredafter7days.Theincreasedlatency
continuedforupto3weeksafterdiscontinuationofantibiotics.Compositeandindividual
morbiditiesfortheneonatewerelowerintheantibioticgroup.Theincidenceof
chorioamnionitisandneonatalsepsis,includinggroupBstreptococcisepsis,wasdecreased.
[17]

TheORACLEtrialusederythromycinalone,amoxicillinclavulanicacidalone,oramoxicillin
clavulanicacidincombinationwitherythromycin.Theirresultsweredifferentinthatno
significantdifferencewasnotedinlatencytodeliveryandneonatalmorbiditywasnot
decreasedasdefinedintheirprimaryoutcome(death,chroniclungdisease,andmajor
cerebralabnormalityonultrasonography).Decreasedneedforsupplementaloxygenand
positivebloodcultureresultswereapparent.Whenamoxicillinclavulanicacidwasused
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eitheraloneorincombinationwitherythromycin,anincreasedriskofnecrotizing
enterocolitis(1.9%vs0.5%,p=0.001)waspresent.[18]

Basedoncurrentevidence,7daysofantibiotics,asproposedbytheNICHDMFMUstudyof
PROM,shouldbetheantibioticregimenusedinpatientswithPPROMwhoarebeing
managedexpectantly.Whenanotherantibioticisbeingusedforotherindications,suchasa
urinarytractinfection,attemptsshouldbemadetoavoidduplicatedtherapy.Forexample,a
patientbeingtreatedwithacephalosporinforaurinarytractinfectiondoesnotneed
penicillintherapy.Therapylongerthan7daysshouldbeavoidedithasnotbeenshownto
bemoreeffectiveandmaypromotetheemergenceofresistanceorganisms.

RevisedguidelinesfromtheCentersforDiseaseControlandPrevention(CDC)recommend
thatwomenwithpretermPROMwhoarenotinlaborshouldreceiveintravenousgroupB
streptococcus(GBS)coverageforatleastthefirst48hoursofpretermPROMlatency
prophylaxis,untiltheGBStestresultsobtainedonadmissionareavailable.[19]However,
GBStestresultsshouldnotaffectthedurationofantibiotictherapy.Ifthepatientcompletes
thefull7daycourseofantibioticprophylaxishasnoevidenceofinfectionorlabor,
intrapartumGBSprophylaxiscanbemanagedbasedontheresultsofthebaselineGBStest
atthetimeofpretermPROM,unless5weekshavepassed.ThisisbecauseanegativeGBS
testresultisconsideredvalidfor5weeks.[20,21]

Antenatalcorticosteroidtreatment
Theuseofcorticosteroidstoacceleratelungmaturityshouldbeconsideredinallpatients
withPPROMwithariskofinfantprematurityfrom2434weeks'gestation.Thelatency
periodhasbeensuggestedtobetooshortfortheeffectsofcorticosteroidstomakea
differenceinneonatalmorbidityhowever,thisclearlydoesnotappeartobethecase.Most
patientswithPPROMremainpregnantat48hoursandthuswillbenefitfromcorticosteroid
therapy.Theuseofsteroidshasalsobeensuggestedtoincreasetheriskofinfection.
However,thecurrentevidencedoesnotsupportthisconcernbasedonindividualstudies
andmetaanalysesnodifference(eitherhigherorlowerratesofinfections)hasbeen
observedwithcorticosteroiduse.

Incontrasttotheseconcerns,dataindicatethattheuseofcorticosteroidsreducesneonatal
morbidityandmortality.Theratesofrespiratorydistresssyndrome(RDS),necrotizing
enterocolitis,andintraventricularhemorrhagewerealllowerwheneither12mgof
betamethasoneIMwasgiventwiceina24hourintervalordexamethasone6mgq12hwas
givenfor4doses.[22]

CurrentACOGrecommendations[23,2]

Asinglecourseofcorticosteroidsisrecommendedforpregnantwomen2434weeks'
gestationwhoareatriskofpretermdeliverywithin7daysandasearlyas23weeksif
deliveryisimminent.
Asinglerescuecourseofantenatalcorticosteroidsmaybeconsideredifthe
antecedenttreatmentwasgivenmorethan2weeksprior,thegestationalageisless
than326/7weeks,andthewomanisjudgedbythecliniciantobelikelytogivebirth
withinthenextweek.However,regularlyscheduledrepeatcoursesormorethan2
coursesarenotrecommended.
Furtherresearchregardingtherisksandbenefits,optimaldose,andtimingofasingle
rescuecourseofsteroidtreatmentisneeded.

