Management of premature rupture of the fetal membranes at term
- William E Scorza, MD
William E Scorza, MD
- Chief of Obstetrics and Gynecology
- Division of Maternal Fetal Medicine
- Lehigh Valley Physician Group
Premature rupture of the membranes (PROM) refers to rupture of the fetal membranes prior to the onset of regular uterine contractions. It may occur at term (≥37 weeks of gestation) or preterm (<37 weeks of gestation); the latter is designated preterm PROM (PPROM). Midtrimester PROM typically refers to PPROM at 16 to 26 weeks of gestation; this is an arbitrary definition, which varies slightly among investigators. The frequencies of term, preterm, and midtrimester PROM are approximately 8, 3, and <1 percent of pregnancies, respectively. Why membranes rupture at term and whether different etiologies account for premature versus intrapartum membrane rupture is not well understood.
The management of term PROM will be reviewed here. Issues regarding midtrimester PROM and PPROM are discussed separately. (See "Midtrimester preterm premature rupture of membranes" and "Preterm premature (prelabor) rupture of membranes".)
Women with term PROM should be evaluated by a clinician. Whether the patient should be evaluated immediately or can remain at home for a few hours to see if labor begins has not been studied extensively. In the absence of high-quality data supporting the safety of delaying evaluation, the most prudent approach is prompt assessment to confirm membrane rupture, determine fetal position, evaluate maternal and fetal status, and discuss options for further management.
●The diagnosis of PROM is based upon a characteristic history (ie, leaking fluid per vagina) and confirmatory speculum examination in which fluid is seen flowing from the cervical os. If the diagnosis is uncertain, diagnostic testing is performed on fluid in the posterior fornix. The clinical manifestations and diagnosis of PROM are the same across gestation and are discussed in detail separately. (See "Preterm premature (prelabor) rupture of membranes", section on 'Diagnosis'.)
Digital cervicovaginal examination should be avoided, as it has been associated with an increased risk of intrauterine infection.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Gafni A, Goeree R, Myhr TL, et al. Induction of labour versus expectant management for prelabour rupture of the membranes at term: an economic evaluation. TERMPROM Study Group. Term Prelabour Rupture of the Membranes. CMAJ 1997; 157:1519.
- Middleton P, Shepherd E, Flenady V, et al. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev 2017; 1:CD005302.
- Hannah ME, Ohlsson A, Farine D, et al. 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.
- Tan BP, Hannah ME. Prostaglandins versus oxytocin for prelabour rupture of membranes at term. Cochrane Database Syst Rev 2000; :CD000159.
- Lin MG, Nuthalapaty FS, Carver AR, et al. Misoprostol for labor induction in women with term premature rupture of membranes: a meta-analysis. Obstet Gynecol 2005; 106:593.
- Hofmeyr GJ, Gülmezoglu AM, Pileggi C. Vaginal misoprostol for cervical ripening and induction of labour. Cochrane Database Syst Rev 2010; :CD000941.
- Crane JM, Young DC. Induction of labour with a favourable cervix and/or pre-labour rupture of membranes. Best Pract Res Clin Obstet Gynaecol 2003; 17:795.
- Lange AP, Secher NJ, Nielsen FH, Pedersen GT. Stimulation of labor in cases of premature rupture of the membranes at or near term. A consecutive randomized study of prostaglandin E2-tablets and intravenous oxytocin. Acta Obstet Gynecol Scand 1981; 60:207.
- McQueen D, Neilson JP, Whittle MJ. Pre-labour rupture of membranes with an unripe cervix: a random trial of management. J Obstet Gynaecol 1990; 10:495.
- Güngördük K, Asicioglu O, Besimoglu B, et al. Labor induction in term premature rupture of membranes: comparison between oxytocin and dinoprostone followed 6 hours later by oxytocin. Am J Obstet Gynecol 2012; 206:60.e1.
- ACOG Committee on Practice Bulletins -- Obstetrics. ACOG Practice Bulletin No. 107: Induction of labor. Obstet Gynecol 2009; 114:386. Reaffirmed 2016.
- Tang J, Kapp N, Dragoman M, de Souza JP. WHO recommendations for misoprostol use for obstetric and gynecologic indications. Int J Gynaecol Obstet 2013; 121:186.
