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.
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- 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