2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

Premature rupture of membranes at term (term

PROM)
Overview and Recommendations
Background

Premature rupture of membranes (PROM) at term refers to the rupture of chorioamniotic membranes 1
hour prior to the onset of labor in a women at 37 weeks gestation.
A prior history of PROM is a risk factor for PROM at term.
PROM occurs in 8% of term deliveries and most cases occur in women without identifiable risk factors.
Complications may include chorioamnionitis and umbilical cord prolapse.
50% of women with PROM at term who are managed expectantly will deliver within 5 hours and 95%
within 28 hours.

Evaluation

Diagnose PROM clinically based on patient history of fluid leaking from the vagina and/or visualization
of amniotic fluid passing from the cervical os and pooling in the vagina prior to the onset of labor.
Tests of pooled vaginal fluids such as a pH test using Nitrazine paper, and fern test (arborization of dried
vaginal fluid), or placental alpha-microglobulin-1 immunoassay (AmniSure) may also be used to identify
amniotic fluid.
Perform digital cervical examinations only if the patient is in active labor (Strong recommendation).

Management
Confirm gestational age and initiate fetal heart rate monitoring (Strong recommendation).
Delivery is recommended.
Induce labor at the time of presentation, usually with oxytocin IV infusion (Strong
recommendation).
Misoprostol 50-100 mcg orally or vaginally every 4 hours is also an option for labor induction.
Decision to provide group B streptococcal prophylaxis should be based on prior culture results or risk
factors if previous cultures were not done (Strong recommendation).

Related Summaries
Fetal monitoring during labor
Complications of labor and delivery
Labor dystocia
Labor induction and cervical ripening
Preterm premature rupture of membranes (PPROM)

General Information
1/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

Description

rupture of chorioamniotic membranes 1 hour prior to onset of labor at 37 weeks gestation or beyond(3)

Also called

term PROM
prelabor rupture of membranes

Definitions

term premature rupture of membranes - premature rupture of membranes after 37 weeks gestation
preterm premature rupture of membranes (PPROM) - premature rupture of membranes before 37 weeks
gestation

Epidemiology
Who is most affected

most cases of PROM occur in women without identifiable risk factors(1)

Incidence/Prevalence

reported in 8% of term deliveries(1)

Likely risk factors

risk factors for PROM at or near term in retrospective cohort

2,208 deliveries among women aged 25-41 years in Sweden evaluated
risk factors for PROM at term included
primiparity
prior history of PROM
premature contractions
first trimester bleeding
Reference - J Perinat Med 2000;28(6):491

Chlamydia trachomatis infection appears associated with increased risk of preterm delivery and
premature rupture of membranes
based on retrospective cohort study using Washington state birth certificate data
851 women diagnosed with C. trachomatis infection (noted with check box on birth certificate from
2003) were compared with 3,404 randomly selected women without C. trachomatis infection
women with C. trachomatis infection at increased risk of preterm delivery (relative risk 1.46) and
premature rupture of membranes (relative risk 1.5)
Reference - Sex Transm Infect 2007 Aug;83(4):314 full-text
DynaMed commentary -- analysis of timing of premature rupture of membranes (term or preterm)
not reported

Possible risk factors

body mass index < 20 kg/m2 may be associated with PROM at term

2/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

based on case-control study comparing 220 pregnant women with PROM and 220 pregnant women
without PROM
body mass index < 20 kg/m2 and history of PROM in prior pregnancy associated with PROM in
adjusted analysis
Reference - Aust N Z J Obstet Gynaecol 2000 Feb;40(1):30

Factors not associated with increased risk

group B streptococcal (GBS) colonization in pregnancy not associated with increased risk of
preterm labor or premature rupture of membranes
based on prospective cohort study
615 women cultured vaginally for GBS at 22-26 weeks gestation and again at admission for term
labor, preterm labor, or premature rupture of membranes included
antibiotics were not given antenatally based on GBS cultures
no significant differences between groups in risk of preterm labor or PROM
Reference - Obstet Gynecol 1998 Dec;92(6):926

