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Home > Professional Reference > Premature Rupture of Membranes

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Premature Rupture of Membranes

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Synonym: pre-labour rupture of membranes

Premature rupture of membranes (PROM) is the rupture of the membranes prior to the onset of labour.

Pre-term PROM is the rupture of membranes prior to the onset of labour in a patient who is at less than 37 weeks' gestation.

Most women go into spontaneous labour within 24 hours of rupturing their membranes, but 6% of women will not be in spontaneous labour within 96 hours. However, the earlier in gestation the rupture occurs, the less likely that the onset of labour will be within a specified time period.1

Epidemiology

  • Pre-labour rupture of the membranes occurs in 6-19% of term pregnancies.2
  • Pre-term PROM in 2% of all pregnancies.3

Risk factors

Risk factors for pre-term PROM are:

  • Smoking
  • Previous pre-term delivery
  • Vaginal bleeding (at any time during the pregnancy)

Presentation

Mother may give history of a 'popping sensation' or a 'gush' with continuous watery liquid draining thereafter. Their underwear or pad may be damp.

Investigations

Do not do a vaginal inspection as this will increase the risk of ascending infection.
Earliest clinical signs of ascending infection are fetal tachycardia and a mild increase in maternal temperature.

  • Diagnosis of rupture of membranes:
    • Actually seeing amniotic fluid draining from the cervix is the most accurate test. Sterile speculum examination: check for liquor and umbilical cord.
    • Nitrazine test may help to confirm the diagnosis. Urine, semen and other contaminants may give a false positive test result.
    • Regular pad checks.
  • Ultrasound to check for gestation and liquor volume.
  • Temperature monitoring at least 12-hrly for ascending infection:
    • High vaginal swab.
    • If infection suspected, check full blood count, CRP, MSU and blood cultures; start broad spectrum antibiotic.
  • Fetal monitoring.

Management

Refer urgently to hospital if:

  • Pre-term PROM is suspected.
  • Ascending infection is suspected: maternal or fetal tachycardia, temperature, abdominal tenderness.

Antibiotic administration

  • Antibiotics are associated with a delay in delivery and a reduction in major neonatal morbidity.
  • Co-amoxiclav should be avoided in women at risk of pre-term delivery because of the increased risk of neonatal necrotising enterocolitis.
  • Therefore erythromycin may be a better choice.4 The recommended dose is 250 mg qds for 10 days.3

Delaying premature birth

The following factors have been shown to be significantly associated with pre-term delivery:5

  • Low body mass index.
  • Maternal pulmonary disease.
  • Onset of contractions within 2 weeks of PROM.
  • Short cervix (≤25 mm).
  • Positive results of fetal fibronectin screening.
  • Bacterial vaginosis.
  • Previous pre-term birth caused by PROM (in multiparous women).

The overall outcome for the neonate depends on gestational age. The prognosis improves with gestational age, especially between 24 and 27 weeks and so prolonging the pregnancy is beneficial in such cases.6

Tocolytics, e.g. atosiban, nifedipine or ritodrine, may delay delivery by 48 hours and therefore enable time for antenatal corticosteroids to be given. They should only be considered in the presence of uterine activity.

Antenatal steroids should be given if gestation is between 24 and 36 weeks. Dexamethasone accelerates fetal surfactant production and lung maturation. Antenatal steroids have been shown to reduce respiratory distress syndrome, intraventricular haemorrhage and mortality by 40%.7

Delivery or expectant management?

Consider delivery if:

  • Evidence of ascending infection, fetal distress or gestation over 34 weeks; evidence shows that expectant management of women at 34 weeks and beyond is of limited benefit.8
  • Women with pre-labour rupture of the membranes at term (over 37 weeks) should be offered a choice of immediate induction of labour or expectant management.
  • For a pregnancy that has reached term, if emergency admission is not required within the first 72 hours after admission, woman can be managed at home with outpatient monitoring for infection and fetal well-being.
  • However, it is recommended that women with pre-labour rupture of the membranes at term should not exceed 96 hours following membrane rupture.2 The increase in risk of maternal and fetal infection increases with increasing time between the rupture of membranes and the onset of labour.

Complications

Artificial rupture of membranes

Controversial subject with debate between those wary of potential complications and unnecessary intervention, against those with equal concerns for the benefits, when indicated, of closer monitoring of the baby and avoidance of excessively long labour.

Indications

  • Induction of labour.
  • Augmentation (speed up) labour.
  • Fetal monitoring in labour: monitoring liquor, fetal scalp electrode, fetal blood sample.

Complications

  • Increased pain to the mother.
  • Fetal distress.
  • Maternal or fetal sepsis.
  • Cord prolapse.
  • Wrong dates - prematurity.
  • Rupture of vasa previa with likely resultant fetal exsanguination (fetal mortality 33-100%).

Document references

  1. Savitz DA, Ananth CV, Luther ER, et al; Influence of gestational age on the time from spontaneous rupture of the chorioamniotic membranes to the onset of labor. Am J Perinatol. 1997 Mar;14(3):129-33. [abstract]
  2. NICE (inherited guideline). Induction of labour. July 2008.
  3. Preterm Prelabour Rupture of Membranes, Royal College of Obstetricians and Gynaecologists (November 2006)
  4. Kenyon S, Boulvain M, Neilson J; Antibiotics for preterm rupture of membranes. Cochrane Database Syst Rev. 2003;(2):CD001058. [abstract]
  5. Mercer BM, Goldenberg RL, Meis PJ, et al; The Preterm Prediction Study: prediction of preterm premature rupture of membranes through clinical findings and ancillary testing. The National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Am J Obstet Gynecol. 2000 Sep;183(3):738-45. [abstract]
  6. Klein JM; Neonatal morbidity and mortality secondary to premature rupture of membranes. Obstet Gynecol Clin North Am. 1992 Jun;19(2):265-80. [abstract]
  7. Antenatal Corticosteroids to Prevent Respiratory Distress Syndrome, Royal College of Obstetricians and Gynaecologists (2004)
  8. Lieman JM, Brumfield CG, Carlo W, et al; Preterm premature rupture of membranes: is there an optimal gestational age for delivery? Obstet Gynecol. 2005 Jan;105(1):12-7. [abstract]

Internet and further reading

Acknowledgements

EMIS is grateful to Dr Hayley Willacy for writing this article and to Dr Colin Tidy for earlier versions. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2009.
Document ID: 2654
Document Version: 21
Document Reference: bgp24668
Last Updated: 21 Jul 2009
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