Preterm pre-labour rupture of membranes

Preterm pre-labour rupture of membranes (PPROM) is defined as spontaneous rupture of the membranes before the onset of labour prior to 37 weeks gestation. PPROM is associated with over 60 per cent of preterm births, complicates 2-4 per cent of all singleton pregnancies and 7-20 per cent of twin pregnancies.

The aetiology for PPROM is uncertain, though probably multifactorial.

Risk factors for PPROM include:

• intra-amniotic infection
• placental abruption
• invasive uterine procedures (for example amniocentesis, cordocentesis, chorionic villus sampling, cervical cerclage).

The interval between PPROM and the onset of labour is influenced by many factors. Women with PPROM have a 50 per cent chance of going into labour within 24 to 48 hours and a 70-90 per cent chance of going into labour within seven days. If PPROM occurs between 24 and 28 weeks gestation, the latency period before birth is generally longer than if occurring closer to term.

For assistance with PPROM assessment and management, contact PIPER: 1300 137 650.

See Abbreviations

On the telephone

Careful history taking is essential to determine the possibility of PPROM and assess the presence of any complicating risk factors. This is often done over the phone.

Ask these questions:

• What time did the membranes rupture?
• What is the volume, colour and odour of the fluid on the woman's pad (if applicable)?
• Does the woman feel unwell?
• Is the baby moving normally?
• Has the woman had any medical problems in her pregnancy?
• Does she know her GBS status?
• Is this a singleton pregnancy?
• Has the woman had a previous caesarean section?

The woman should present for assessment as soon as possible. She should tell her midwife or doctor if contractions begin.

On presentation

• Perform a general and obstetric examination.
• Confirm the presence of liquor on the woman's pad, if relevant.
• If no evidence of liquor is present, a sterile speculum examination may be indicated.
• If no liquor is visualised during the speculum examination, a diagnostic tool such as the Amnisure or Al-Sense Panty Liner™ can be used.
• Take low and high vaginal swabs.
• Electronic fetal monitoring to assess fetal wellbeing:
  • ≥28/40 CTG
  • <28/40 auscultation of FHR with doppler
  • CTG may be indicated after 26 weeks if concern about fetal wellbeing after FH is auscultated.
• Commence antibiotic prophylaxis.

Document

Record:

• time of PPROM
• type and colour of fluid loss
• amount of fluid loss
• signs of infection, including offensive smelling vaginal discharge, uterine tenderness, maternal fever and fetal tachycardia
• obstetric, medical and surgical history
• risk factors
• maternal and fetal observations.

Assess for a differential diagnosis:

• leakage of urine (incontinence)
• physiological vaginal discharge
• bacterial infection for example, bacterial vaginosis
• cervical mucous (show), which may be a sign of impending labour.

Abdominal palpation

Depending on the gestation, abdominal palpation may be appropriate to assess fetal size and presentation. Note that any abdominal tenderness may indicate infection.

Ultrasound examination

Arrange an ultrasound examination for gestational age, fetal wellbeing and growth, and estimation of amniotic fluid index (AFI).

AFI provides a useful diagnosis of oligohydramnios but is not diagnostic of ROM.

Management is influenced by the gestational age of the fetus, the presence of infection, advanced labour and evidence of fetal compromise.

Practice points

• If a woman has PPROM before 34 weeks, IOL should not be carried out unless there are additional obstetric indications (for example, infection or fetal compromise).
• If a woman has PPROM after 34 weeks, the decision to undertake IOL should consider the balance of risks and benefits for the woman and baby and the local availability of Special Care or Neonatal Intensive Care nursery facilities.
• If the woman is known to be GBS positive, consider active management from 34+0, after corticosteroid treatment.
• Clinicians must consider the availability of resources at their health service, including:
  • availability of clinicians skilled and experienced in care of the premature neonate
  • ability to provide continuous fetal monitoring and clinicians skilled and experienced in CTG interpretation
  • immediate availability of caesarean facilities.
• Consult with PIPER for advice on management and transfer: 1300 137 650.
• For birth at <34/40 or suspected chorioamnionitis, ensure the placenta is sent for histopathological examination.

Note: Cervical cerlage (cervical stitch)

If PPROM is confirmed and birth is likely, cervical stitch must be removed.

