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

Management of Premature Rupture of Membranes (PROM)

The management of premature rupture of membranes requires individualized counseling about maternal and fetal risks, with antibiotics recommended for expectant management at ≥24 weeks gestation, while all patients with previable PROM should be offered abortion care due to significant maternal risks. 1, 2

Initial Assessment and Diagnosis

• Evaluate for signs of infection including maternal fever, tachycardia, purulent cervical discharge, fetal tachycardia, and uterine tenderness 2
• Perform fetal biometry, amniotic fluid volume assessment, and fetal Doppler waveform analysis at initial diagnosis 3
• Diagnosis of PROM is made through sterile speculum examination, nitrazine test, ferning test, or newer diagnostic tests like Amnisure or Actim test 4
• Important to note that intraamniotic infection may present without maternal fever, especially at earlier gestational ages 2

Management Based on Gestational Age

Previable PROM (<20 weeks)

• All patients should be offered abortion care due to high maternal risks and poor fetal outcomes 1, 2
• Expectant management can be offered in absence of contraindications 1
• No surviving neonates reported after PROM at <16 weeks of gestation 2
• Shared decision-making regarding antibiotic use is recommended 3

Periviable PROM (20-23 6/7 weeks)

• Antibiotics can be considered (GRADE 2C recommendation) 1
• Neonatal survival rates: approximately 20% after PROM at 16-19 weeks, 30% after PROM at 20-21 weeks, and 41% after PROM at 22-23 weeks 2, 3

PROM at ≥24 weeks

• Antibiotics strongly recommended (GRADE 1B) for pregnant individuals who choose expectant management 1
• Administer antenatal corticosteroids between 24+0 and 34+0 weeks gestation to accelerate fetal lung maturity 3
• Magnesium sulfate recommended for fetal neuroprotection when delivery is anticipated before 32 weeks 3

Antibiotic Regimen

• Recommended 7-day course: IV ampicillin and erythromycin for 48 hours followed by oral amoxicillin and erythromycin for 5 days 2, 5
• Azithromycin can replace erythromycin if unavailable 2, 5
• Avoid amoxicillin-clavulanic acid due to increased risk of necrotizing enterocolitis 2, 3
• Prophylactic antibiotics recommended after 18 hours of membrane rupture regardless of other risk factors 5

Monitoring During Expectant Management

• Initial observation in hospital is reasonable to ensure stability 1, 2
• For outpatient management:
  • Daily temperature monitoring by patient 2, 3
  • Monitor for signs of complications: vaginal bleeding, discolored or malodorous discharge, abdominal pain 2, 3
  • Weekly outpatient visits for assessment of maternal vital signs, fetal heart rate, physical examination, and laboratory evaluation 2, 3

Maternal and Fetal Risks

• Expectant management increases risk of maternal complications including infection, hemorrhage, and death compared to abortion care 2, 3
• Intraamniotic infection occurs in 38% of expectant management cases versus 13% with immediate intervention 2
• Maternal sepsis occurs in up to 6.8% of previable and periviable PROM cases 2, 3
• Maternal mortality rate associated with expectant management of PROM at 14-24 weeks is approximately 45 per 100,000 patients 2, 3
• Neonatal complications include pulmonary hypoplasia, respiratory distress, skeletal deformities, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, and retinopathy of prematurity 2
• Long-term respiratory problems requiring treatment occur in 50-57% of children 2

Special Considerations

• Antenatal corticosteroids and magnesium sulfate are not recommended until the time when neonatal resuscitation and intensive care would be considered appropriate 1
• Serial amnioinfusions and amniopatch are considered investigational and should be used only in clinical trial settings 1
• For cerclage management after previable or periviable PROM, it is reasonable to either remove the cerclage or leave it in situ after discussing risks and benefits 1
• In subsequent pregnancies after previable or periviable PROM, follow guidelines for management of pregnant persons with previous spontaneous preterm birth 1, 2

Common Pitfalls to Avoid

• Delaying diagnosis and treatment of intraamniotic infection due to absence of maternal fever 2, 3
• Using amoxicillin-clavulanic acid, which increases risk of necrotizing enterocolitis 2, 3
• Prolonged or repeated antibiotic courses beyond what would be used for PROM at later gestational ages 1
• Administering antenatal corticosteroids and magnesium sulfate before the time when neonatal resuscitation would be appropriate 1, 3
• Failing to administer antibiotics promptly after 18 hours of membrane rupture 5