Basics

PROM occurs when you have a patient that has ruptured the membranes but the onset of labour has not occurred yet. Check out some important definitions below.

PROM at term

This refers to the rupture of membranes before the onset of labour at term (> 37 weeks of gestation).

PROM before 37 weeks = PPROM

Preterm Prelabour Rupture of Membranes (PPROM) occurs when there is a rupture of membranes before 37 weeks of gestation. Similar to PROM, this diagnosis should be confirmed with a sterile speculum examination to demonstrate the leakage of the amniotic fluid. All cases should be referred to a higher level of care.

Diagnosis

This is confirmed using:

Visual inspection, with noticeable liquor.
Speculum examination.
pH testing of the vaginal fluids.
Ultrasound may be necessary in order to visualize the amount of amniotic fluid left.
- Assess fetal weight

Management

Depends on the gestational age and the weight of the fetus. The management of PROM and PPROM can be done by using the steps below.

Note If the patient does not develop uterine contractions within 12 hours of rupture of membranes, then antibiotics should be given to the patient.

Gestational age ≥34 weeks or estimated fetal weight ≥2 kg:

Antibiotics: Give Ampicillin 2g IV stat, then 1g IV 4 hourly AND Metronidazole 400mg PO 8 hourly.
If the patient is in labour, allow the labour to progress. Remember that after 34 weeks, the fetus has good lung maturity and there is no need for neuroprotection.
If the patient is not in labour within 12-24 hours, induce the labour with oxytocin or misoprostol (PO) – this depends on the Bishop score.

Gestational age 26-33+ weeks (PPROM) or estimated fetal weight 800g – 1999g:

This patient needs admission and should be managed in a facility that can manage these kinds of preterm deliveries.
Avoid performing digital examinations. This is because unnecessary digital examination may introduce pathogens and result in chorioamnionitis.
Antibiotics: Amoxicillin 500 mg PO 8 hourly AND metronidazole 400mg PO 8 hourly for 5 days. If there is a penicillin allergy, you should replace amoxicillin with azithromycin 500mg PO daily.
Steroids:
- Betamethasone 12 mg IM 12 hourly for 2 doses. This will depend on the availability of the steroid, may also use Dexamethasone 8mg IM 8 hourly (for 3 doses). Take note that there are several ways of prescribing this depending on your institution.
- The benefits of antenatal corticosteroids reduce mortality, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis.
- Corticosteroids are maximally effective from 24 hours of administration.
Tocolysis: Do not tocolysis the patient, irrespective of the number of steroid doses given.
Monitor:
- Monitor maternal and fetal vital signs 4 hourly e.g. maternal temperature, maternal heart rate, fetal heart rate, and pad checks.
- Daily CTGs
Chorioamnionitis Screen: Screen for chorioamnionitis daily. Perform daily palpations of the abdomen (you may find a tender uterus).
Investigations: White cell count or CRP is not sensitive enough, and not always done.
Delivery:
- Induce the patient if the following is met:
  - Patient is34 weeks or
  - At ≥ a fetal weight of 2 kg, or
  - If there are signs of chorioamnionitis.
- During labour, give ampicillin 2 g IV stat, then 1 g IV 4 hourly.

Gestational age ≤24 weeks or estimated fetal weight ≤600g:

Confirm the rupture of membranes with an obstetric ultrasound – liquour would be decreased.
If this is true, treat it as an inevitable miscarriage.
You may induce labor with oxytocin 10-20 units in 1 L Ringer-lactate at 125 mL/hr.
Always remember that in some institutions, depending on the facilities available, a miscarriage may be defined as pregnancy loss that is less than 26-28 weeks and this will be treated as such.

Referral

The criteria for referral depend on your institution. However, patients with prolonged rupture of membranes (>12 hours), suspected chorioamnionitis, or meconium-stained liquor should be referred to a higher level of care as required.

References and Further Reading 1. The National Department of Health, South Africa: Essential Drugs Programme. Primary Healthcare Standard Treatment Guideline and Essential Medicine List. 7th ed. South African National Department of Health; 2020.
2. Ebrahim , B. Obstetrics: WITS University, Dept. of Obs. & Gyn. Common Obstetric Problems. University of the Witwatersrand.
3. Antenatal corticosteroid therapy for fetal maturation (no date) ACOG. Available at: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/antenatal-corticosteroid-therapy-for-fetal-maturation (Accessed: November 7, 2022)

Published on November 7, 2022

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Prelabour Rupture of Membranes (PROM) and PPROM