Rupture of the Membranes: Preterm Premature (PPROM) CPG

Rupture of the membranes prior to 37 completed weeks gestation

and

prior to the onset of labour.

• Management

• Continuing management

• Special circumstances

• Audit (Jan 2005)

Management

Diagnosis

• All women presenting with a history of PPROM must have a sterile speculum examination

• A digital vaginal examination should NOT be performed

• Ultrasound examination showing markedly reduced liquor volume in the presence of normal fetal kidneys and the absence of IUGR is highly suggestive of ROM, however normal liquor volume does not exclude the diagnosis

• If the diagnosis is in doubt, the patient may be admitted for pad checks

Evaluation

• General examination including pulse and temperature

• Abdominal examination

• Sterile speculum examination

• CTG

• FBE

• A cervical suture, if present, should be removed immediately and submitted for culture

• Birth suite ultrasound examination if presentation is in doubt

Prophylaxis of neonatal respiratory distress syndrome

Tocolysis

Continuing management

Delivery

• Where the gestation is > 36 weeks at presentation, induction of labour (if there are no contraindications to vaginal delivery) should be commenced at the next convenient opportunity (Refer CPG Premature Rupture of Membranes at Term).
  

• If the woman is GBS positive, consideration should be given to prompt induction of labour from 32 weeks.
  

• In women who are being managed conservatively (see below), delivery should be effected if there is evidence of intrauterine infection, or when the gestation reaches 36 weeks.

Antibiotics

• Prophylactic antibiotics improve the outcome in PPROM. The drug of choice is erythromycin 250 mg orally qid
  

• This recommendation only applies to women with no clinical signs of infection and no other indication for the use of antibiotics. Refer CPG Strategies to prevent early onset gbs sepsis in neonates
  

• Once labour has commenced - Refer CPG Strategies to prevent early onset gbs sepsis in neonates
  
  

Surveillance for infection, growth

• Clinical observations

• FBE weekly

• CTG twice per week

• Weekly assessment of fundal height

• Formal ultrasound examination initially, then every fortnight

Outpatient management

• All women should be observed in hospital for 72 hours. If they remain well and are not in labour, they can then be discharged for outpatient management. The woman would be instructed to take her temperature t.d.s., observe PV Loss and be aware of fetal movements - returning if there are reduced fetal movements felt. They should be seen once each week in the PDCC and once each week in the antenatal clinic (complex care) with the above surveillance performed at each visit.

• Women who are referred to the hospital as in-utero transfers can be transferred back to the referring hospital at 34 weeks.

Special circumstances

PPROM remote from term

Audit