Guideline sources The following summarized guidelines for the evaluation and management of premature rupture of membranes (PROM) are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2022; 2018; 2017; 2012), the Royal College of Obstetricians and Gynaecologists (RCOG 2019), the American College of Obstetricians and Gynecologists (ACOG 2018; 2017), the World Health Organization (WHO 2015), the Society for Maternal-Fetal Medicine (SMFM 2015), and the Center for Disease Control (CDC 2011; 2010). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Guidelines 1. Screening and diagnosis Epidemiology: recognize that preterm prelabor rupture of membranes complicates approximately 3% of pregnancies and causes approximately one-third of all spontaneous preterm deliveries. A Show 4 more https://web.pathway.md/diseases/recptTxP2FXaIzQF2 1/8 6/29/23, 11:26 PM Premature rupture of membranes Pathway Show 4 more Diagnosis: As per SOGC 2022 guidelines, elicit history and perform a physical examination by a sterile speculum with direct visualization of fluid in the posterior fornix for the diagnosis of preterm prelabour rupture of membranes. B Show 3 more As per RCOG 2019 guidelines: Elicit maternal history and perform a sterile speculum examination for the diagnosis of spontaneous rupture of the membranes. B Consider obtaining insulin-like growth factor-binding protein 1 or placental alpha microglobulin-1 of vaginal fluid to guide further management if no amniotic fluid is observed on speculum examination. C 2. Diagnostic investigations Initial evaluation: assess maternal and fetal status with the aim of ruling out active labor, infection (chorioamnionitis), placental abruption, or fetal distress, all conditions warranting immediate delivery once preterm prelabor rupture of membranes is diagnosed. A Evaluation for GBS colonization: As per SOGC 2022 guidelines, obtain a vaginal/rectal swab to test for group B Streptococcus colonization, if not previously done within 5 weeks, once preterm prelabor rupture of membranes is diagnosed. B As per CTFPHC 2018 guidelines, screen for colonization with group B streptococcus in all females at 35-37 weeks of gestation with culture taken from one swab first to the vagina and then to the rectum through the anal sphincter, B including females with planned Cesarean delivery because of their risk of labor or ruptured membranes earlier than the scheduled Cesarean delivery. B As per CDC 2010 guidelines, screen for vaginal and rectal group B Streptococcus colonization in all pregnant females at 35-37 weeks of gestation. B Evaluation for chorioamnionitis: As per SOGC 2022 guidelines, do not obtain serial monitoring of white cell count or other markers of inflammation in the absence of other clinical signs of infection. D As per RCOG 2019 guidelines, obtain clinical assessment, maternal blood tests (CRP and white cell count), and fetal HR for the diagnosis of chorioamnionitis in patients with preterm PROM. B 3. Medical management Setting of care: As per SOGC 2022 guidelines, insufficient evidence to recommend hospital versus home management for preterm prelabor rupture of membranes. I Show 2 more https://web.pathway.md/diseases/recptTxP2FXaIzQF2 2/8 6/29/23, 11:26 PM Premature rupture of membranes Pathway As per RCOG 2019 guidelines: Individualize the decision to offer outpatient care in patients with preterm prelabor rupture of membranes, taking into account markers of delivery latency. E Manage patients in a subsequent pregnancy following preterm prelabor rupture of membranes by an obstetrician with an interest in preterm birth. E Expectant management: As per SOGC 2022 guidelines, insufficient evidence regarding different management strategies or timing in the setting of previable preterm prelabor rupture of membranes. I Show 2 more As per RCOG 2019 guidelines, offer expectant management until 37+0 weeks of gestation in patients with preterm prelabor rupture of membranes after 24+0 weeks of gestation without contraindications to continuing the pregnancy. Discuss the timing of birth with each patient on an individual basis