Etiology and Pathogenesis

Causes

combination of normal physiologic weakening of membranes and shearing forces of uterine

contractions(1)

History and Physical

History

Chief concern (CC)

fluid passing from vagina(3)

Physical

General physical

assess for elevated fever (> 100.4 degrees F with chorioamnionitis)

tachycardia may be present (maternal and fetal) with chorioamnionitis

Abdomen

fundal height measurement, Leopold's maneuvers (or ultrasound) for size and presentation

Pelvic

avoid digital exam for patients not in active labor(1)

on sterile speculum exam look for(1)
pooling of fluid
leakage of fluid from cervical os
3/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

cervical effacement and dilatation (visual assessment)

evidence of cervicitis
umbilical cord prolapse
obtain fluid from posterior fornix for evaluation of
pH with Nitrazine paper (amniotic fluid usually has pH 7.1-7.3 and turns Nitrazine paper blue)
ferning
uterine tenderness may indicate chorioamnionitis

Diagnosis
Making the diagnosis

diagnosis usually made clinically by patient history of leaking fluid from vagina and/or visualization of
amniotic fluid passing from cervical os and pooling in vagina prior to the onset of labor(1, 3)
tests on pooled vaginal fluid
Nitrazine paper(3)
positive for amniotic fluid if dark blue
amniotic fluid pH 7.1-7.3, while urine and vaginal secretions usually acidic (< 7.0)
false positives with blood, semen, alkaline antiseptics, or bacterial vaginosis
false negatives may occur with prolonged membrane rupture and minimal residual fluid
fern test - let amniotic fluid dry on glass slide(1, 3)
positive if microscopy reveals fern pattern with multiple fine branches
cervical mucus can cause false positive
significant blood can cause false negative
unaffected by pH
ultrasound not diagnostic but assessing amniotic fluid volume may aid in diagnosis(1)

Differential diagnosis

mucous "show" with cervical effacement and dilatation(2)

discharge from vaginitis or cervicitis(2)
urinary incontinence(2)
semen(2)
vaginal douches(2)

Testing overview

ultrasound for gestational age, presentation, amniotic fluid index(3)

biophysical profile - score 6 within 24 hours of delivery may correlate with increased risk of perinatal
infection(1)
fetal heart rate monitoring(1)
cervical cultures for gonorrhea and chlamydia if indicated(3)
anovaginal cultures for group B streptococcus(3)
transabdominal instillation of indigo carmine dye if diagnosis unclear after full evaluation

Other diagnostic testing

placental alpha-microglobulin-1 immunoassay (AmniSure)

4/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

placental alpha-microglobulin-1 in amniotic fluid may detect rupture of fetal membranes in

