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Premature rupture of membranes

Key sources
The following summarized guidelines for the evaluation and management of premature rupture of membranes 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).
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Guidelines

1.Screening and diagnosis

Epidemiology: recognize that PPROM complicates approximately 3% of pregnancies and causes approximately one-third of all spontaneous preterm deliveries.
A
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  • Diagnosis

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 PPROM is diagnosed.
A

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  • Evaluation for GBS colonization

  • Evaluation for chorioamnionitis

3.Medical management

Setting of care: as per SOGC 2022 guidelines, insufficient evidence to recommend hospital versus home management for PPROM.
I
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  • Expectant management

  • Antibiotics (indications)

  • Antibiotics (choice of regimen)

  • Corticosteroids

  • Tocolytics

4.Nonpharmacologic interventions

Bed rest: do not offer bed rest in patients with PPROM.
D

5.Therapeutic procedures

Amnioinfusion: do not perform amnioinfusion as part of routine clinical practice in patients with PPROM.
D

6.Specific circumstances

Patients with cervical cerclage
Recognize that PPROM 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 PPROM and cervical cerclage; either option is reasonable in the absence of signs of infection or other contraindications to retaining a cerclage.
I

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  • Patients with asymptomatic bacteriuria

  • Patients with vasa previa

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 PPROM.
B
Consider including amniotic fluid volume at the time of rupture in counseling patients and families with previable PPROM, as anhydramnios and oligohydramnios are more frequently associated with pregnancy loss and pulmonary hypoplasia compared with normal amniotic fluid volumes.
C

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 PPROM.
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