PPROM < 23 weeks gestation

Flowchart - PPROM <23 weeks

Practice points

• Outcomes for extremely preterm infants depend on place of birth and access to neonatal intensive care
• Consult with PIPER for advice on management and transfer: 1300 137 650
• Consult with neonatologists if available
• Parental attitudes must be taken into account in formulating a management plan

Established labour

• Prepare for birth
• Provide counselling for the woman and her family about what to expect
• Provide emotional support
• Discuss available pharmacological and non-pharmacological pain relief
• Offer referral to social work, spiritual care and pastoral care

Not in labour

Signs of sepsis/chorioamnionitis or antepartum haemorrhage

• Manage actively

No signs of sepsis/chorioamnionitis or antepartum haemorrhage

• Expectant management is acceptable when the risks of amnionitis and pulmonary hypoplasia are less than the risk of extreme preterm birth and neonatal death.
• If delivery does not occur, further antibiotic prophylaxis is indicated when labour recurs
• Ultrasound examination for fetal growth and wellbeing
• Weekly HVS
• Bi-weekly FBE and CRP
• Daily FHR auscultation
• Daily documentation of fetal movements: for immediate review if woman reports reduced or absent fetal movements

PPROM 23+0-33+6 weeks gestation

Flowchart - PPROM 23+0-33+6 weeks

Established labour

See Preterm labour

• Prepare for birth or transfer:
  • aim for in-utero transfer when possible
  • contact PIPER: 1300 137 650.
• Consider tocolysis, corticosteroids and MgSO4
• Provide counselling for the woman and family.
• Orientate the woman and family to SCN/NICU if time allows.
• Offer referrals to social work, spiritual care and pastoral care.

Not in labour

Signs of sepsis/chorioamnionitis or antepartum haemorrhage

• Manage actively: Plan for IOL or caesarean section

See Induction of labour

No signs of sepsis/chorioamnionitis or antepartum haemorrhage

• Ultrasound examination for fetal growth and wellbeing.
• Daily clinical assessment by the obstetric team.
• If delivery does not occur, further antibiotic prophylaxis is indicated when labour recurs.
• BD observations of maternal temperature, pulse, respiratory rate, oxygen saturation, PV loss and uterine activity and pain or tenderness.
• Weekly HVS.
• FBE and CRP daily for three days, then bi-weekly- consecutive daily CRP>20 mg/L suggestive of infection
• Fetal surveillance:
  • all gestations: daily documentation of fetal movements; for immediate review if woman reports reduced or absent fetal movements
  • ≥28/40 daily CTG for six days, then twice weekly
  • <28/40 daily FHR auscultation.
• Increase fetal surveillance if:
  • increasing abdominal pain or tenderness
  • change in PV loss
  • APH
  • reduced fetal movements.

PPROM at 34+0-36+6 weeks gestation

Flowchart - PPROM at 34+0-36+6 weeks

Established labour

See Preterm labour

• Prepare for birth or transfer:
  • aim for in-utero transfer when possible
  • contact PIPER: 1300 137 650.
• Corticosteroids if <36+6 weeks:
  • Betamethasone 11.4 mg IM
    then
  • Betamethasone 11.4mg IM in 24 hours
  • consider second dose at 12 hours if birth likely within 24 hours.
• Provide counselling for the woman and family.
• Orientate the woman and family to SCN/NICU if time allows.
• Offer referrals to social work, spiritual care and pastoral care.

Not in labour

Signs of sepsis/chorioamnionitis, antepartum haemorrhage, or GBS positive and ≥36+0

• Manage actively: Plan for IOL or caesarean section

See Induction of labour

GBS positive and 34+0-35+6

• Consider active management after corticosteroid treatment

See Induction of labour

No signs of sepsis/chorioamnionitis or antepartum haemorrhage

• Ultrasound examination for fetal growth and wellbeing.
• Await spontaneous labour until 37 weeks.
• Antibiotic prophylaxis.
• Daily clinical assessment by the obstetric team.
• If delivery does not occur, further antibiotic prophylaxis is indicated during labour.
• BD observations of maternal temperature, pulse, respiratory rate, oxygen saturation, PV loss and uterine activity and pain or tenderness.
• Weekly HVS.
• FBE and CRP daily for three days, then bi-weekly - consecutive daily CRP>20 mg/L suggestive of infection.
• Fetal surveillance - daily CTG for six days, then twice weekly.
• Daily documentation of fetal movements; for immediate review if woman reports reduced or absent fetal movements.
• Increase fetal surveillance if:
  • increasing abdominal pain or tenderness
  • change in PV loss
  • APH
  • reduced fetal movements.