women 25 weeks gestation (level 2 [mid-level] evidence)
based on systematic review without assessment of study quality
systematic review of 12 diagnostic studies evaluating amniotic fluid for placental alpha-
microglobulin-1 (PAMG-1) and insulin-like growth factor binding protein-1 (IGFBP-1) for
detection of rupture of fetal membranes in 1,455 women
studies included patients with suspected rupture of fetal membranes between 25 and 37 weeks
gestation
pooled diagnostic performance for detection of rupture of fetal membranes
PAMG-1 had sensitivity 96.9% and specificity 98.5% in analysis of 6 studies with 915
patients
IGFBP-1 had sensitivity 83.9% and specificity 87.8% in analysis of 6 studies with 540
patients
Reference - J Perinat Med 2013 May 1;41(3):233
placental alpha-microglobulin-1 immunoassay (AmniSure) of vaginal fluid more sensitive
than conventional testing for rupture of membranes (level 1 [likely reliable] evidence)
based on diagnostic cohort study
prospective study of 184 consecutive women with signs or symptoms of ROM
initial diagnosis of ROM based on either of
amniotic fluid seen leaking from cervical os on speculum exam
2 or 3 of visual pooling of fluid in posterior fornix, positive Nitrazine test, and
microscopic evidence of ferning
clinically negative or uncertain cases were confirmed with
follow-up evaluation in 1-3 days
amnio-dye testing in small subset of high-risk very preterm women
diagnosis and management blinded from AmniSure test
AmniSure results available in 5 minutes
1 patient not analyzed due to loss to follow-up
159 (87%) diagnosed with ROM
initial clinical evaluation had 87.4% sensitivity, 100% specificity, 100% positive predictive
value and 54.5% negative predictive value
AmniSure had 98.7% sensitivity, 87.5% specificity, 98.1% positive predictive value and
91.3% negative predictive value
Reference - Obstet Gynecol 2007 Mar;109(3):634
commercially available absorbent pad (AmnioSense) can rule out ruptured membranes (level 1
[likely reliable] evidence)
based on prospective cohort study with
157 women with suspected ruptured membranes at 18-42 weeks gestation (median 37 weeks) used
AmnioSense
one midwife recorded result
second midwife performed speculum exam blinded to AmnioSense result
18 women excluded, mostly due to incomplete data sets
139 women analyzed
59 (42%) had spontaneous ruptured membranes based on speculum exam
AmnioSense had 98% sensitivity, 65% specificity, 67% positive predictive value and 98% negative
predictive value for ruptured membranes
Reference - BJOG 2009 Jan;116(2):313
fetal fibronectin in cervical secretion of limited value in clinical management of patients with
equivocal rupture of membranes at term
based on cohort study
116 women with history of PROM at term but no visible amniotic fluid leakage had fetal fibronectin
checked with commercially available kit (ROM check, limit of detection 100 ng/L)
median time interval between presumed ROM and delivery 64 hours with positive test vs. 80 hours
with negative fibronectin test (p = 0.28)
5/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

Reference - Acta Obstet Gynecol Scand 1996 Feb;75(2):132

transabdominal instillation of indigo carmine dye may be used confirm membrane rupture if diagnosis
unclear after full evaluation(1)
ultrasonographically guided
passage of blue-dyed fluid into vagina (documented by stained tampon or pad) confirms membrane
rupture
maternal urine will also stain blue and should not be confused with amniotic fluid

Treatment
Treatment overview

routine monitoring
initiate fetal heart rate monitoring
digital cervical examinations should be avoided unless patient in active labor or imminent delivery
anticipated (ACOG Level B)
delivery recommended (ACOG Level B)
labor should be induced at time of presentation, usually with oxytocin IV infusion (ACOG Level A)
labor induction reduces risk of some maternal infectious morbidity without increasing cesarean
sections and operative vaginal births (level 1 [likely reliable] evidence)
misoprostol
misoprostol appears safe and effective for labor induction after term premature rupture of
membranes (level 2 [mid-level] evidence)
oral misoprostol 50-100 mcg every 4 hours shortens time to delivery after term premature
rupture of membranes (level 1 [likely reliable] evidence)
prophylactic antibiotics may not reduce risk of maternal or neonatal infection but may increase risk of
cesarean delivery in women with PROM at or near term (level 2 [mid-level] evidence)
base decision of group B streptococcal prophylaxis on prior culture results or risk factors if previous
cultures not done(1)

Labor induction

American College of Obstetrics and Gynecology (ACOG) clinical management guidelines for PROM(1)
confirm gestational age
initiate fetal heart rate monitoring
delivery recommended (ACOG Level B)
labor should be induced, usually with oxytocin IV infusion (ACOG Level A)
digital cervical examinations should be avoided unless patient in active labor or imminent delivery
anticipated (ACOG Level B)
base decision of group B streptococcal prophylaxis on prior culture results or risk factors if previous
cultures not done
induction for term PROM reduces risk of some maternal infectious morbidity without increasing
cesarean sections and operative vaginal births (level 1 [likely reliable] evidence)
based on Cochrane review
systematic review of 12 randomized or quasi-randomized trials of induction compared with
expectant management in 6,814 women with prelabor rupture of membranes at term (37 weeks
gestation or more)
induction was generally with oxytocin or prostaglandin, but 1 trial used homeopathic caulophyllum
no overall differences in rates of cesarean section (12 trials with 6,814 women), operative vaginal
birth (7 trials with 5,511 women), or neonatal infection (9 trials with 6,406 infants)
induction associated with significantly fewer

