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  Threatened preterm birth with rupture of membranes

Threatened preterm birth with rupture of membranes - PERS - Perinatal Emergency Referral Service

(Preterm contractions with rupture of membranes or Preterm prelabour rupture of membranes)





Objective
To achieve safe delivery at the optimum gestation in the setting of preterm premature rupture of membranes (pPROM), both avoiding unnecessary prematurity and minimising the risks of perinatal infection.

Background
This common obstetric complication is associated with hazards to both baby and mother. pPROM complicates 2-3%1,2 of pregnancies and is the cause of 30-40% of all preterm births.3,4

The baby runs the risks of:
  • Prematurity if preterm PROM (pPROM) occurs well before term
  • Infectionif the interval between PROM and delivery is prolonged.

The mother runs the risk of infection as well as the risks associated with intervention, especially an increased chance of Caesarean section.

The majority of women who undergo prelabour rupture of their membranes (PROM) go into labour spontaneously. In patients with pPROM who are managed expectantly there is an inverse relationship between gestational age at the time of membrane rupture and delivery. In women who undergo prelabour rupture of membranes near term more than fifty percent (50%) labour within 5 hours of rupturing their membranes, and about 95% give birth within 28 hours.5 On the other hand, a review of twelve studies of midtrimester (16-26 weeks) pPROM found that 57% of these women had delivered within one week of membrane rupture and 22% remained undelivered four weeks later.6

In general, the greatest risks to the fetus prior to 34 weeks gestation are the complications of prematurity including fetal death, respiratory distress syndrome, chronic lung disease, intraventricular haemorrhage, necrotising enterocolitis and retinopathy. After 34 weeks the greatest risk to the fetus is infection.

Initial Management
On admission, the diagnosis of ruptured membranes must be established. An accurate diagnosis of rupture of the membranes is crucial to management. Avoid digital examination (unless there is a suspicion of cord presentation or prolapse) as it increases the risk of infection and does not provide more information than a speculum examination.7 Take low vaginal swabs for group B streptococcus, Trichomonas vaginalis and Mycoplasma hominis. Swabs for Chlamydia trachomatous and Neisseria gonorrhoea should be considered in high-risk groups. It should be noted, however, that lower genital tract swabs are, overall, poor predictors of intrauterine infection in women with pPROM.8

The presence of contractions is noted and signs of infection are sought. These include fever, tachycardia, offensive discharge and uterine tenderness.

An ultrasound examination is useful to assess fetal size, presentation and normality, as well as the liquor volume. Cardiotocography (CTG) should be performed for at least 30 minutes.

Management details

Antibiotics


  • Prospective randomised controlled trials have found a significant prolongation of pregnancy and a significant reduction in the incidence of chorioamnionitis, perinatal morbidity, neonatal sepsis, necrotising enterocolitis and respiratory distress syndrome where intravenous antibiotics have been used.9-11 Currently no one specific antibiotic regime appears to be superior to another.12 Therefore, the recommendations of the ORACLE trial13 (oral Erythromycin 250mg four times per day for seven days) are commonly used as standard treatment in this regard.
  • Women with rupture of membranes greater than 18 hours should be given intravenous Group B Streptococcus prophylaxis when they labour.

Tocolysis


  • There is no evidence to support the use of prophylactic tocolytics to improve neonatal outcome prior to the onset of contractions.
  • If pPROM occurs before 34 weeks and labour begins it should be inhibited as per the Preterm Labour guideline, to allow the use of corticosteroids, providing there is no sign of sepsis (fever, maternal and/or fetal tachycardia, uterine tenderness and irritability, leucocytosis), antepartum haemorrhage or other contraindication to steroid use.
  • If pPROM occurs between 34 and 37 weeks and labour begins, there is no satisfactory evidence to guide management; therefore, management needs to be individualised.

Amniocentesis:


  • Has been suggested to be useful between 32-36 weeks gestation to assess fetal lung maturity and suitability for induction of labour. However, this course of action has not been widely adopted. The use of this investigation should only be undertaken by individuals highly experienced in the invasive ultrasound procedures undertaken in level III units.
  • May be useful when intra-amniotic infection is suspected. In this instance diagnosis is based upon an amniotic fluid glucose <1 mmol/L, a positive gram stain, or a positive amniotic fluid culture.14-16

Special cases:


  • If a cervical suture is present, there is a very high risk of sepsis. The suture should be removed as soon as possible. Prompt delivery in a Level III setting should be considered, whatever the gestation.
  • Known carriers of Group B streptococcus who present with PROM should be treated with IV penicillin, and labour should be augmented within 6 hours of admission.
  • If pathogens are detected from the genital tract swabs and/or there is clinical evidence of sepsis, antibiotics should be prescribed as part of active intervention to ensure delivery, whatever the gestation. If the pathogen is not specifically identified, IV penicillin, gentamicin and metronidazole provide an appropriate regimen.
  • The presence of gram positive cocci on initial Gram stain of a cervical swab should not lead to a presumptive diagnosis of Group B streptococcus - cultures must be awaited.

