What is the management for Premature Rupture of Membranes (PROM)?

From the Guidelines

Management of Premature Rupture of Membranes (PROM) should prioritize individualized counseling about the maternal and fetal risks and benefits of both abortion care and expectant management, with antibiotics recommended for pregnant individuals who choose expectant management after PPROM at 24 0/7 weeks of gestation or later. The approach to managing PROM depends on the gestational age and the presence of infection. For previable and periviable preterm prelabor rupture of membranes, the management is particularly challenging due to the substantial risk of maternal morbidity and mortality with no guarantee of fetal benefit 1.

Key Considerations

• Individualized counseling is crucial for pregnant patients with previable and periviable PPROM to guide an informed decision about management options, including abortion care and expectant management 1.
• Antibiotics are recommended for pregnant individuals who choose expectant management after PPROM at 24 0/7 weeks of gestation or later, with consideration for antibiotics at 20 0/7 to 23 6/7 weeks of gestation 1.
• Administration of antenatal corticosteroids and magnesium sulfate is not recommended until the time when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient 1.
• Serial amnioinfusions and amniopatch are considered investigational and should only be used in a clinical trial setting, not for routine care of previable and periviable preterm prelabor rupture of membranes 1.

Management Approach

• For term PROM (≥37 weeks), induction of labor is typically recommended within 24 hours to reduce infection risk.
• For preterm PROM (<37 weeks), management includes hospitalization and administration of antibiotics, with corticosteroids and magnesium sulfate considered based on gestational age and fetal status.
• Expectant management may be appropriate for preterm PROM between 24-34 weeks without infection, while delivery is indicated for chorioamnionitis, non-reassuring fetal status, or advanced labor regardless of gestational age.

This approach aims to balance the risks of prematurity against those of intrauterine infection, optimizing both maternal and neonatal outcomes 1.

From the Research

Management of Premature Rupture of Membranes (PROM)

The management of PROM involves several key considerations, including the gestational age at the time of rupture and the presence of any maternal or fetal contraindications.

• With term PROM, labor may be induced at the time of presentation or patients may be observed for up to 24-72 hours for the onset of spontaneous labor 2.
• For preterm PROM, antibiotics should be administered to prolong pregnancy and decrease maternal and neonatal morbidity, particularly at earlier gestational ages (< 32 weeks) 3.
• Antenatal corticosteroids should be administered to gravidas with PROM before 32 weeks of gestation to reduce the risks of respiratory distress syndrome, neonatal intraventricular hemorrhage, necrotizing enterocolitis, and neonatal death 2, 4.
• Digital cervical examinations should not be performed in patients with PROM who are not in labor and in whom immediate induction of labor is not planned 2.

Antibiotic Therapy

• Antibiotics should be administered to women with preterm PROM to prolong pregnancy and decrease maternal and neonatal morbidity 3.
• The use of antibiotics should be gestational-age dependent, with the evidence for benefit being greater at earlier gestational ages (< 32 weeks) 3.
• Antibiotic regimens may consist of an initial parenteral phase followed by an oral phase, or may consist of only an oral phase, with penicillins or macrolide antibiotics being the antibiotics of choice 3.

Expectant Management

• Patients with PROM prior to 30-32 weeks of gestation should be managed conservatively if no maternal or fetal contraindications exist 2.
• Expectant management from viability until late preterm period is universally recommended, although there are discrepancies on the optimal timing of delivery 5.
• Magnesium sulfate should be administered in case of imminent preterm delivery, although there is no consensus on the upper gestational age limit 5.

Diagnostic Modalities

• Various diagnostic modalities include sterile speculum examination, the nitrazine test, the ferning test, and the latest advances, which are the Amnisure test and the Actim test 6.
• The diagnosis of PPROM should be mainly based on sterile speculum examination and patient's history, followed by additional tests in equivocal cases 5.