6/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

women with chorioamnionitis (relative risk [RR] 0.74, 95% CI 0.56-0.97, NNT 50), in 9 trials
with 6,611 women
women with endometritis (RR 0.3, 95% CI 0.12-0.74), in 4 trials with 445 women
infants receiving neonatal intensive or special care (RR 0.72, 95% CI 0.57-0.92, NNT 20,
based on 5 trials with 5,679 infants)
Reference - Cochrane Database Syst Rev 2006 Jan 25;(1):CD005302, commentary can be found in
Am Fam Physician 2006 Jul 1;74(1):79 full-text, Evid Based Med 2007 Feb;12(1):16
induction of labor reduces maternal chorioamnionitis and shortens labor compared to expectant
management in term PROM but does not lower neonatal infection rate (level 1 [likely reliable]
evidence)
based on randomized trial
5,041 women with term PROM not in active labor randomized to 1 of 3 groups
labor induction with IV oxytocin
labor induction with vaginal prostaglandin E2 gel
expectant management up to 4 days (with induction for evidence of fetal or maternal
compromise)
about 78% of women in expectant management group went into spontaneous labor
comparing induction with either method vs. expectant management
induced patients had shorter time to active labor (p < 0.001)
induced patients had shorter duration of active labor (p < 0.001)
no significant differences in
cesarean section rates (about 10% in all groups)
neonatal infection rate (oxytocin-induced group had 2% neonatal infection based on
culture and white blood cell compared with about 3% for other groups)
perinatal deaths
4 deaths occurred, all in the expectant management group
1 was due to sepsis without symptoms
comparing oxytocin induction vs. expectant management
clinical chorioamnionitis in 4% vs. 8.6% (p < 0.001, NNT 22)
postpartum fever in 1.9% vs. 3.6% (p = 0.008, NNT 59)
no difference comparing prostaglandin E2-induction vs. expectant management for clinical
chorioamnionitis or postpartum fever
much larger study would be necessary to determine if induction results in decrease of perinatal
mortality
Reference - TERMPROM (N Engl J Med 1996 Apr 18;334(16):1005 full-text)
editorial notes 3 studies (Am J Perinatol 1989 Apr;6(2):181, Obstet Gynecol 1991 May;77(5):664,
Obstet Gynecol 1993 Mar;81(3):332) which showed advantages for induction with prostaglandin E2
over oxytocin and suggests use of induction (oxytocin if favorable cervix, prostaglandin
preparations if unfavorable cervix) over expectant management (N Engl J Med 1996 Apr
18;334(16):1053)
one-third of women in expectant management group had initial digital vaginal exam which may
have increased risk of infection (J Fam Pract 1996 Jul;43(1):19)
see also Labor induction and cervical ripening

Medications

Medications for labor induction

oxytocin generally used for induction of labor for women 34 weeks gestation(1)

misoprostol
misoprostol appears safe and effective for labor induction after premature rupture of
membranes at term (level 2 [mid-level] evidence)
7/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