References
  • Drife JO. Preterm rupture of the membranes. Br Med J (Clin Res Ed). 1982; 6342: 583-584.
  • Alger LS, Lovchik JC, Hebel JR, Blackmon LR, Crenshaw MC. The association of Chlamydia trachomatis, Neisseria gonorrhoeae, and group B streptococci with preterm rupture of the membranes and pregnancy outcome. Am J Obstet Gynecol. 1988; 159: 397-404.
  • Silver RK, MacGregor SN, Hobart ED. Impact of residual amniotic fluid volume in patients receiving parenteral tocolysis after premature rupture of the membranes. Am J Obstet Gynecol. 1989; 161: 784-787.
  • Veille JC. Management of preterm premature rupture of membranes. Clin Perinatol. 1988;15: 851-862.
  • Hannah ME, Ohlsson A, Farine D, Hewson SA, Hodnett ED, Myhr TL, Wang EE, Weston JA, Willan AR. Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group. N Engl J Med. 1996;334:1005-1010.
  • Schucker JL, Mercer BM. Midtrimester premature rupture of the membranes. Semin Perinatol. 1996; 20: 389-400
  • Lenihan JP Jr. Relationship of antepartum pelvic examinations to premature rupture of the membranes. Obstet Gynecol. 1984; 63: 33-37
  • Carroll SG, Papaioannou S, Ntumazah IL, Philpott-Howard J, Nicolaides KH. Lower genital tract swabs in the prediction of intrauterine infection in preterm prelabour rupture of the membranes. Br J Obstet Gynaecol. 1996; 103: 54-59.
  • Mercer BM, Miodovnik M, Thurnau GR, Goldenberg RL, Das AF, Ramsey RD, Rabello YA, Meis PJ, Moawad AH, Iams JD, Van Dorsten JP, Paul RH, Bottoms SF, Merenstein G, Thom EA, Roberts JM, McNellis D. Antibiotic therapy for reduction of infant morbidity after preterm premature rupture of the membranes. A randomized controlled trial. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. JAMA. 1997; 278: 989-995.
  • Egarter C, Leitich H, Karas H, Wieser F, Husslein P, Kaider A, Schemper M. Antibiotic treatment in preterm premature rupture of membranes and neonatal morbidity: a metaanalysis. Am J Obstet Gynecol. 1996; 174: 589-597.
  • Lovett SM, Weiss JD, Diogo MJ, Williams PT, Garite TJ. A prospective, double-blind, randomized, controlled clinical trial of ampicillin-sulbactam for preterm premature rupture of membranes in women receiving antenatal corticosteroid therapy. Am J Obstet Gynecol. 1997; 176: 1030-1038.
  • Ehrenberg HM, Mercer BM. Antibiotics and the management of preterm premature rupture of the fetal membranes. Clin Perinatol. 2001; 28: 807-818.
  • Kenyon SL, Taylor DJ, Tarnow-Mordi W; ORACLE Collaborative Group. Broad-spectrum antibiotics for preterm, prelabour rupture of fetal membranes: the ORACLE I randomised trial. ORACLE Collaborative Group. Lancet. 2001; 357: 979-988.
  • Belady PH, Farkouh LJ, Gibbs RS. Intra-amniotic infection and premature rupture of the membranes. Clin Perinatol. 1997; 24 43-57.
  • Broekhuizen FF, Gilman M, Hamilton PR. Amniocentesis for gram stain and culture in preterm premature rupture of the membranes. Obstet Gynecol. 1985; 66: 316-321.
  • Romero R, Yoon BH, Mazor M, Gomez R, Gonzalez R, Diamond MP, Baumann P, Araneda H, Kenney JS, Cotton DB, et al. A comparative study of the diagnostic performance of amniotic fluid glucose, white blood cell count, interleukin-6, and gram stain in the detection of microbial invasion in patients with preterm premature rupture of membranes. Am J Obstet Gynecol. 1993; 169: 839-851.

 
 
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