Tocolytics
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ThemostcommoncauseoflaborinthesettingofPPROMisunderlyingchorioamnionitis.
Theuseoftocolysisinthatsettingisnotjustified.Nodataindicatethatadministering
tocolysisbenefitstheneonate.[24]Inonestudy,prophylactictocolysiswasfoundtobriefly
prolonglatency.InanotherstudybyJazayerietal,latencywasshorterwhenmagnesium
sulfatewasgiven.[25]Theuseoftocolysis,unlikecorticosteroidsandantibiotics,shouldbe
consideredonlywhenaclearclinicalbenefitexists,suchasintransportofthemothertoa
tertiaryinstitutionwithaNICU.

Manylargeclinicalstudieshaveevaluatedneuroprotectivebenefitsfromexposureto
magnesiumsulfateinpretermneonates.Thestudiesshowareductionincerebralpalsyin
survivinginfantswhowereexposedtomagnesium.Noneoftheindividualstudiesfounda
benefitwithregardtotheirprimaryoutcome.However,availableevidencesuggeststhat
magnesiumsulfategivenbeforeanticipatedearlypretermbirthreducestheriskofcerebral
palsyinsurvivinginfants,[26,27]Physicianselectingtousemagnesiumsulfateforfetal
neuroprotectionshoulddevelopspecificguidelinesregardinginclusioncriteria,treatment
regimens,concurrenttocolysis,andmonitoringinaccordancewithoneofthelargertrials.[28]

Inthesestudies,1224hoursofexposurewasusedwitheithera4or6gbolusanda
maintenancedoseof12g.Thesefindingsshouldbediscussedwithpatientsundergoing
expectantmanagementofPROM.[29]

Notethatantenataladministrationofmagnesiumsulfateinpretermchildren(atriskofbeing
deliveredat24.0weeks'gestation)inthesettingofchorioamnionitisdoesnotappearto
provideneuroprotection.[30]

Theuseoftocolysisfor48hourstoadministersteroidsandallowaccelerationoffetallung
maturityhasbeenproposedandisbeingusedbysomeobstetricians.Nodatasupportthe
efficacyofthispracticeand,assuch,whenusedinthismanner,thelackofevidenceto
supportthispracticeshouldbediscussedwithpatientstoallowinformedconsentpriortothe
useoftocolyticsandthepotentialcomplicationsandsideeffects.

Summary
PPROMisacommoncomplicationofpregnancyoccurringinabout3%ofallpregnancies.
TheobstetricianneedstobefamiliarwithappropriatemanagementofPPROM.Highrisk
consultationwithamaternalfetalmedicinesubspecialistshouldbeconsideredinallcasesto
ensureappropriatecurrenttherapyisinstituted.

Ingeneral,thefollowingguidelinesshouldbefollowed:

ROMdiagnosisneedstobeconfirmed.
Digitalvaginalexaminationsshouldbeavoided.
Ultrasonographyshouldbeperformedtoconfirmgestationalage,estimatedfetal
weight,presentation,amnioticfluidindex,andfetalanatomyifnotalreadyfully
evaluated.
Antibioticsneedtobegivenbasedonpresentevidence.SeeMedicalTreatment.
Corticosteroidsshouldbegiventoacceleratelungmaturitybetween24and34weeks.
Informedconsentshouldbeobtainedforexpectantmanagementversusdeliverywith
carefuldocumentationinthechart.
InPPROM,theruleshouldbehospitalizationafterviabilityinaninstitutionwherecare
foraprematureneonatecanbeprovided.
Maternalhealthistheprimaryindicatorfortheneedtodeliver.Anyevidenceof
infectionormaternalinstabilityduetocomplicationsofPPROM,suchasbleeding,
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requirescarefulevaluationanddeterminationoftheappropriatenessofexpectant
management.
Fetalmonitoringshouldbeperformedatleastdailyuntildelivery,andfetalwellbeing
andgrowthshouldbeevaluatedperiodicallywithultrasonography.
After32weeks'andcertainlyafter34weeks'gestation,theappropriatenessof
expectantmanagementofPPROMshouldbereevaluatedindividuallyforeachcase.
PROMattermshouldbemanagedbydeliveryunlessreasonsexisttoconsiderwaiting
forspontaneouslabor.Largeenoughstudiestodocumentneonatalsafetyofexpectant
managementofPROMattermdonotexist.