based on systematic review of trials with methodological limitations

systematic review of 15 randomized trials of oral or vaginal misoprostol compared with
placebo, expectant management or oxytocin in women at term (at least 36 weeks gestation)
with premature rupture of membranes
all trials had 1 limitation including
lack of blinding
no intention-to-treat analysis
misoprostol compared with placebo or expectant management in 6 trials with 453 women
4 trials used oral misoprostol 50-200 mcg every 4-12 hours, 2 trials used vaginal
misoprostol 50 mcg every 4-6 hours
misoprostol associated with increased rates of vaginal delivery within 12 hours (relative
risk 2.71, 95% CI 1.87-3.92) in analysis of 2 trials with 151 women
misoprostol reduced oxytocin use (based on all 6 trials) and increased tachysystole (in
analysis of 5 trials with 373 patients)
no significant differences in rates of vaginal delivery within 24 hours, hypertonus,
hyperstimulation syndrome, and adverse neonatal and maternal outcomes
misoprostol compared with oxytocin in 9 trials with 1,130 women
6 trials used oral misoprostol 50-100 mcg every 4-6 hours, 3 trials used vaginal
misoprostol 25-50 mcg every 4-6 hours
similar rates of vaginal delivery within 24 hours and within 12 hours (53.9% vs. 54.8%)
similar rates of tachysystole, hypertonus, hyperstimulation syndrome, and adverse
neonatal and maternal outcomes
Reference - Obstet Gynecol 2005 Sep;106(3):593
oral misoprostol 50-100 mcg every 4 hours shortens time to delivery after premature rupture
of membranes at term (level 1 [likely reliable] evidence)
based on randomized trial
100 Chinese women at 37-42 weeks gestation with prelabor rupture of membranes within 6
hours and otherwise uncomplicated singleton pregnancy were randomized to misoprostol 50
mcg vs. misoprostol 100 mcg given orally every 4 hours until active labor or maximum 6
doses vs. placebo (vitamin B6 50 mg)
labor defined as cervical dilatation at least 3 cm plus regular uterine contractions every 3
minutes
comparing misoprostol 50 mcg vs. misoprostol 100 mcg vs. placebo
delivery within 24 hours of rupture of membranes in 91% vs. 94% vs. 47% (p < 0.0001,
NNT 3)
mean time from rupture of membranes to delivery 14.5 vs. 13 vs. 25.1 hours (p <
0.0001)
vacuum delivery in 6% vs. 0% vs. 9% (not significant)
cesarean delivery in 9% vs. 12% vs. 9% (not significant)
uterine hyperstimulation in 0% vs. 6% vs. 0% (not significant)
Reference - Acta Obstet Gynecol Scand 2006;85(9):1128
misoprostol appears comparable to oxytocin for induction with premature rupture of
membranes (level 2 [mid-level] evidence)
based on randomized trial with inadequate power to rule out clinically significant differences
758 women with singleton pregnancies > 34 weeks gestation with premature rupture of
membranes and no prior cesarean delivery randomized to induction with misoprostol vs.
oxytocin IV (standard group)
misoprostol orally (vaginally if cervix unfavorable)
standard induction method using either of
vaginal dinoprostone plus oxytocin IV if cervix unfavorable
oxytocin IV alone if cervix favorable
comparing misoprostol vs. oxytocin
cesarean section 14% vs. 18% (not significant)
failed vaginal delivery 24 hours 24% vs. 31% (not significant)
8/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

