P RACTICE BULLET IN
clinical management guidelines for obstetrician gynecologists
Number 160, January 2016 (Replaces Practice Bulletin Number 139, October 2013)
INTERIM UPDATE: This Practice Bulletin is updated to reflect a limited, focused change in gestational age at which to
consider antenatal corticosteroids.
Committee on Practice BulletinsObstetrics. This Practice Bulletin was developed by the Committee on Practice BulletinsObstetrics with the assis-
tance of Robert Ehsanipoor, MD. The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care.
These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the
needs of the individual patient, resources, and limitations unique to the institution or type of practice.
expectantly gave birth within 5 hours and 95% gave birth compared with membrane rupture before 22 weeks of
within 28 hours of membrane rupture (13). The most gestation (57.7% versus 14.4%, respectively) (26).
significant maternal consequence of term PROM is Most studies of second-trimester and previable
intrauterine infection, the risk of which increases with PROM are retrospective and include only expectantly
the duration of membrane rupture. managed cases. Thus, they likely overestimate survival
rates because of selection bias. Survival data may vary
Preterm Premature Rupture of by institution.
Membranes Significant maternal complications that occur after
Regardless of obstetric management or clinical presen- previable PROM include intraamniotic infection, endo-
tation, birth within 1 week of membrane rupture occurs metritis, abruptio placentae, and retained placenta (26).
in at least one half of patients with preterm PROM (5). Although it occurs infrequently, life-threatening mater-
Latency after membrane rupture is inversely correlated nal infection may complicate expectant management of
with the gestational age at membrane rupture (14). previable PROM. Maternal sepsis is reported in approxi-
Cessation of amniotic fluid leakage with restoration of mately 1% of cases (26), and isolated maternal deaths
normal amniotic fluid volume may occur in the setting due to infection have been reported in this setting.
of spontaneous preterm PROM and is associated with Latency periods appear to be prolonged with
favorable outcomes (15). second-trimester preterm PROM compared with later
gestational ages. However, 4050% of patients with
Among women with preterm PROM, clinically
previable PROM will give birth within the first week and
evident intraamniotic infection occurs in approxi-
approximately 7080% will give birth 25 weeks after
mately 1525% (16), and postpartum infection occurs
membrane rupture (2628).
in approximately 1520%; the incidence of infection is
The rate of pulmonary hypoplasia after PROM
higher at earlier gestational ages (6, 17). Abruptio pla-
before 24 weeks of gestation varies widely among
centae complicates 25% of pregnancies with preterm
reports, but is likely in the range of 1020%. Pulmonary
PROM (18, 19).
hypoplasia is associated with a high risk of mortality
The most significant risks to the fetus after preterm
(26), but is rarely lethal with membrane rupture sub-
PROM are complications of prematurity. Respiratory
sequent to 2324 weeks of gestation (29), presumably
distress has been reported to be the most common com-
because alveolar growth adequate to support postnatal
plication of preterm birth (20). Sepsis, intraventricular
development already has occurred. Early gestational age
hemorrhage, and necrotizing enterocolitis also are asso-
at membrane rupture, and low residual amniotic fluid
ciated with prematurity, but these are less common near
volume are the primary determinants of the incidence of
to term. Preterm PROM with intrauterine inflammation
pulmonary hypoplasia (30, 31).
has been associated with an increased risk of neurode-
Prolonged oligohydramnios also can result in fetal
velopmental impairment (21, 22), and early gestational
deformations, including Potter-like facies (eg, low-set
age at membrane rupture also has been associated with
ears and epicanthal folds) and limb contractures or other
an increased risk of neonatal white matter damage (23).
positioning abnormalities. The reported frequency of
However, there are no data that suggest that immediate
skeletal deformations varies widely (1.538%) but many
delivery after presentation with PROM will avert these
of these resolve with postnatal growth and physical
risks. Infection and umbilical cord accident contribute
therapy (26, 32).
to the 12% risk of antenatal fetal demise after preterm
PROM (24).