Premature rupture of membranes (PROM) is the rupture of the membranes prior to the onset of labour.
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.
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- PROM occurs in 6-19% of term pregnancies.
- PPROM occurs in 2% of all pregnancies.
- PPROM is associated with 40% of preterm deliveries and can lead to significant morbidity and mortality.
Risk factors for PPROM are:
- Smoking. Heavy cigarette smoking increases the risk of PPROM more at early gestational age than at term.
- Previous preterm delivery.
- Vaginal bleeding (at any time during the pregnancy).
- There is an association between lower genital tract infection and PPROM.
- Around a third of women with PPROM have positive amniotic fluid cultures.
The mother may give history of a 'popping sensation' or a 'gush' with continuous watery liquid draining thereafter. Their underwear or pad may be damp.
The earliest clinical signs of ascending infection are fetal tachycardia and a mild increase in maternal temperature. An offensive vaginal discharge may also be present in some women.
- 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 the umbilical cord.
- Nitrazine testing may help to confirm the diagnosis. Urine, semen and other contaminants may give a false positive test result.
- Regular pad checks.
- Ultrasound may be useful to check for gestation and liquor volume.
- Temperature monitoring at least 12-hourly for ascending infection:
- High vaginal swab.
- If infection is suspected, check FBC, CRP, MSU and blood cultures; start broad-spectrum antibiotic treatment.
- Fetal monitoring.
Note: regular weekly vaginal swabs and/or maternal blood tests are not usually indicated.
- Refer urgently to hospital if:
- PPROM is suspected.
- Ascending infection is suspected: maternal or fetal tachycardia, temperature, abdominal tenderness.
- Women are usually seen in hospital and admitted for the first 48 hours. After this time, management at home - which includes taking 4- to 8-hourly temperatures - may be possible for some women.
- Antibiotic administration:
- Tocolytics - eg, atosiban, nifedipine or ritodrine - are no longer recommended, as they do not significantly improve perinatal outcome.
- Amnio-infusion is not currently recommended for routine clinical management of PPROM.
- Antenatal steroids should be given if gestation is between 24+0 and 34+6 weeks. Antenatal steroids are associated with a significant reduction in rates of neonatal death, respiratory distress syndrome and intraventricular haemorrhage and are safe for the mother.
Delivery or expectant management?
- There is currently insufficient evidence to guide clinical practice on the benefits and harms of immediate delivery compared with expectant management for women with PPROM. 
- Delivery should usually be considered at 34 weeks.
- If the pregnancy continues over 36 weeks then the mother should be informed that they have an increased risk of chorioamnionitis and a reduced risk of respiratory problems for the neonate.
- It is recommended that women with PROM at term should not exceed 96 hours following membrane rupture. The risk of maternal and fetal infection increases with longer time between the rupture of membranes and the onset of labour.
- The three main causes of neonatal mortality associated with PPROM are prematurity, sepsis and pulmonary hypoplasia.
- Preterm delivery.
- Umbilical cord prolapse.
- Placental abruption.
- (Early in pregnancy) may lead to oligohydramnios.
- Increased incidence of retained placenta and primary and secondary postpartum haemorrhage.
Further reading & references
- Intrapartum care, NICE Clinical Guideline (2007)
- Induction of labour, NICE Clinical Guideline (July 2008)
- Preterm Prelabour Rupture of Membranes, Royal College of Obstetricians and Gynaecologists (November 2006 - minor amendment October 2010)
- England MC, Benjamin A, Abenhaim HA; Increased Risk of Preterm Premature Rupture of Membranes at Early Gestational Ages among Maternal Cigarette Smokers. Am J Perinatol. 2013 Jan 17.
- Cousens S, Blencowe H, Gravett M, et al; Antibiotics for pre-term pre-labour rupture of membranes: prevention of neonatal deaths due to complications of pre-term birth and infection. Int J Epidemiol. 2010 Apr;39 Suppl 1:i134-43. doi: 10.1093/ije/dyq030.
- Prevention of Early Onset Neonatal Group B Streptococcal Disease, Royal College of Obstretricians and Gynaecologists (2012)
- Hofmeyr GJ, Essilfie-Appiah G, Lawrie TA; Amnioinfusion for preterm premature rupture of membranes. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD000942. doi: 10.1002/14651858.CD000942.pub2.
- Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality; Royal College of Obstetricians and Gynaecologists (October 2010)
- Buchanan SL, Crowther CA, Levett KM, et al; Planned early birth versus expectant management for women with preterm prelabour rupture of membranes prior to 37 weeks' gestation for improving pregnancy outcome. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD004735. doi: 10.1002/14651858.CD004735.pub3.
|Original Author: Dr Colin Tidy||Current Version: Dr Louise Newson||Peer Reviewer: Dr John Cox|
|Last Checked: 12/02/2013||Document ID: 2654 Version: 22||© EMIS|
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