Reference - BJOG 2008 Nov;115(12):1503

sublingual misoprostol appears more effective at inducing labor at lower dose compared with
oral misoprostol (level 2 [mid-level] evidence)
based on randomized trial without blinding
100 women with single pregnancy and pre-labor rupture of membrane randomized to
misoprostol 50 mcg sublingually vs. 100 mcg orally every 4 hours (maximum 2 doses)
comparing sublingual vs. oral misoprostol
delivery within 12 hours of induction in 92% vs. 84% (p < 0.05, NNT 13)
delivered with 1 dose in 64% vs. 32% (p < 0.05, NNT 3)
required oxytocin augmentation in 36% vs. 70% (p < 0.05)
cesarean section in 8% vs. 20% (not significant)
no significant difference in fetal or maternal complications
Reference - J Coll Physicians Surg Pak 2010 Apr;20(4):242
dinoprostone
addition of vaginal dinoprostone before oxytocin may increase rate of vaginal delivery
compared to oxytocin alone in women having labor induction for term PROM (level 2 [mid-
level] evidence)
based on randomized trial without blinding
450 patients (mean age 27 years) with premature rupture of membranes at term randomized to
labor induction with sustained-release dinoprostone pessary vs. oxytocin IV
dinoprostone given at 0.3 mg/hour for up to 12 hours followed by oxytocin IV 6 hours
later
oxytocin given at 2 milliunits/minute and increased incrementally to 32
milliunits/minute or until 4 contractions within 10 minutes
comparing dinoprostone plus oxytocin vs. oxytocin only
vaginal delivery in 81.6% vs. 69.7% (p = 0.004, NNT 9)
vaginal delivery within 24 hours in 78.5% vs. 63.3% (p = 0.001, NNT 7)
mean hospital stay 1.4 days vs. 1.7 days (p = 0.002)
no significant differences in patient satisfaction, analgesia use, maternal complications, or
neonatal outcomes
Reference - Am J Obstet Gynecol 2012 Jan;206(1):60.e1
addition of vaginal dinoprostone to IV oxytocin induction does not appear associated with
expedited delivery or increased maternal satisfaction (level 2 [mid-level] evidence)
based on randomized trial without adequate power
116 nulliparous women with uncomplicated term premature rupture of membranes and
Bishop score 6 requiring induction of labor randomized to dinoprostone 3 mg pessary plus
IV oxytocin vs. placebo plus IV oxytocin
no significant difference between groups in
vaginal delivery rate within 12 hours
maternal satisfaction with birth process
rate of uterine hyperstimulation
overall vaginal delivery rate
time from induction initiation to delivery
Reference - Obstet Gynecol 2009 May;113(5):1059
see also Labor induction and cervical ripening

Antibiotics

routine antibiotic administration not recommended for women with premature rupture of membranes
(PROM) at or near term (WHO Strong recommendation, Low-quality evidence) (WHO 2015 PDF)
prophylactic antibiotics may not reduce risk of maternal or neonatal infection but may increase risk
of cesarean delivery in women with PROM at or near term (level 2 [mid-level] evidence)
based on Cochrane review limited by clinical heterogeneity

9/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

systematic review of 4 randomized trials comparing prophylactic antibiotics vs. placebo or no

antibiotics in 2,639 women with PROM at or near term
results limited by heterogeneity in prophylactic antibiotics evaluated
prophylactic antibiotics included
ampicillin 1 g IV every 6 hours plus gentamicin 80 mg intramuscularly every 8 hours (or
erythromycin 500 mg intramuscularly every 6 hours if penicillin allergy) (1 trial)
cefuroxime 750 mg IV every 8 hours plus clindamycin 600 mg IV every 6 hours for 48 hours
then cefuroxime 250 mg orally every 12 hours plus clindamycin 300 mg orally every 6 hours
for 24 hours (1 trial)
ampicillin 1 g IV every 6 hours plus gentamicin 240 mg IV once daily (1 trial)
single-dose ampicillin-sulbactam 1,500 mg IV (1 trial)
no significant differences in
endometritis (risk ratio 0.34, 95% CI 0.05-2.31) in analysis of 4 trials with 2,639 women
results limited by significant heterogeneity
prophylactic antibiotics group favored in all trials evaluating multiple-administration
interventions
chorioamnionitis in analysis of 4 trials with 2,639 women
early-onset neonatal sepsis in analyses of 4 trials with 2,639 infants, results limited by
significant heterogeneity
perinatal mortality in analysis of 4 trials with 2,639 infants
prophylactic antibiotics associated with increased cesarean delivery in analysis of 3 trials with 1,906
women
risk ratio 1.33 (95% CI 1.09-1.61)
NNH 20 (95% CI 11-74)
no neonatal mortality in 3 trials with 1,906 infants
Reference - Cochrane Database Syst Rev 2014 Oct 29;(10):CD001807
DynaMed commentary -- largest trial used only one dose of antibiotics possibly explaining lack of
significant effect on clinical outcomes
antibiotic prophylaxis may reduce risk of chorioamnionitis and endometritis in women with PROM
at or near term and latency > 12 hours (level 2 [mid-level] evidence)
based on systematic review of subgroup analyses of randomized trials
systematic review of 5 randomized trials evaluating antibiotic prophylaxis in 2,699 women with
term or near-term PROM
antibiotic regimens in 4 randomized trials described in Cochrane review above, other randomized
trial used penicillin 4 million units IV every 4 hours or gentamicin 80 mg IV every 8 hours for
women with penicillin allergy
comparing antibiotic prophylaxis to placebo or no treatment in women with latency > 12 hours
(planned subgroup analysis)
antibiotic prophylaxis associated with decreased risk of
chorioamnionitis in subgroup analysis of 999 women in 3 trials
relative risk 0.49 (95% CI 0.27-0.91)
NNT 23-186 with chorioamnionitis in 6% of control group
endometritis in subgroup analysis of 999 women in 3 trials
relative risk 0.12 (95% CI 0.02-0.62)
NNT 47-120 with endometritis in 2.2% of control group
no significant differences in other maternal or neonatal outcomes
findings consistent with Cochrane review above for overall analyses
Reference - Am J Obstet Gynecol 2015 May;212(5):627.e1