References

1.MercerB,MilluzziC,CollinM.Periviablebirthat20to26weeksofgestation:
proximatecauses,previousobstetrichistoryandrecurrencerisk.AmJObstet
Gynecol.2005Sep.193(3Pt2):117580.[Medline].

2.PracticeBulletinNo.160:PrematureRuptureofMembranes.ObstetGynecol.2016
Jan.127(1):e3951.[Medline].

3.MercerBM.Pretermprematureruptureofthemembranes:diagnosisand
management.ClinPerinatol.2004Dec.31(4):76582,vi.[Medline].

4.AagaardTilleryKM,NuthalapatyFS,RamseyPS,RaminKD.Pretermpremature
ruptureofmembranes:perspectivessurroundingcontroversiesinmanagement.AmJ
Perinatol.2005Aug.22(6):28797.[Medline].

5.EchebiriNC,McDoomMM,PullenJA,AaltoMM,PatelNN,DoyleNM.Placental
alphamicroglobulin1andcombinedtraditionaldiagnostictest:acostbenefitanalysis.
AmJObstetGynecol.2015Jan.212(1):77.e110.[Medline].

6.NgBK,LimPS,ShafieeMN,etal.ComparisonbetweenAmniSureplacentalalpha
microglobulin1rapidimmunoassayandstandarddiagnosticmethodsfordetectionof
ruptureofmembranes.BiomedResInt.2013.2013:587438.[Medline].

7.PasquierJC,BujoldE.Asystematicreviewofintentionaldeliveryinwomenwith
pretermprelaborruptureofmembranes.JMaternFetalNeonatalMed.2007Jul.
20(7):5678.[Medline].

8.HartlingL,ChariR,FriesenC,VandermeerB,LacazeMasmonteilT.Asystematic
reviewofintentionaldeliveryinwomenwithpretermprelaborruptureofmembranes.J
MaternFetalNeonatalMed.2006Mar.19(3):17787.[Medline].

9.HannahME,OhlssonA,FarineD,etal.Inductionoflaborcomparedwithexpectant
managementforprelaborruptureofthemembranesatterm.TERMPROMStudy
Group.NEnglJMed.1996Apr18.334(16):100510.[Medline].

10.SeawardPG,HannahME,MyhrTL,etal.InternationalMulticentreTermPrelabor
RuptureofMembranesStudy:evaluationofpredictorsofclinicalchorioamnionitisand
postpartumfeverinpatientswithprelaborruptureofmembranesatterm.AmJObstet
Gynecol.1997Nov.177(5):10249.[Medline].

11.MozurkewichE.Managementofprematureruptureofmembranesatterm:an
evidencebasedapproach.ClinObstetGynecol.1999Dec.42(4):74956.[Medline].

12.EkinA,GezerC,KulhanG,etal.Canplateletcountandmeanplateletvolumeduring
http://emedicine.medscape.com/article/261137-overview 9/14
11/17/2016 Premature Rupture of Membranes: Overview, Premature Rupture of Membranes (at Term), Premature Preterm Rupture of Membranes

thefirsttrimesterofpregnancypredictpretermprematureruptureofmembranes?.J
ObstetGynaecolRes.2014Aug11.[Medline].

13.SimhanHN,CanavanTP.Pretermprematureruptureofmembranes:diagnosis,
evaluationandmanagementstrategies.BJOG.2005Mar.112Suppl1:327.[Medline].

14.WatersTP,MercerBM.Themanagementofpretermprematureruptureofthe
membranesnearthelimitoffetalviability.AmJObstetGynecol.2009Sep.
201(3):23040.[Medline].

15.MurisC,GirardB,CreveuilC,DurinL,HerlicoviezM,DreyfusM.Managementof
prematureruptureofmembranesbefore25weeks.EurJObstetGynecolReprodBiol.
2007Apr.131(2):1638.[Medline].

16.VerganiP,GhidiniA,LocatelliA,etal.Riskfactorsforpulmonaryhypoplasiainsecond
trimesterprematureruptureofmembranes.AmJObstetGynecol.1994May.170(5Pt
1):135964.[Medline].

17.MercerBM,MiodovnikM,ThurnauGR,etal.Antibiotictherapyforreductionofinfant
morbidityafterpretermprematureruptureofthemembranes.Arandomizedcontrolled
trial.NationalInstituteofChildHealthandHumanDevelopmentMaternalFetal
MedicineUnitsNetwork.JAMA.1997Sep24.278(12):98995.[Medline].