Maternal assessment

Observations

Admission to hospital - perform baseline assessment for:

• Temperature
• Pulse
• Blood pressure (BP)
• Respirations
• O2 saturation
• Uterine activity or tenderness
• Vaginal discharge
• Urinalysis

Ongoing observations

4-hourly:

• Temperature
• Pulse
• Fetal activity
• Uterine activity and/or tenderness
• Vaginal discharge - assess colour and amount. Note if discharge is 'offensive smelling' this may indicate infection

Daily:

• BP
• Assess bowel activity

Pathology tests

On admission:

• Full blood examination (FBE)
• C-reactive protein (CRP)
• Mid-stream urine (MSU)
• Low vaginal swab (LVS)
• Endocervical swab (ECS) if screening required for chlamydia

Ongoing follow-up pathology tests:

• FBE and/or CRP if there is suspicion of infection

Fetal surveillance

The frequency of tests is adjusted according to the maternal and fetal clinical situation.

FHR

• Perform an initial period of electronic FHR monitoring and uterine activity monitoring on admission to identify abnormal FHR and evaluate for contractions:
  • FHR auscultation at ≥23 weeks and <28 weeks
  • CTG if ≥28 weeks.
• Thereafter, FHR daily.

CTG

• Daily if gestation is ≥28 weeks.

Ultrasound

If the fetus is ≥23 weeks gestation - weekly AFI, BPP, umbilical artery (UA) Doppler studies.

Antibiotic treatment

Practice points

• Antibiotic administration to women with PPROM allows short-term benefits by prolonging pregnancy and reducing risks of maternal and neonatal sepsis.
• A delay in onset of labour may allow time for effective prophylactic corticosteroids.

Avoid the use of Amoxicillin/Clavulanate (Augmentin Duo Forte™) as it is associated with neonatal necrotising enterocolitis.

Antibiotics and dosage

If the woman has a positive screening result for Group B Streptococcus (GBS) see Neonatal eHandbook - GBS sepsis prevention for neonates for management.

• Penicillin-hypersensitive women who do not have a history of anaphylaxis following administration of a penicillin or a cephalosporin should receive Cephazolin 2 g IV loading dose, followed by Cephazolin 1g IV every eight hours.

No evidence of chorioamnionitis

Commence antibiotic prophylaxis:

• Benzylpenicillin 3 g IV loading dose, then 1.8 g IV every four hours for 48 hours or until delivery if this occurs earlier.
• If allergic to penicillin, give clindamycin 900 mg IV in 50-100 ml over at least 20 minutes every eight hours, for 48 hours or until delivery if this occurs earlier.
• Oral erythromycin 250 mg four times a day for 10 days or until delivery if this occurs earlier.
• Further benzylpenicillin prophylaxis, as above, is indicated whenever labour recurs.

Signs of chorioamnionitis

The diagnosis of chorioamnionitis can be very difficult and relies on the clinical signs and symptoms.

The clinical picture may include any of the following:

• maternal fever
• increased white cell count (>15 x 109/L)
• maternal tachycardia (>100 bpm)
• fetal tachycardia (>160 bpm)
• uterine tenderness
• offensive smelling vaginal discharge
• C-reactive protein >40.

Check for any other site of infection (for example, urinary or respiratory tract) that could cause these changes.

Suspected or diagnosed chorioamnionitis

• Loading dose ampicillin or amoxycillin 2 g IV, then 1 g every six hours
  and
• Gentamicin 5 mg/kg IV daily
  and
• Metronidazole 500 mg IV every 12 hours

Penicillin allergy/hypersensitivity

• Lincomycin or clindamycin 900 mg IV every eight hours
  and
• Gentamicin 5 mg/kg IV daily
  and
• Metronidazole 500 mg IV every 12 hours

Plan for delivery under intravenous antibiotic cover.

Postnatal maternal antibiotics

For chorioamnionitis, consider treatment with continued:

• Ampicillin (or amoxycillin) 2 g IV every six hours for five days
• Gentamicin IV 5 mg/kg daily for five days
• Metronidazole 500 mg IV every 12 hours

Corticosteroids are effective in preventing adverse perinatal outcomes, particularly respiratory distress syndrome, and in increasing the likelihood of neonatal survival. 

Repeated doses of corticosteroids reduce the occurrence and severity of neonatal lung disease and the risk of serious health problems in the first few weeks of life.

Dosage and administration

• If ≤36+6 weeks:
  • Betamethasone 11.4 mg IM

then

• Betamethasone 11.4 mg IM in 24 hours
• Consider second dose at 12 hours if birth is likely within 24 hours
• When the gestational age is 32+6 days or less, a repeat antenatal corticosteroid dose may be given seven days or more after the first course in women still considered at risk of early preterm birth
• If betamethasone is unavailable, give IM dexamethasone in two doses of 12 mg, 24 hours apart.

Magnesium Sulfate (MgSO4)

If early preterm birth (<30weeks) is planned or expected within 24 hours, a magnesium sulphate infusion can be offered (if no contra-indications) to women for potential fetal neuro-protection.

