New recommendations for PROM management
American College of Obstetricians and Gynecologists Committee on Practice Bulletins–Obstetrics. ACOG practice bulletin no. 217: Prelabor rupture of membranes. Obstet Gynecol. 2020;135:e80-e97.
Rupture of membranes prior to the onset of labor occurs at term in 8% of pregnancies and in the preterm period in 2% to 3% of pregnancies.6 Accurate diagnosis, gestational age, evidence of infection, and discussion of the risks and benefits to the mother and fetus/neonate are necessary to optimize outcomes. In the absence of other indications for delivery, a gestational age of 34 or more weeks traditionally has been the cutoff to proceed with delivery, although this has not been globally agreed on and/or practiced.
ACOG has published a comprehensive update that incorporates the results of the PPROMT trial and other recommendations for the diagnosis and management of both term and preterm prelabor rupture of membranes (PROM).6,7
Making the diagnosis
Diagnosis of PROM usually can be made clinically via history and the classic triad of physical exam findings—pooling of fluid, basic pH, and ferning; some institutions also use commercially available tests that detect placental-derived proteins. Both ACOG and the US Food and Drug Administration caution against using these tests alone without clinical evaluation due to concern for false-positives and false-negatives that lead to adverse maternal and fetal/neonatal outcomes. For equivocal cases, ultrasonography for amniotic fluid evaluation and ultrasonography-guided dye tests can be used to assist in accurate diagnosis, especially in the preterm period in which there are significant implications for pregnancy management.
PROM management depends on gestational age
All management recommendations require reassuring fetal testing, evaluation for infection, and no other contraindications to expectant management. Once these are established, the most important determinant of PROM management then becomes gestational age.
Previable PROM
Previable PROM (usually defined as less than 23–24 weeks) has high risks of both maternal and fetal/neonatal morbidity and mortality from infection, hemorrhage, pulmonary hypoplasia, and extreme prematurity. These very difficult cases benefit from a multidisciplinary approach to patient counseling regarding expectant management versus immediate delivery.
If expectant management is chosen, outpatient management with close monitoring for signs of maternal infection may be done until an agreed on gestational age of viability. Then inpatient management with fetal monitoring, corticosteroids, tocolysis, magnesium for neuroprotection, and group B streptococcus (GBS) prophylaxis may be considered as appropriate.
Preterm PROM at less than 34 weeks
If the mother and fetus are otherwise stable, PROM at less than 34 weeks warrants inpatient expectant management with close maternal and fetal monitoring for signs of infection and labor. Management includes latency antibiotics, antenatal corticosteroids, magnesium for neuroprotection if less than 32 weeks’ gestation and at risk for imminent delivery, and GBS prophylaxis. While tocolysis may increase latency and help with steroid course completion, it should be used cautiously and avoided in cases of abruption or chorioamnionitis. Although there is no definitive recommendation published, a rescue course of steroids may be considered as appropriate but should not delay an indicated delivery.
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