Premature (Prelabor) Rupture of Membranes ; NICE Guideline 2022; Dr Ahmed Walid-1.pptx

1. Prelabor Rupture of
Membranes
(NICE Guideline, 2022)
DR/ Ahmed Walid Anwar Morad
Professor of OB/GYN
Faculty of Medicine
Benha University
2023

2.  Definitions/ incidence
 Etiology & pathophysiology
 Diagnosis
 Complications
 Prophylaxis
 Management
• PPROM
• Term PROM
• PROM in special cases
 Take Home Message
 References; PPROM (NICE 2022)/ ACOG 2015

3. Prelabor Rupture of Membranes
(PROM)
Definitions:
 Prelabor rupture of membrane (PROM): →
ROM (Amnion & Chorion) before the onset of
labor irrespective to the gestational age (GA).
It may be:
Term PROM(>
37 wks)
Preterm
PROM(<37 wks)
Previable
Viable
20wk
22wk
24wk
28wk

4. Prelabor Rupture of Membranes
(PROM)
Definitions:
 Prolonged rupture of membranes → ROM for
more than 18- 24hs before delivery.
 Latency period: Period from PROM to the onset of
labor.
 Interval period: Period from PROM to delivery of
Latent Period 

Gestational Age

1 week
50%
26 wk
36 hours
50%
32 wk
24 hours
90%
37 wk

5. Prelabor Rupture of Membranes
(PROM)
Incidence:
 PROM Complicates 10% of all deliveries
 8% at term &
 2% preterm (PPROM)  30% of preterm
births (PPROM single most known cause of
PTL)

6. Etiology
=
Risk factors +
Pathophysiology

8. Pathophysiology: Weakness of amnion with decreased
tensile strength due to collagen degradation
 At term: Physiological Process
due to:
 At PPROM: Pathologic
Process, (e.g. Inflammation
/infection) → release of:
 Pro-inflammatory cytokines,
  metalloproteinase. &
 Activation of catabolic
enzymes, such as collagenase

9. Diagnosis

11. No pooling of amniotic fluid
Biochemical immunoassay in Vaginal fluid:
Interpretation
Detected protein
Test
 Positive:
• Support diagnosis
• Should be used in conjunction
with clinical findings
 Negative
• PPROM is unlikely
• Ask woman to return for checkup
with any suspected finding
PAMG-1(Placental alpha
microglobulin-1)
1. Amnisur
e:
IGFBP-1 (insulin-like
growth factor binding
protein-1)
2. ACTIM
PROM
2 protein markers
(Placental protein 12 &
alpha fetoprotein)
3. ROM
Plus
(Not
approved by
NICE)
Don't perform diagnostic tests if labor is established

13. What is about AF Identification Tests?
1. Nitrazine Paper turns from yellow to blue as AF is
alkaline (pH 7-7 .5)
2. Nile blue sulfate: detect fat containing cells (–ve
before 36 weeks)
3. Fern test: +ve (high NaCl in AF→ arborization)
4. AmnioSense: absorbent pads that change color
from yellow to green or blue at pH≥ 6.5
 Not recommended for diagnosis of PPROM

14. What is about ?
1. Ultrasound: for AFI may be helpful but not
diagnostic.
2. AF dye instillation under US guidance then tampon
test: (Indigo Carmine or sodium fluorescein)
  incidence of infection, ROM and fetal trauma.
 Not recommended for diagnosis of PPROM

17. DD of PPROM
1) Vaginal discharge (Physiological/ Pathological)
2) Urine Incontinence
3) Perspiration (Sweat)
4) Hydrorrhea Gravidarum: Periodic watery
discharge occurs probably due to excessive
decidual glandular secretion (No fetal elements)
5) Chronic accidental Hemorrhage
 Fluid is brownish & malodorous.
 Microscopy & chemistry: blood elements

18. Complications of PPROM
Fetal & Neonatal Complications :( ↑ perinatal mortality and neonatal morbidity.)
due to
1. Premature birth and related complications (e.g., bronchopulmonary dysplasia,
necrotizing enterocolitis, intraventricular hemorrhage, cerebral palsy)
2. Oligohydramnios:
Prolonged Severe
• Fetal pulmonary hypoplasia (esp. if
PPROM (<26 wks or latency > 6 wks)
• Skeletal deformities e.g.
arthrogryposis, talipes equinovarus,
amputation,
• Cord compression
• Abnormal fetal heart pattern in
labor
3. Neonatal infections e.g. pneumonia, septicemia
4. Fetal death: due to Infections and cord accident

19. Complications of PPROM
Maternal Complications:
1. During pregnancy 2. During labor: 3. After labor
 Chorioamnionitis
 Abruptio placentae
 Malpresentation
 PTL
 Increased induction rate
 Increased CS rate (due to
Malpresentation, dry
labor,& cord accidents)
 PPHge (retained placenta)
 Postpartum Endometritis.