Dosage and administration

• Loading dose MgSO4 4g IV bolus over 20 minutes
• Maintenance dose MgSO4 1g/hr IV for 24 hrs or until birth - whichever is first

Tocolysis

Tocolysis may be used to allow a course of corticosteroids to be completed and/or if a woman is requiring transfer to a tertiary hospital.

Where contractions are present, nifedipine may be commenced to prolong pregnancy for 48 hours while corticosteroid cover is established, if there are no other signs of chorioamnionitis.

Dosage and administration

• Nifedipine 20mg oral
• If contractions persist after 30 minutes, repeat nifedipine 20mg oral
• If contractions persist after a further 30 minutes, repeat nifedipine 20mg oral
• Maintenance therapy 20mg every 6 hours for 48 hours

After 24 hours, medical review is required to determine the dose of maintenance treatment with controlled release nifedipine (Adalat®Oros) 2-3 times per day

If a woman presents with PPROM at a gestation outside the service's Newborn Capability Level, aim for in-utero transfer wherever possible.

Within Victoria, consult with PIPER for support with assessment and transfer: 1300 137 650.

Following Obstetric Consultant review after 72 hours of initial hospitalisation, the decision for outpatient management may be considered for all women based on:

• Gestation and presentation (cephalic presentation > 23 weeks)
• Proximity of woman's residence to the hospital
• Absence of signs of threatened premature labour
• No evidence of infection
• Absence of maternal or fetal risk factors
• Absence of fetal compromise
• Singleton pregnancy

If a woman is deemed suitable for outpatient management she should:

• Attend weekly outpatient visits to the Maternal Fetal Assessment Unit
• Attend weekly antenatal clinic appointment for Obstetric Team Consultant review.

The lead maternity care provider should:

• Arrange a Paediatric consultation for gestations under 32 weeks, or in pregnancies with other complications.
• Discuss management of prematurity (for example, feeding methods, Neonatal Intensive Care (NICU) admissions, risk factors and outcomes)
• Arrange a tour of Neonatal Intensive Care (NICU) for the woman and her support person

Maternal education

Patient information sheet on PPROM

A woman going home for outpatient management should be advised to:

• Monitor her temperature
• Wear sanitary pads not tampons, and return to hospital if she has abnormal smelling vaginal discharge, or abnormal appearance of the vaginal discharge
• Avoid vaginal intercourse
• Have showers rather than baths and avoid swimming
• Monitor fetal movements and notify the hospital if fetal movements are decreased
• Notify and return to the hospital if any signs of threatened premature labour, vaginal bleeding, or abdominal pain / tenderness
• Undertake frequent leg exercises and wear graduated compression stockings until full ongoing mobility is assured.

Communication

Treatment and care should take into account women's individual needs and preferences. Women with PPROM should have an opportunity to make informed decisions about their care and treatment, in partnership with the clinicians providing their care.

Good communication between clinicians and women is essential. It should be supported by evidence-based, written information tailored to the needs of the individual woman. Treatment, care and information provided should be culturally appropriate. It should also be accessible to women, their partners, support people and families and take into account any specific needs such as physical or cognitive disabilities or limitations to their ability to understand spoken or written English.

Documentation

The following should be documented in the woman's hospital medical record and (where applicable) her hand-held medical record:

• Discussion of risks and benefits of management
• Discussion of the woman's questions regarding PPROM
• Plan for expectant management if labour commences
• Consultation, referral or escalation

Audit and performance improvement

All maternity services should have processes in place for:

• auditing clinical practice and outcomes
• providing feedback to clinicians on audit results
• addressing risks, if identified
• implementing change, if indicated.

Potential auditable standards for PPROM:

• rates of expectant and active management
• rates of maternal and neonatal sepsis
• SCN/NICU admission after PPROM
• maternal and neonatal readmission for sepsis
• adherence to standards of care.

For further information or assistance with auditing, please contact us.

References

• Antenatal betamethasone for women at risk for late preterm delivery (2016) Gyamfi-Bannerman, C. et.al. New England Journal of Medicine, 374(14), 1311-1320.
• Antibiotics for prelabour rupture of membranes at or near term (2014). Wojcieszek, A.M. et.al. Cochrane Database of Systematic Reviews.
• Preterm Prelabour Rupture of the Membranes Clinical Guideline (2015). SA Department of Health.
• Preterm Prelabour Rupture of Membranes (PPROM) Clinical Practice Guideline (2016). KEMH.
• Management of Perinatal Infections (2014). Palasanthiran, Starr, Jones & Giles. NSW: Australian Society for Infectious Diseases.