Other management
acupuncture did not appear to reduce time to active phase of labor after PROM in first pregnancy
(level 2 [mid-level] evidence)
based on randomized trial without blinding
10/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

106 pregnant women with PROM randomized to acupuncture vs. control

no significant differences in time to active phase of labor, need for induction or self-reported well-
being
Reference - Acta Obstet Gynecol Scand 2007;86(12):1447
acupuncture might reduce duration of active phase of labor for women with term PROM (level 2
[mid-level] evidence)
based on randomized trial without blinding
100 women with singleton pregnancies and spontaneous rupture of membranes at term before labor
onset were randomized to acupuncture (20-minute session) vs. no acupuncture
induction with prostaglandins or oxytocin used if no spontaneous labor within 24 hours of rupture
only 91 women analyzed
comparing acupuncture vs. control
mean time from rupture to delivery 29.1 vs. 32.7 hours (not significant)
mean duration of active phase of labor 4.4 vs. 6.1 hours (p = 0.027)
no significant difference in rates of labor induction
21% vs. 44% used oxytocin > 2 hours (p = 0.018, NNT 5)
Reference - Acta Obstet Gynecol Scand 2006;85(11):1348

Complications and Prognosis

Complications

chorioamnionitis (2)
time from rupture to delivery > 12 hours associated with increased risk of chorioamnionitis
and endomyometritis in term pregnancy
based on retrospective cohort of 3,841 women with premature rupture of membranes at > 37
weeks gestational age
risk for chorioamnionitis and endomyometritis increased with time from rupture to delivery of
> 12 hours (adjusted odds ratio 2.3 [95% CI 1.2-4.4])
> 16 hours (adjusted odds ratio 2.5 [95% CI 1.1-5.6])
Reference - Am J Obstet Gynecol 2008 Jun;198(6):700e1
neonatal infection associated with chorioamnionitis and positive maternal group B streptococcal
status in women with term PROM
based on secondary analysis of randomized trial of 5,028 patients with term PROM
133 infants (2.6%) had definite or probable neonatal infection
risk factors associated with neonatal infection included
clinical chorioamnionitis (odds ratio [OR] 5.89, 95% CI 3.68-9.43)
positive maternal group B streptococcal status (OR 3.08, 95% CI 2.02-4.68)
7-8 vaginal digital exams before delivery (OR 2.37, 95% CI 1.03-5.43)
24-48 hours between membrane rupture and active labor (OR 1.97, 95% CI 1.11-3.48)
> 48 hours between membrane rupture and active labor (OR 2.25, 95% CI 1.21-4.18)
maternal antibiotics before delivery (OR 1.63, 95% CI 1.01-2.62)
Reference - Am J Obstet Gynecol 1998 Sep;179(3 Pt 1):635
placental abruption (2)
umbilical cord compression during labor(2)
umbilical cord prolapse

Prognosis

50% of women with PROM at term managed expectantly will deliver within 5 hours and 95% within 28
hours(1)

