Current Concepts in the Management of

Premature Rupture of the Membranes

Ali Al-Ibrahim
Resident, Obstetrics and Gynecology
Preterm Birth: Scope of the Problem
 Preterm Birth Occurs in 11% of All Births in
the USA
 A Major Factor Contributing to Perinatal
Morbidity and Mortality
 Rate Has Increased by 17% over the Last 15
Years
 PROM a Complication in 25 - 33% of Preterm
Births
 Background Information
 PROM defined as occurring before 37 weeks
gestation
 The gestational age at which membranes
rupture has significant implications with
regard to etiology and consequences
 Accurate assessment and knowledge of
maternal, fetal and neonatal risks are crucial to
obstetrical decision making and management
 Etiology
 At term, PROM may be from physiological
changes

 Infection has been shown to play an important

role, especially with PPROM

 Many times PROM may occur in the absence of

any risk factors
 Associations with PPROM
 Preterm Labor  Abdominal trauma
 Uterine distention  Amniocentesis
 Prior preterm delivery  Prior PROM.
 Cervical factors  Uterine anomalies.
 Infection  Fetal malformation
 Cigarette Smoking  Malpresentation.
 Lower SE status  Placental anomalies.
Microbes isolated in AF of those with IUI
 PROM in a Term Pregnancy
 Occurs in 8% of pregnancies, usually followed
by spontaneous onset of labor and delivery
 Major maternal risk is infection
 Major fetal risk is cord compression and
infection
 In a large randomized study, 50% of patients
managed expectantly delivered in 5 hours and
95% did so in 28 hours
 Preterm Premature Rupture of
Membranes
 Regardless of management, birth within one
week is the most likely outcome
 The earlier the PROM, the greater the potential
for pregnancy prolongation
 2.8-13% of patients have spontaneous cessation
of fluid leakage
 Clinical infection occurs in 13-60% of patients
 Preterm Premature Rupture of
Membranes
 Post partum infection occurs in 2 - 13% of
patients
 Serious infections are rare
 Fetal malpresentations are more commonly
encountered
 Abruption occurs in 4 - 12% of patients with
PPROM
 The most significant risk is prematurity
Midtrimester Premature Rupture
of Membranes
 PPROM at 16 - 26 weeks occurs in 1% of all
pregnancies
 The overall neonatal survival at 24 - 26 weeks is
50 - 75%
 The survival with PPROM is comparable but
decreased with infection or malformations
 Maternal complications are intraamniotic
infection, endometritis, retained placenta, and
postpartum hemorrhage
 Midtrimester Premature Rupture
of Membranes
 Maternal sepsis is rare, occurring in 1% of all cases
 Stillbirths occur in 3.8 - 21.7% of PPROM patients at 16
- 26 weeks gestation
 Survival with PPROM prior to 24 weeks gestation is ~
30%
 PPROM then is associated with a prolonged latency
period from 10.6 to 21.5 days (12 studies)
 Delivery occurs in one week in 57% of patients
 How Is Premature Rupture of the
Membranes Diagnosed?
 Most are diagnosed by history and physical examination
 Sterile speculum exam can confirm the diagnosis,
inspect for cervicitis or cord prolapse, assess cervical
dilation and effacement, and obtain cultures
 If the diagnosis cannot be made, then vaginal nitrazine
testing can be utilized
 When the clinical history and exam is unclear, then an
ultrasound exam may be useful
 Membrane rupture can be diagnosed unequivocally with
transabdominal instillation of indigo carmine dye
 What Is the Optimal Method of
Initial Management of a Patient
with PROM at Term?
 Fetal heart rate monitoring to assess fetal status
 Dating criteria should be reviewed
 Estimation of fetal weight and position
 Group B streptococcus status should be
determined
 Other cultures should also be taken
 When Should Labor be Induced in
Patients with Term PROM?
 Fetal presentation, gestational age,and status should be
established
 Decision based on relative risks of infection versus
failed induction and operative delivery
 If the cervix is unfavorable, there is little difference in
outcome with an induction versus expectant
management
 Risk of maternal infection increases with expectant
management
 When Should One Elect Delivery
for the Fetus Near Term in the
Presence of PROM?
 The relative risks with expectant management and the
potential benefit from expectant management can be
determined
 Amniotic fluid can be obtained for lung maturity studies
 If the AF studies are mature, then an induction can be
considered
 With PPROM prior to 30-32 weeks, the patient is best
served with expectant management, prophlactic
antibiotics and steroid administration
 What Is the General Approach to
PPROM Patients?

 Expectant management with bed rest,

pelvic rest, and observation for infection
 If infection is suspected, an

amniocentesis may be performed

 Should Tocolytics Be Considered in
Patients with PPROM?
 Prophylactic tocolytics after PPROM
have not been shown to prolong latency
 Therapeutic tocolysis has not been shown

to prolong the latency period

 The effect of tocolytics to permit

antibiotic administration and

corticosteroid administration has not yet
been investigated
 Should Antenatal Corticosteroids Be
Administered in Patients with PPROM?

 Lewis demonstrated a significant reduction in RDS

with steroid administration (18% vs 44%)
 The NICHD Research Study demonstrated a benefit
regardless of membrane status
 The NICHD Panel recommends steroids in patients
from 24 to 32 weeks gestation in the absence of
infection
 It would seem better to adopt a rescue approach
rather than a routine administration regimen
Should Antibiotics Be Administered to Patients
with PPROM?
 Two large meta-analyses done from studies on PPROM
in the last ten years have both shown a benefit in using
adjunctive antibiotics with expectant management
 A large multicenter study with antibiotics but no
steroids or tocolytics also showed a benefit
 Another prospective randomized double blinded study
looked at patients with PPROM and treated with
antibiotics and steroids for all patients showed similar
results (ORACLE I)
 The NICHD regimen was ampicillin and erythromycin
for 48 hours, followed by the same agents orally for 5
days if delivery did not occur
What Is the Optimal Regimen for
Antepartum Fetal Surveillance for
Patients with PPROM Managed
Expectantly?

 Both NSTs and Biophysical Profiles have been

used in such patients
 How Does Management Differ in
Patients with Second-Trimester
PROM?
 Those presenting at 24 - 26 weeks gestation
may be considered viable and treated with
expectant management
 Those with PPROM before 24 weeks should be
counseled about the impact of immediate
delivery and the potential risks of expectant
management with the most up-tp-date
information as possible
 Current Recommendations
 With term PROM, labor may be induced at the of
presentation or the patient may be observed for
24 - 72 hours for the onset of labor
 Antibiotics should be administered if there is
PROM with expectant management up to 35
weeks gestation
 Antepartum corticosteroids should be
administered to gravidas before 32 weeks
gestation
 Current Recommendations
 Sterile speculum examinations should be done
rather than digital exams unless immediate
induction of labor is planned
 Patients with PPROM prior to 32 weeks
gestation should be managed conservatively if
no contraindication exists
 Tocolytics may be utilized to administer
corticosteroids and antibiotics
 Antenatal corticosteroids may be given up to 32
weeks gestation
Thank You