What is the management of a patient with suspected ruptured fetal membranes (premature rupture of membranes, PROM)?

Management of Suspected Ruptured Fetal Membranes (PROM)

All patients with previable and periviable preterm prelabor rupture of membranes (PPROM) should be offered abortion care, and expectant management can also be offered in the absence of contraindications. 1

Initial Assessment and Diagnosis

• Diagnosis is typically established by direct observation of pooling of amniotic fluid in the vaginal vault 2
• In unclear cases, nitrazine and fern tests can be used to confirm the diagnosis 2
• Other diagnostic tests include vaginal swab assays for placental alpha macroglobulin-1, AFP, or IGFBP1 3

Management Based on Gestational Age

Term PROM (≥37 weeks)

• Patients with favorable cervices should undergo induction of labor with oxytocin 2
• Patients with unfavorable cervices should undergo induction with prostaglandin compounds 2
• Minimize vaginal examinations to reduce infection risk 2

Preterm PROM (Before 37 weeks)

Previable PROM (<20 weeks)

• Provide individualized counseling about maternal and fetal risks/benefits of both abortion care and expectant management 1
• Offer abortion care to all patients due to high maternal risks and poor fetal outcomes 4
• There are no surviving neonates reported after PPROM at <16 weeks of gestation 5

Periviable PROM (20-23 6/7 weeks)

• Antibiotics can be considered to prolong latency (GRADE 2C) 1, 4
• Offer abortion care as an option 1
• Expectant management can be offered in absence of contraindications 1

PPROM at ≥24 weeks

• Antibiotics are strongly recommended (GRADE 1B) 1, 4
• Recommended regimen: IV ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 days 4, 5
• Avoid amoxicillin-clavulanic acid due to increased risk of necrotizing enterocolitis 4, 5
• Administer antenatal corticosteroids between 24+0 and 34+0 weeks gestation 4
• Magnesium sulfate for fetal neuroprotection when delivery is anticipated before 32 weeks 4

Contraindications to Expectant Management

• Clinical chorioamnionitis/intraamniotic infection 1
• Active heavy bleeding 1
• Fetal demise 1
• Note: Clinical symptoms of infection may be less overt at earlier gestational ages 1
• Diagnosis of intraamniotic infection should not be delayed due to absence of maternal fever 1

Monitoring During Expectant Management

• For outpatient management:

  • Daily temperature monitoring by patient 4, 5
  • Monitor for signs of infection, vaginal bleeding, discolored/malodorous discharge, and abdominal pain 5
  • Weekly outpatient visits for assessment of maternal vital signs, fetal heart rate, physical examination, and laboratory evaluation 4, 5

• Indications for hospital readmission:

  • Signs of hemorrhage, infection, fetal demise 4
  • Reaching viability for administration of antenatal corticosteroids and magnesium sulfate 4

Cerclage Management with PPROM

• Cerclage management after previable or periviable PPROM is similar to management at later gestational ages 1
• It is reasonable to either remove the cerclage or leave it in situ after discussing risks and benefits (GRADE 2C) 1, 4
• The only randomized clinical trial showed no significant pregnancy prolongation with cerclage retention compared to removal 6

Special Considerations

• Serial amnioinfusions and amniopatch are considered investigational and should only be used in clinical trial settings (GRADE 1B) 1, 4
• Administration of antenatal corticosteroids and magnesium sulfate is not recommended until the time when neonatal resuscitation would be considered appropriate and desired by the patient (GRADE 1B) 1
• In subsequent pregnancies after previable or periviable PPROM, follow guidelines for management of pregnant persons with previous spontaneous preterm birth (GRADE 1C) 1, 5

Common Pitfalls to Avoid

• Delaying diagnosis of intraamniotic infection due to absence of maternal fever 1
• Using amoxicillin-clavulanic acid, which increases risk of necrotizing enterocolitis 4, 5
• Failing to offer abortion care as an option for previable and periviable PPROM 1
• Administering antenatal corticosteroids before the period when neonatal resuscitation would be considered 1