Guideline No. 430: Diagnosis and management of preterm prelabour rupture of membranes

Abstract

ObjectiveTo provide clear and concise guidelines for the diagnosis and management of preterm prelabour rupture of membranes (PPROM) Target PopulationAll patients with PPROM <37 weeks gestation Benefits, Harms, and CostsThis guideline aims to provide the first Canadian general guideline on the management of preterm membrane rupture. It includes a comprehensive and up-to-date review of the evidence on the diagnosis, management, timing and method of delivery. EvidenceThe following search terms were entered into PubMed/Medline and Cochrane in 2021: preterm premature rupture of membranes, PPROM, chorioamnionitis, Nitrazine test, ferning, commercial tests, placental alpha microglobulin-1 (PAMG-1) test, insulin-like growth factor-binding protein-1 (IGFBP-1) test, ultrasonography, PPROM/antenatal corticosteroids, PPROM/Magnesium sulphate, PPROM/ antibiotic treatment, PPROM/tocolysis, PPROM/preterm labour, PPROM/Neonatal outcomes, PPROM/mortality, PPROM/outpatient/inpatient, PPROM/cerclage, previable PPROM.Articles included were randomized controlled trials, meta-analyses, systematic reviews, guidelines, and observational studies. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Intended AudienceAll prenatal and perinatal health care providers. SUMMARY STATEMENTS1.Preterm prelabour rupture of membranes complicates approximately 3% of pregnancies and causes approximately one-third of all spontaneous preterm deliveries (high).2.Preterm prelabour rupture of membranes is associated with high neonatal mortality and short- and long-term severe neonatal morbidity such as periventricular leukomalacia, bronchopulmonary dysplasia, necrotizing enterocolitis, retinopathy of prematurity, and adverse neurodevelopment outcomes (high).3.The latency period from rupture of membranes to delivery is negatively correlated with gestational age at preterm prelabour rupture of membranes (high).4.There is insufficient evidence on both the testing modality and the optimal frequency of testing to prevent adverse maternal and perinatal outcomes (low).5.Bed rest is not beneficial in the setting of preterm prelabour rupture of membranes and has adverse maternal effects (high).6.Serial monitoring of white cell count or other markers of inflammation have not been proven to be useful in the absence of other clinical signs of infection (low).7.There is insufficient evidence to recommend hospital versus home management for preterm prelabour rupture of membranes (low).8.Preterm prelabour rupture of membranes may complicate up to 38% of pregnancies in patients who have undergone cervical cerclage (moderate).9.There are no randomized controlled trials comparing different management strategies (or timing) in the setting of previable preterm prelabour rupture of membranes (low).10.Amniotic fluid volume at time of rupture may be helpful in counselling patients and families with previable preterm prelabour rupture of membranes, as anhydramnios and oligohydramnios are more frequently associated with pregnancy loss and pulmonary hypoplasia compared with normal amniotic fluid volumes (low).11.There is conflicting evidence about the relationship between the gestational age at preterm prelabour rupture of membranes in a previous pregnancy and future pregnancy risks (low).12.There is conflicting evidence about the effectiveness of prevention strategies for reducing complications in subsequent pregnancies for patients with a history of preterm prelabour rupture of membranes (moderate).13.The reported recurrence risk of preterm prelabour rupture of membranes in future pregnancy ranges from 10% to 32%, but the most common complication in future pregnancy is preterm birth (34%–46%) (moderate). RECOMMENDATIONS1.The diagnosis of preterm prelabour rupture of membranes should be based on the combination of patient’s history and physical examination by a sterile speculum with direct visualization of fluid in the posterior fornix (strong, moderate).2.Digital exam should be avoided to reduce the risk of infection, unless the patient is in active labour (strong, moderate).3.Multiple conventional tests (nitrazine, ferning test, and ultrasound evaluation of amniotic fluid volume) should be considered to confirm the diagnosis of preterm prelabour rupture of membranes when amniotic fluid is not visible at speculum examination (strong, moderate).4.Commercial tests, particularly placental alpha microglobulin-1 (PAMG-1), should be considered following conventional tests in equivocal cases or used as the primary tests in rural and remote areas if other diagnostic options are not available or feasible (strong, moderate).5.Once preterm prelabour rupture of membranes is diagnosed, the initial assessment should include maternal and fetal status with the principal purpose of ruling out active labour, infection (chorioamnionitis), placental abruption, or fetal distress, all conditions that warrant immediate delivery (strong, high).6.Once preterm prelabour rupture of membranes is diagnosed, a vaginal/rectal swab should be obtained to test for group B Streptococcus colonization if not previously done within 5 weeks (conditional, moderate).7.Expectant management with maternal and fetal monitoring should be offered to patients who have no contraindications to continuing the pregnancy (strong, moderate).8.Given that the rate of preterm birth is highest immediately following preterm prelabour rupture of membranes, hospitalization is recommended for the first few days following diagnosis (conditional, low).9.Based on the gestational age at preterm prelabour rupture of membranes and local capacity and resources, antenatal transfer to centres specialized in preterm care should be considered (strong, high).10.The optimal antibiotic regimen for preterm prelabour rupture of membranes remains unclear. If group B Streptococcus status is unknown or positive, the antibiotic regimen should include coverage for this pathogen (strong, moderate).11.The following 2 antibiotic regimens may be used: 1) a macrolide (erythromycin, azithromycin, or clarithromycin) alone or associated with group B Streptococcus coverage for 2 days (if group B Streptococcus status is unknown or positive), or 2) a combination of ampicillin/amoxicillin and a macrolide independently of group B Streptococcus status. There are no data to support extending the antibiotic therapy beyond 10 days (strong, moderate).12.Alternative antibiotic therapy can be considered based on local data on antibiotic resistance (conditional, low).13.Antenatal corticosteroid therapy should be routinely administered to patients with preterm prelabour rupture of membranes at the time of diagnosis when gestational age criteria are met (strong, moderate).14.There is insufficient evidence to support prolonged or recurrent use of tocolysis in the context of preterm prelabour rupture of membranes except for ensuring the full course of corticosteroids for 48 hours, or during transfer to a tertiary care centre in the absence of infection or abruption (conditional, moderate).15.Magnesium sulphate administration for fetal neuroprotection is recommended following preterm prelabour rupture of membranes once the patient is in active labour or prior to indicated delivery, when gestational age criteria are met (strong, moderate).16.If preterm prelabour rupture of membranes occurs before 34 weeks gestation, expectant management with careful monitoring is recommended at least until 35 weeks, in the absence of contraindications, such as infection, placental abruption, cord accident, or abnormal fetal health surveillance. There is conflicting evidence regarding the optimal timing of delivery in cases of preterm prelabour rupture of membranes during the late-preterm period (340 and 366 weeks gestation). If there is evidence of group B Streptococcus colonization, induction of labour should be considered (conditional, moderate).17.In patients with preterm prelabour rupture of membranes and cervical cerclage, there is insufficient evidence on whether the cerclage should be removed or remain in situ. In the absence of signs of infection or other contraindications to retaining a cerclage, either option is reasonable (conditional, low).18.Patients with previable preterm prelabour rupture of membranes should have a consultation with a maternal–fetal medicine specialist and neonatology specialist for comprehensive counselling about prognosis and risks, multidisciplinary management planning, and shared decision-making (conditional, moderate).