with careful consideration of patient preference and ongoing clinical assessment. A Antibiotics, indications: As per RCOG 2019 guidelines, administer antibiotic therapy (preferably erythromycin) for 10 days or until the patient is in established labor (whichever is sooner) following the diagnosis of preterm prelabor rupture of membranes. A As per ACOG 2018 guidelines: Administer antibiotic prophylaxis to prolong the latency period between membrane rupture and delivery. in patients with prelabor rupture of membranes at < 34+0 weeks of gestation. A Do not use antibiotic prophylaxis for pregnancy prolongation in patients with preterm labor and intact membranes. D As per SOGC 2017 guidelines: Administer antibiotics following preterm prelabor rupture of membranes at 32 weeks of gestation to prolong pregnancy and decrease maternal and neonatal morbidity in patients not in labor. A Administer antibiotics to prolong pregnancy in patients with preterm prelabor rupture of membranes at > 32 weeks of gestation if fetal lung maturity cannot be proven and/or delivery is not planned. A As per WHO 2015 guidelines: Administer antibiotics in patients with preterm prelabor rupture of membranes. B Do not administer antibiotics routinely in patients with prelabor rupture of membranes at (or near) term. D Antibiotics, choice of regimen: As per SOGC 2022 guidelines, insufficient evidence regarding the optimal antibiotic regimen for preterm prelabor rupture of membranes. Include coverage for group B Streptococcus status if the status is unknown or positive. I Show 3 more As per SOGC 2017 guidelines, consider using antibiotic regimens consisting of an initial parenteral phase followed by an oral phase, or of only an oral phase. B https://web.pathway.md/diseases/recptTxP2FXaIzQF2 3/8 6/29/23, 11:26 PM Premature rupture of membranes Pathway Show 3 more As per WHO 2015 guidelines: Administer erythromycin as the antibiotic of choice for prophylaxis in patients with preterm prelabor rupture of membranes. B Do not use a combination of amoxicillin and clavulanic acid in patients with preterm prelabor rupture of membranes. D Corticosteroids: As per SOGC 2022 guidelines, administer antenatal corticosteroids routinely in patients with preterm prelabor rupture of membranes at the time of diagnosis when gestational age criteria are met. B As per RCOG 2019 guidelines, administer corticosteroids between 24+0 and 33+6 weeks of gestation in patients with preterm prelabor rupture of membranes. Consider administering corticosteroids up to 35+6 weeks of gestation. A As per ACOG 2017 guidelines: Administer a single course of corticosteroids in pregnant females between 24+0 weeks and 33+6 weeks of gestation at risk of preterm delivery within 7 days, including for patients with ruptured membranes and multiple gestations. Consider administering corticosteroids starting at 23+0 weeks of gestation at risk of preterm delivery within 7 days, based on a family's decision regarding resuscitation, irrespective of membrane rupture status and regardless of fetal number. E Insufficient evidence to recommend for or against the administration of a repeat or rescue course of corticosteroids in patients with preterm prelabor rupture of membranes. I As per WHO 2015 guidelines, administer antenatal corticosteroids in patients with preterm prelabor rupture of membranes and no clinical signs of infection. A Tocolytics: As per SOGC 2022 guidelines: Insufficient evidence to support prolonged or recurrent use of tocolysis in the context of preterm prelabor rupture of membranes except for ensuring the full course of corticosteroids for 48 hours, or during transfer to a tertiary care center in the absence of infection or abruption. I Administer magnesium sulfate for fetal neuroprotection following preterm prelabor rupture of membranes once the patient is in active labor or before indicated delivery, when gestational age criteria are met. B As per RCOG 2019 guidelines: Do not use tocolysis in patients with preterm prelabor rupture of membranes. D Administer IV magnesium sulfate between 24 and 29 weeks of gestation