24. Management
of
PROM

25. Prophylactic Management of PROM
In women with history of PPROM in the previous
pregnancy
 Progesterone supplementation starting at 16-24 weeks
 Cervical cerclage indicated in the present singleton gestation
with:
1. Cervical length < 25 mm before 24 weeks
2. Previous spontaneous preterm birth < 34 weeks

26. Management of PROM
Preterm
PROM(<37 wks)
Nonviable
Viable
24wk
Term
PROM
(> 37 wks)

27. Management of PPROM (GA ≥ 24 wks;
Viable)
Active management
Conservative management
1. Gestational age ≥ 37 Weeks
2. Pulmonary maturity is achieved.
3. There is evidence of
chorioamnionitis.
4. Fetal compromise
5. Labor pains
PPROM:
 ≥ 24 weeks’ & < 37 weeks
gestation
 No contraindications to
continuing the pregnancy
A+B+C+D

28. Lines of conservative management
A) Inpatient versus outpatient
Outpatient
Inpatient
Decision is individualized based
on:
• Past obstetric history
• Distance from home to hospital
• Home support
RCOG: if delivery is imminent
ACOG: hospitalization of all cases;
Why?
 Latency is commonly short-term
 Infection may be present
suddenly
 Umbilical cord compression
At home: avoid intercourse, measure temperature (4-8h) & hospital visit
weekly or any complaint

29. Lines of conservative management
B) Advices:
1) Rest: Complete bed rest to prevent more leakage
of liquor. Controversies
2) Avoid vaginal examination except if: patient is in
labor under complete aseptic conditions to
exclude:
 Cord prolapse &
 Assess degree of cervical dilatation & effacement.

31. D) Drugs:
1. Antibiotics:
 Prophylactic/ Latency
 GBS Prophylaxis
 Therapeutic in Chorioamnionitis
2. Antenatal Corticosteroids
3. Magnesium sulfate for fetal neuroprotection
4. Tocolytics

32. 1) Antibiotics
Not
recommended
Coamoxiclav
(Amoxicillin +
Clavulanic acid):
due to increased
risk for
necrotizing
enterocolitis.

33. 1) Antibiotics

34. 1) Antibiotics
Therapeutic antibiotics: In cases of Chorioamnionitis
■ Antibiotics are modified after culture result.
■ Antibiotics are also given to neonate in proper
doses.

35. 2) Antenatal maternal corticosteroids

36. 2) Antenatal maternal corticosteroids
Risks
Benefits
Long-term
Short-term

Neonatal
 Risk of mental ,
behavior &
neurocognitive disorders
Hypoglycemia in late
preterm
RDS, IVH, Necrotizing
enterocolitis
Neonatal mortality
Not increase risk of neonatal sepsis or chorioamnionitis but increase risk of
Endometritis

37. 3) Magnesium sulfate for neuroprotection

38. 3) Magnesium sulfate for neuroprotection
Monitoring (No long-term adverse effects)
Neonate
Mother
If used > 24 hours
Monitor neonatal Ca and Mg and skletal
adverse effects
 Pulse, BP, RR and deep tendon
reflexes every 4 hours
 Urine output ; more frequent
monitoring/ reduce or stop the dose
of MgSO4

39. PPROM; Labor and delivery
 Timing: Indications of active management …….
 Mode of birth:
 VD; is the role when there are no contraindications
 CS; only for obstetric indications e.g., Breech
 Misoprostol & oxytocin are similarly effective cervical ripening agents
 Prostaglandin E2 is an effective alternative with no risk of infections
 Mechanical methods of cervical ripening are contraindicated.

40. PPROM; Labor and delivery
 Fetal monitoring:
• CTG or Intermittent auscultation
• Avoid ( fetal scalp electrode & fetal blood sampling) before 34
wks
 Baby:
 At or below level of placenta
 Delay cord clamping for 60 sec when mother and baby are stable
 Intra-partum antibiotic prophylaxis in GBS …………

41. Management of Pre-viable PPROM
(GA < 24 wks)
 Counseling.
 Expectant management or induction of labor
 Drugs:
Not recommended
Recommended
 Corticosteroids
 MgSO4
 Tocolytics
 Antibiotics

42. Management of Term PROM

43. Other treatment options:
1)Amnioinfusion: Not recommended in women
with:
 PROM during labor
 PPROM as a method to prevent lung hypoplasia
2) Tissue sealant (e.g., fibrin glue, gelatin sponge) :
not recommended

44. Specific cases of PPROM

45. Specific cases of PPROM
HIV infection and PPROM
 Optimal obstetric management is unclear
 Follow: Standard HIV guidelines by Multidisciplinary team.
 The duration of ROM is not correlated with vertical transmission risk in
patients who are on highly active antiretroviral therapy as they have a low viral
load.
 The management should be individualized based on; gestational age, viral load,
and duration since the patient is on antiretroviral therapy

46. Specific cases of PPROM

47. Take Home Message

48. Take Home Message
1. PROM means ROM before onset of labor regardless of the
gestational age.
2. Term PROM is usually a reflection of normal physiology,
however PPROM is a reflection of pathological processes.
3. PPROM is a single most known cause of PTL

49. Take Home Message
4. Accurate diagnosis of ROM is essential and can be achieved by; simple
history and sterile speculum examination alone. Additional tests (IGFBP-1 &
PAMG-1) can be used when there is doubt about diagnosis.
5. A digital vaginal examination in PPROM should be avoided unless advanced
labor is impending.
6. Management guidelines for PPROM should be strictly followed to minimize
maternal and fetal complications

50. Take Home Message
7. Criteria for conservative and active management should be clear.
8. Conservative management includes; hospitalization (home
management), Rest, minimize PV, Drugs (Antibiotics,
Corticosteroids, Tocolytics,& Mg SO4)
9. LSCS should be done only for obstetric indications in case of
PROM.