RCOG and ACOG Guidelines for Preterm Labour Management
The American College of Obstetricians and Gynecologists (ACOG) recommends individualized counseling about maternal and fetal risks for patients with preterm prelabor rupture of membranes (PPROM), offering both abortion care and expectant management options depending on gestational age and clinical circumstances. 1
Diagnosis and Initial Assessment
- Diagnosis of preterm labor is based on clinical criteria, physical examination, transvaginal ultrasound measurement of cervical length, and use of biomarkers 2
- Initial assessment should include evaluation for signs of infection, placental abruption, and fetal well-being 1
- Fetal biometry, amniotic fluid volume assessment, and fetal Doppler waveform analysis should be performed at first diagnosis of preterm complications 1
Management Based on Gestational Age
Previable PPROM (<20 weeks)
- All patients should be offered abortion care due to high maternal risks and poor fetal outcomes 1
- Expectant management can also be offered in absence of contraindications 1
- Shared decision-making regarding antibiotic use is recommended at this gestational age 1
Periviable PPROM (20-23 6/7 weeks)
- Antibiotics can be considered to prolong latency (GRADE 2C) 1
- The recommended regimen includes a 7-day course with intravenous ampicillin and erythromycin for 48 hours followed by oral amoxicillin and erythromycin for 5 days 1
- Azithromycin can substitute for erythromycin when unavailable 1
- Avoid amoxicillin-clavulanic acid due to increased risk of necrotizing enterocolitis 1
PPROM at ≥24 weeks
- Antibiotics are strongly recommended (GRADE 1B) 1
- Antenatal corticosteroids should be administered between 24+0 and 34+0 weeks gestation 1, 3
- Magnesium sulfate for fetal neuroprotection should be given when delivery is anticipated before 32 weeks 1, 4
Pharmacological Management
Antibiotics
- 7-day course of antibiotic therapy with IV ampicillin and erythromycin for 48 hours followed by oral amoxicillin and erythromycin for 5 days 1
- Azithromycin can replace erythromycin if unavailable 1
- Avoid amoxicillin-clavulanic acid due to increased risk of necrotizing enterocolitis 1
Antenatal Corticosteroids
- Recommended between 24+0 and 34+0 weeks gestation 1, 3
- Options include betamethasone (two doses of 12 mg 24 hours apart) or dexamethasone (four doses of 6 mg at 12-hour intervals) 5
- Optimal time interval between administration and delivery is 1-7 days 5
- Reduces risk of respiratory distress syndrome, intraventricular hemorrhage, and neonatal mortality 3
Magnesium Sulfate
- Recommended for fetal neuroprotection when delivery is anticipated before 32 weeks 1
- Caution: FDA warns that continuous administration beyond 5-7 days can lead to fetal hypocalcemia and bone abnormalities 6
- Monitor for maternal toxicity: maintain patellar reflexes, respiratory rate ≥16/min, and urine output ≥100 mL over 4 hours 6
Special Considerations
Cerclage Management with PPROM
- Similar management to PPROM at later gestational ages 1
- Reasonable to either remove cerclage or leave it in situ after discussing risks and benefits 1
Serial Amnioinfusions and Amniopatch
- Considered investigational and should only be used in clinical trial settings 1
- Not recommended for routine care of previable and periviable PPROM (GRADE 1B) 1
Subsequent Pregnancies
- Follow guidelines for management of pregnant persons with previous spontaneous preterm birth 1
Monitoring and Follow-up
- For outpatient management: monitor for signs of infection including daily temperature checks 1
- Watch for contractions, vaginal bleeding, discolored/malodorous discharge, and abdominal pain 1
- Weekly outpatient visits recommended for assessment of maternal vital signs, fetal heart rate, physical examination, and possible laboratory evaluation 1
- Hospital readmission indicated for hemorrhage, infection, fetal demise, or when reaching viability for administration of antenatal corticosteroids and magnesium sulfate 1