in patients with preterm prelabor rupture of membranes in established labor or having a planned preterm birth within 24 hours. A 4. Nonpharmacologic interventions Bed rest: do not offer bed rest in patients with preterm prelabor rupture of membranes. D https://web.pathway.md/diseases/recptTxP2FXaIzQF2 4/8 6/29/23, 11:26 PM Premature rupture of membranes Pathway 5. Therapeutic procedures Amnioinfusion: do not perform amnioinfusion as part of routine clinical practice in patients with preterm prelabor rupture of membranes. D 6. Specific circumstances Patients with cervical cerclage: Recognize that preterm prelabor rupture of membranes may complicate up to 38% of pregnancies in patients with cervical cerclage. B Insufficient evidence on whether the cerclage should be removed or remain in situ in patients with preterm prelabor rupture of membranes and cervical cerclage; either option is reasonable in the absence of signs of infection or other contraindications to retaining a cerclage. I Patients with asymptomatic bacteriuria: administer appropriate IV antibiotics for the treatment of documented group B streptococcal bacteriuria (regardless of the level of CFUs per mL) at the time of labor or rupture of membranes, to prevent early-onset neonatal group B streptococcal disease. B Patients with vasa previa: As per RCOG 2019 guidelines: Perform Cesarean delivery without delay in patients with vasa previa developing PROM and/or labor at viable gestational ages. B Ensure delivery before rupturing of membranes while minimizing the impact of iatrogenic prematurity as the ultimate management goal of confirmed vasa previa. B As per SOGC 2017 guidelines, perform Cesarean delivery in a birthing unit with continuous electronic fetal HR monitoring and a rapid biochemical test for fetal Hgb, obtained as soon as possible if time permits, in case of PROM. Perform urgent Cesarean delivery if any of the tests are abnormal. B As per SMFM 2015 guidelines, perform Cesarean delivery if a patient with pregnancy at viable gestational age has an antenatal diagnosis of vasa previa and then develops PROM or labor. B 7. Patient education General counseling: As per SOGC 2022 guidelines: Provide consultation with a maternal-fetal medicine specialist and neonatology specialist for comprehensive counseling about prognosis and risks, multidisciplinary management planning, and shared decision-making in patients with previable preterm prelabor rupture of membranes. B Consider including amniotic fluid volume at the time of rupture in counseling patients and families with previable preterm prelabor rupture of membranes, as anhydramnios and https://web.pathway.md/diseases/recptTxP2FXaIzQF2 5/8 6/29/23, 11:26 PM Premature rupture of membranes Pathway oligohydramnios are more frequently associated with pregnancy loss and pulmonary hypoplasia compared with normal amniotic fluid volumes. C As per RCOG 2019 guidelines, offer additional emotional support during pregnancy and postnatally in patients with preterm prelabor rupture of membranes and their partners. E 8. Preventative measures Prevention of complications: As per SOGC 2022 guidelines: Insufficient evidence on both the testing modality and the optimal frequency of testing to prevent adverse maternal and perinatal outcomes. I Insufficient evidence about the effectiveness of prevention strategies for reducing complications in subsequent pregnancies in patients with a history of preterm prelabor rupture of membranes. I As per RCOG 2019 guidelines, insufficient evidence regarding the optimal methods of monitoring to predict adverse fetal outcomes after preterm prelabor rupture of membranes. I 9. Follow-up and surveillance Postnatal monitoring: Obtain observation for 48 hours in well-appearing term infants whose mothers received no or inadequate intrapartum antibiotic prophylaxis (including clindamycin or vancomycin) and had rupture of membranes for < 18 hours. B Obtain a limited evaluation (blood culture and CBC with differential and platelets at birth) and observation for at least 48 hours in well-appearing term infants born to