- Amorosa JMH, Stone J, Factor SH, et al. A randomized trial of Foley Bulb for Labor Induction in Premature Rupture of Membranes in Nulliparas (FLIP). Am J Obstet Gynecol 2017; 217:360.e1.
- Wolff K, Swahn ML, Westgren M. Balloon catheter for induction of labor in nulliparous women with prelabor rupture of the membranes at term. A preliminary report. Gynecol Obstet Invest 1998; 46:1.
- Cabrera IB, Quiñones JN, Durie D, et al. Use of intracervical balloons and chorioamnionitis in term premature rupture of membranes. J Matern Fetal Neonatal Med 2016; 29:967.
- Mackeen AD, Walker L, Ruhstaller K, et al. Foley catheter vs prostaglandin as ripening agent in pregnant women with premature rupture of membranes. J Am Osteopath Assoc 2014; 114:686.
- Mackeen AD, Durie DE, Lin M, et al. Foley plus oxytocin versus oxytocin alone for labor induction greater than or equal to 34 weeks after premature rupture of membranes (PROM): a randomized controlled trial. Am J Obstet Gynecol 2017; 216:S72.
- Romero R, Hanaoka S, Mazor M, et al. Meconium-stained amniotic fluid: a risk factor for microbial invasion of the amniotic cavity. Am J Obstet Gynecol 1991; 164:859.
- Seaward PG, Hannah ME, Myhr TL, et al. International Multicentre Term Prelabor Rupture of Membranes Study: evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term. Am J Obstet Gynecol 1997; 177:1024.
- Seaward PG, Hannah ME, Myhr TL, et al. International multicenter term PROM study: evaluation of predictors of neonatal infection in infants born to patients with premature rupture of membranes at term. Premature Rupture of the Membranes. Am J Obstet Gynecol 1998; 179:635.
- Keirse MJ, Ottervanger HP, Smit W. Controversies: prelabor rupture of the membranes at term: the case for expectant management. J Perinat Med 1996; 24:563.
- Hannah ME, Hodnett ED, Willan A, et al. Prelabor rupture of the membranes at term: expectant management at home or in hospital? The TermPROM Study Group. Obstet Gynecol 2000; 96:533.
- Ellestad SC, Swamy GK, Sinclair T, et al. Preterm premature rupture of membrane management--inpatient versus outpatient: a retrospective review. Am J Perinatol 2008; 25:69.
- Saccone G, Berghella V. Antibiotic prophylaxis for term or near-term premature rupture of membranes: metaanalysis of randomized trials. Am J Obstet Gynecol 2015; 212:627.e1.
- Wojcieszek AM, Stock OM, Flenady V. Antibiotics for prelabour rupture of membranes at or near term. Cochrane Database Syst Rev 2014; :CD001807.
- https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Term-Prelabour-Rupture-of-Membranes-(Term-Prom)-(C-Obs-36)-Review-Mar-14.pdf?ext=.pdf (Accessed on April 12, 2017).
- http://sogc.org/wp-content/uploads/2013/09/October2013-CPG298-ENG-Online_Final.pdf (Accessed on April 17, 2014).
- Committee on Obstetric Practice. Committee Opinion No. 687: Approaches to Limit Intervention During Labor and Birth. Obstet Gynecol 2017; 129:e20.
- Hannah ME, Ohlsson A, Wang EE, et al. Maternal colonization with group B Streptococcus and prelabor rupture of membranes at term: the role of induction of labor. TermPROM Study Group. Am J Obstet Gynecol 1997; 177:780.
- INITIAL EVALUATION
- ACTIVE OR EXPECTANT MANAGEMENT?
- Our approach
- ACTIVE MANAGEMENT
- Oxytocin induction
- Alternatives for women with an unfavorable cervix
- - Misoprostol or prostaglandin E2
- - Balloon catheter
- EXPECTANT MANAGEMENT
- Duration of expectant management
- Expectant management in hospital or at home?
- Antibiotic prophylaxis
- Group B streptococcus colonization
- Maternal and fetal monitoring
- Complete blood count
- Indications for delivery
- MANAGEMENT OF THE NEWBORN
- SUMMARY AND RECOMMENDATIONS