18.KenyonSL,TaylorDJ,TarnowMordiWORACLECollaborativeGroup.Broad
spectrumantibioticsforpreterm,prelabourruptureoffetalmembranes:theORACLEI
randomisedtrial.ORACLECollaborativeGroup.Lancet.2001Mar31.357(9261):979
88.[Medline].

19.ACOG.Practicebulletinno.120:useofprophylacticantibioticsinlaboranddelivery.
ObstetGynecol.2011Jun.117(6):147283.[Medline].

20.VeraniJR,McGeeL,SchragSJ.PreventionofperinatalgroupBstreptococcal
diseaserevisedguidelinesfromCDC,2010.MMWRRecommRep.2010Nov19.
59:136.[Medline].

21.ACOG.ACOGCommitteeOpinionNo.485:PreventionofearlyonsetgroupB
streptococcaldiseaseinnewborns.ObstetGynecol.2011Apr.117(4):101927.
[Medline].

22.ACOGPracticeBulletinNo.80:prematureruptureofmembranes.Clinical
managementguidelinesforobstetriciangynecologists.ObstetGynecol.2007Apr.
109(4):100719.[Medline].

23.ACOGCommitteeOpinionNo.475:Antenatalcorticosteroidtherapyforfetal
maturation.ObstetGynecol.2011Feb.117(2Pt1):4224.[Medline].

24.MercerBM.Istherearolefortocolytictherapyduringconservativemanagementof
pretermprematureruptureofthemembranes?.ClinObstetGynecol.2007Jun.
50(2):48796.[Medline].

25.JazayeriA,JazayeriMK,SutkinG.Tocolysisdoesnotimproveneonataloutcomein
patientswithpretermruptureofmembranes.AmJPerinatol.2003May.20(4):18993.
[Medline].

26.MellerCH,IzbizkyG,OtanoL.Updateontheuseofmagnesiumsulphateforfetal
neuroprotectioninpretermbirth.ArchArgentPediatr.2015Aug.113(4):34551.
http://emedicine.medscape.com/article/261137-overview 10/14
11/17/2016 Premature Rupture of Membranes: Overview, Premature Rupture of Membranes (at Term), Premature Preterm Rupture of Membranes

[Medline].

27.BouetPE,BrunS,MadarH,etal.Implementationofanantenatalmagnesiumsulfate
protocolforfetalneuroprotectioninpreterminfants.SciRep.2015Sep29.5:14732.
[Medline].

28.DeSilvaDA,SawchuckD,vonDadelszenP,etal.Magnesiumsulphateforeclampsia
andfetalneuroprotection:acomparativeanalysisofprotocolsacrossCanadiantertiary
perinatalcentres.JObstetGynaecolCan.2015Nov.37(11):97587.[Medline].

29.CommitteeOpinionNo.455:Magnesiumsulfatebeforeanticipatedpretermbirthfor
neuroprotection.ObstetGynecol.2010Mar.115(3):66971.[Medline].

30.KamyarM,ManuckTA,StoddardGJ,VarnerMW,ClarkE.Magnesiumsulfate,
chorioamnionitis,andneurodevelopmentafterpretermbirth.BJOG.2015Jun3.
[Medline].

31.AlcalayM,HourvitzA,ReichmanB,etal.Prelabourruptureofmembranesatterm:
earlyinductionoflabourversusexpectantmanagement.EurJObstetGynecolReprod
Biol.1996Dec27.70(2):12933.[Medline].

32.FarooqiA,HolmgrenPA,EngbergS,SereniusF.Survivaland2yearoutcomewith
expectantmanagementofsecondtrimesterruptureofmembranes.ObstetGynecol.
1998Dec.92(6):895901.[Medline].

33.HannahME,HodnettED,WillanA,etal.Prelaborruptureofthemembranesatterm:
expectantmanagementathomeorinhospital?TheTermPROMStudyGroup.Obstet
Gynecol.2000Oct.96(4):5338.[Medline].

34.KilbrideHW,YeastJ,ThibeaultDW.Defininglimitsofsurvival:lethalpulmonary
hypoplasiaaftermidtrimesterprematureruptureofmembranes.AmJObstetGynecol.
1996Sep.175(3Pt1):67581.[Medline].