women with no or inadequate intrapartum antibiotic prophylaxis and rupture of membranes for 18 hours before delivery. B Clinical findings Patient demographics Symptoms Pregnancy with preterm gestation Fever Water breaking Past obstetric history Vital signs Chorioamnionitis Tachycardia Gynecologic exam Lab findings Amniotic fluid passing from the cervical canal vaginal fluid AFP vaginal fluid pH vaginal fluid insulin-like growth factor-binding protein 1 Histological findings https://web.pathway.md/diseases/recptTxP2FXaIzQF2 6/8 6/29/23, 11:26 PM Premature rupture of membranes Pathway vaginal fluid placental alpha microglobulin-1 Vaginal fluid fat droplets fern test Likelihood Ratios Pertinent positives The following findings increase the probability of premature rupture of membranes in adults. 14 15 Finding LR+ Value Presence of vaginal fluid fat droplets 35.5 Increased vaginal fluid AFP 18.2 Increased vaginal fluid pH 3.4 Pertinent negatives The following findings decrease the probability of premature rupture of membranes in adults. 14 15 Finding LR- Value Absence of vaginal fluid fat droplets 0 vaginal fluid pH not increased 0.1 vaginal fluid AFP not increased 0.1 References 1. No authors listed. WHO Recommendations on Interventions to Improve Preterm Birth Outcomes. Geneva: World Health Organization; 2015. Open 2. Mark H Yudin, Julie van Schalkwyk, Nancy Van Eyk. No. 233 Antibiotic Therapy in Preterm Premature Rupture of the Membranes. J Obstet Gynaecol Can. 2017 Sep;39 9):e207-e212. Open 3. Stefania Ronzoni, Isabelle Boucoiran, Mark H Yudin et al. Guideline No. 430 Diagnosis and management of preterm prelabour rupture of membranes. J Obstet Gynaecol Can. 2022 Nov;44 11 1193 1208.e1. Open 4. A J Thomson, Royal College of Obstetricians and Gynaecologists. Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24 0 Weeks of Gestation: Green-top Guideline No. 73. BJOG. 2019 Aug;126 9):e152-e166. Open 5. Committee on Obstetric Practice. Committee Opinion No. 713 Antenatal Corticosteroid Therapy for Fetal Maturation. Obstet Gynecol. 2017 Aug;130 2):e102-e109. Open 6. Jennifer R Verani, Lesley McGee, Stephanie J Schrag et al. Prevention of perinatal group B streptococcal disease revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010 Nov 19;59 RR 10 1 36. Open 7. Society of Maternal-Fetal SMFM Publications Committee, Rachel G Sinkey, Anthony O Odibo et al. #37 Diagnosis and management of vasa previa. Am J Obstet Gynecol. 2015 Nov;213 5 615 9. Open 8. Robert Gagnon. No. 231 Guidelines for the Management of Vasa Previa. J Obstet Gynaecol Can. 2017 Oct;39 10):e415-e421. Open https://web.pathway.md/diseases/recptTxP2FXaIzQF2 7/8 6/29/23, 11:26 PM Premature rupture of membranes Pathway 9. Victoria M Allen, Mark H Yudin, INFECTIOUS DISEASES COMMITTEE. Management of group B streptococcal bacteriuria in pregnancy. J Obstet Gynaecol Can. 2012 May;34 5 482 486. Open 10. Deborah Money, Victoria M Allen. No. 298 The Prevention of Early-Onset Neonatal Group B Streptococcal Disease. J Obstet Gynaecol Can. 2018 Aug;40 8):e665-e674. Open 11. No authors listed. WHO Recommendations for Prevention and Treatment of Maternal Peripartum Infections. Geneva: World Health Organization; 2015. Open 12. Committee on Infectious Diseases, Committee on Fetus and Newborn, Carol J Baker et al. Policy statement Recommendations for the prevention of perinatal group B streptococcal GBS disease. Pediatrics. 2011 Sep;128 3 611 6. Open 13. Erm Jauniaux, Z Alfirevic, A G Bhide et al. Vasa Praevia: Diagnosis and Management: Green-top Guideline No. 27b. BJOG. 2019 Jan;126 1):e49-e61. Open 14. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 199 Use of Prophylactic Antibiotics in Labor and Delivery. Obstet Gynecol. 2018 Sep;132 3):e103-e119. Open 15. Davidson KM. Detection of premature rupture of the membranes. Clin Obstet Gynecol. 1991 Dec;34 4 715 22. Open 16. Garite TJ, Gocke SE. Diagnosis of preterm rupture of membranes: is testing for alpha-fetoprotein better than ferning or nitrazine?. Am J Perinatol. 1990 Jul;7 3 276 8. 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