Premature ROM/Preterm Premature
ROM Quick Facts
PROM = Rupture of membranes before
onset of labor. Occurs in ~8% of term pregnancies.
expectantly -> 50% deliver within 5 hours and 95% within 28
hours.However, IOL reduces time to delivery, decreases rates of
chorioamnionitis/endometritis, decreases NICU admissions WITHOUT increasing C/S or operative delivery rates.
prostaglandins equally effective, but lower infection risk with Pitocin.
(i.e. Foley, Cook) are not well studied
Antibiotics for GBS only if positive of unknown with additional
indications…h/o infant with GBS disease, maternal fever, ROM>18h
PPROM = Rupture of membranes
before onset of labor and prior to 37 weeks. Viable PPROM occurs in 3%
of pregnancies, while pre-viable occurs in <1%. Regardless of
intervention, ~50% of women deliver within 1 week. The earlier
gestational age at which PPROM occurs, the longer the latency in most
Risk Factors for
PPROM: intrauterine infection, h/o PPROM/PTL, short CL,
bleeding, low BMI, low socioeconomic status, cigarette smoking,
illicit drug use
PPROM: 15-25% have clinically evident infection, 2-5% have
abruption, 1-2% have fetal demise. If pre-viable, 10-20% have
skeletal deformations, 1% maternal sepsis.
PPROM: SSE for pooling/nitrazine/ferning (can get false+ nitrazine
with blood/semen/antiseptics/BV, false- with prolonged rupture). If
equivocal, can add ultrasound
for oligo and/or Amnisure (but placental protein tests like Amnisure
have false+ 19-30%). Can diagnose with certainty by instilling
indigo carmine into amniotic fluid and doing a
SVE only if
patient appears to be in active labor, as increases risk of
infection. Preferentially use SSE to assess dilation/effacement. SSE
also useful to inspect &
culture for cervicitis, evaluate for
Management of PPROM: Confirm GA and fetal position. Monitor for
labor. Evaluate for signs/sx of fetal distress, infection, abruption
all (indications for delivery). Obtain GBS
Under 24 weeks –
patient counseling, outpatient expectant management vs admission for
IOL, can start latency antibiotics as early as 20 0/7, no
steroids/tocolysis/Mag/GBS prophy until viable
24 0/7 – 33 6/7
weeks (preterm) – Expectant management, latency abx and steroids.
Magnesium if <32 weeks and at risk of imminent delivery.
Insufficient evidence re: prophylactic tocolysis, but therapeutic
tocolysis in patients who are already having contractions is not
recommended. GBS prophy, if indicated, during labor.
Expectant management =
Admission to hospital with periodic assessment for infection (by
VS/exam not labs), abruption, cord compression, fetal well-being
(both ultrasounds and FHR monitoring) and labor. Outpatient
management NOT recommended once viable.
prolong pregnancy, decrease maternal/neonatal infections and
reduce GA dependent morbidity. Below regimen is standard. Avoid
Augmentin, increased risk of NEC. In PCN allergic pts, consider
• IV Amp 2g
q6h + IV Erythro 250mg q6h x48 hours
• Then PO Amox
250 mg q8h + PO Erythro 333 mg q8h x5 days
Steroids are not ~ with an
increased risk of maternal/neonatal infection and a single
course should always be given…however, giving a rescue
course is controversial in PPROM.
34 0/7 – 36 6/7
weeks (late preterm) – delivery, GBS prophy as indicated, steroids
if not previously administered-
Cerclage: Insufficient evidence re: removal vs. retention.
PPROM with HSV:
Risk of vertical transmission during labor is 30-50% with primary
infection, 3% with recurrent infection.
active infection, start treatment for lesions/sx and continue
expectant management. If lesions/sx still present with onset of
labor, then proceed to C/S.
active infection, optimal management is unknown.
PPROM with HIV:
Individualized based on GA, antiretroviral therapy and viral load.
Expectant management likely appropriate if early GA,
antiretroviral therapy with low viral load…as long as patient still
receives intrapartum Zidovudine.
Amniocentesis: Occurs after 1% of procedures. Re-accumulation occurs
in 72% of patients and perinatal survival is 91%.
visits with ultrasonographic examination to assess amniotic fluid
volume are recommended.”
Management of Patients with
History of PPROM
Women with a
singleton gestation and a prior spontaneous preterm birth (due to
either labor or PPROM) should be offered progesterone
supplementation starting b/t 16-24 weeks
cervical length screening. *No data to guide initiation and
frequency of testing.
cerclage if current singleton gestation, history of spontaneous
preterm birth prior to 34 weeks gestation AND a cervical length <25
mm prior to 24 weeks.