35.LauriaMR,GonikB,RomeroR.Pulmonaryhypoplasia:pathogenesis,diagnosis,and
antenatalprediction.ObstetGynecol.1995Sep.86(3):46675.[Medline].

36.LewisDF,FontenotMT,BrooksGG,etal.Latencyperiodafterpretermpremature
ruptureofmembranes:acomparisonofampicillinwithandwithoutsulbactam.Obstet
Gynecol.1995Sep.86(3):3925.[Medline].

37.MercerBM.Managementofpretermprematureruptureofthemembranes.ClinObstet
Gynecol.1998Dec.41(4):87082.[Medline].

38.MercerBM.Pretermprematureruptureofthemembranes:currentapproachesto
evaluationandmanagement.ObstetGynecolClinNorthAm.2005Sep.32(3):41128.
[Medline].

39.NIHConsensusDevelopmentPanel.Effectofcorticosteroidsforfetalmaturationon
perinataloutcomes.NIHConsensusDevelopmentPanelontheEffectof
CorticosteroidsforFetalMaturationonPerinatalOutcomes.JAMA.1995Feb1.
273(5):4138.[Medline].

40.TanBP,HannahME.Oxytocinforprelabourruptureofmembranesatornearterm.
CochraneDatabaseSystRev.2000.(2):CD000157.[Medline].

41.WhitelawA,ThoresenM.Antenatalsteroidsandthedevelopingbrain.ArchDisChild
http://emedicine.medscape.com/article/261137-overview 11/14
11/17/2016 Premature Rupture of Membranes: Overview, Premature Rupture of Membranes (at Term), Premature Preterm Rupture of Membranes

FetalNeonatalEd.2000Sep.83(2):F1547.[Medline].

42.DrassinowerD,FriedmanAM,LevinH,ObicanSG,GyamfiBannermanC.Does
magnesiumexposureaffectneonatalresuscitation?.AmJObstetGynecol.2015Sep.
213(3):424.e15.[Medline].

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AllahyarJazayeri,MD,PhD,FACOG,DACOG,FSMFMMedicalDirectorofPerinatal
Services,AspirusHospitalConsultingStaffandOwner,Women'sSpecialtyCareand
NEWMOMSofGreenBay

AllahyarJazayeri,MD,PhD,FACOG,DACOG,FSMFMisamemberofthefollowing
medicalsocieties:AmericanCollegeofObstetriciansandGynecologists,AmericanInstitute
ofUltrasoundinMedicine,AssociationofProfessorsofGynecologyandObstetrics,Society
forReproductiveInvestigation,SocietyforMaternalFetalMedicine

Disclosure:Nothingtodisclose.

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FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraska
MedicalCenterCollegeofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.

ChiefEditor

CarlVSmith,MDTheDistinguishedChrisJandMarieAOlsonChairofObstetricsand
Gynecology,Professor,DepartmentofObstetricsandGynecology,SeniorAssociateDean
forClinicalAffairs,UniversityofNebraskaMedicalCenter

CarlVSmith,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeof
ObstetriciansandGynecologists,AmericanInstituteofUltrasoundinMedicine,Association
ofProfessorsofGynecologyandObstetrics,CentralAssociationofObstetriciansand
Gynecologists,SocietyforMaternalFetalMedicine,CouncilofUniversityChairsof
ObstetricsandGynecology,NebraskaMedicalAssociation

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http://emedicine.medscape.com/article/261137-overview 12/14
11/17/2016 Premature Rupture of Membranes: Overview, Premature Rupture of Membranes (at Term), Premature Preterm Rupture of Membranes

SuzanneRTrupin,MD,FACOGClinicalProfessor,DepartmentofObstetricsand
Gynecology,UniversityofIllinoisCollegeofMedicineatUrbanaChampaignCEOand
Owner,Women'sHealthPracticeCEOandOwner,HadaCosmeticMedicineandMidwest
SurgicalCenter

SuzanneRTrupin,MD,FACOGisamemberofthefollowingmedicalsocieties:American
CollegeofObstetriciansandGynecologists,AmericanInstituteofUltrasoundinMedicine,
InternationalSocietyforClinicalDensitometry,AAGL,NorthAmericanMenopauseSociety,
AmericanMedicalAssociation,AssociationofReproductiveHealthProfessionals

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previousauthorsPaulTWilkes,MD,andHenryGalan,MD,tothedevelopmentandwriting
ofthisarticle.

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