11/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

Prevention and Screening

Prevention

vitamin C supplementation may reduce risk of PROM (level 2 [mid-level] evidence)

based on randomized trial without intention-to-treat analysis
120 Mexican women randomized to vitamin C 100 mg vs. placebo daily starting at 20 weeks
gestation
109 completed the trial
incidence of PROM 7.7% with vitamin C vs. 24.5% with placebo (p = 0.018, NNT 6)
Reference - Am J Clin Nutr 2005 Apr;81(4):859 full-text

Guidelines and Resources

Guidelines

International guidelines

World Health Organization (WHO) recommendations for prevention and treatment of maternal peripartum
infections can be found at WHO 2015 PDF

United States guidelines

American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 160 on premature rupture
of membranes can be found in Obstet Gynecol 2016 Jan;127(1):192

United Kingdom guidelines

National Institute for Health and Care Excellence (NICE) guideline on antibiotics for prevention and
treatment of early-onset neonatal infection can be found at NICE 2012 Aug:CG149 PDF or at National
Guideline Clearinghouse 2013 Feb 4:38408

Review articles
review of preterm PROM can be found in Am Fam Physician 2006 Feb 15;73(4):659
review of pathogenesis can be found in N Engl J Med 1998 Mar 5;338(10):663
review of preterm labor and PROM can be found in BMJ 1999 Apr 17;318(7190):1059 full-text,
commentary can be found in BMJ 1999 Jul 24;319(7204):257 full-text

MEDLINE search

to search MEDLINE for (premature rupture of membranes at term) with targeted search (Clinical
Queries), click therapy, diagnosis, or prognosis

Patient Information
handout on preterm PROM can be found in Am Fam Physician 2006 Feb 15;73(4):665

ICD-9/ICD-10 Codes
12/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

ICD-9 codes

658.1 premature rupture of membranes

658.10 premature rupture of membranes, unspecified as to episode of care
658.11 premature rupture of membranes, delivered
658.13 premature rupture of membranes, antepartum
658.2 delayed delivery after spontaneous or unspecified rupture of membranes
658.20 delayed delivery after spontaneous or unspecified rupture of membranes, unspecified as to
episode of care
658.21 delayed delivery after spontaneous or unspecified rupture of membranes, delivered
658.23 delayed delivery after spontaneous or unspecified rupture of membranes, antepartum
761.1 premature rupture of membranes affecting fetus or newborn

ICD-10 codes

O42 premature rupture of membranes

O42.0 premature rupture of membranes, onset of labor within 24 hours
ICD-10-CA modification in Canada: O42.0 subdivided and fourth digit added to identify
2 full term premature rupture of membranes, onset of labor within 24 hours
9 premature rupture of membranes, onset of labor within 24 hours, unspecified whether
preterm or full term
O42.1 premature rupture of membranes, onset of labor after 24 hours
ICD-10-CA modification in Canada: O42.1 subdivided and fourth digit added to identify
2 full term premature rupture of membranes, onset of labor after 24 hours
9 premature rupture of membranes, onset of labor after 24 hours, unspecified whether
preterm or full term
O42.2 premature rupture of membranes, labor delayed by therapy
O42.9 premature rupture of membranes, unspecified
O75.6 delayed delivery after spontaneous or unspecified rupture of membranes
P01.1 fetus and newborn affected by premature rupture of membranes

References
General references used

1. ACOG Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 160: premature rupture of
membranes. Obstet Gynecol 2016 Jan;127(1):192
2. Mercer BM. Preterm premature rupture of the membranes. Obstet Gynecol. 2003 Jan;101(1):178-93
3. Canavan TP, Simhan HN, Caritis S. An evidence-based approach to the evaluation and treatment of
premature rupture of membranes: Part I. Obstet Gynecol Surv. 2004 Sep;59(9):669-77

Recommendation grading systems used

American College of Obstetricians and Gynecologists (ACOG) grades of recommendation

Level A - recommendations based on good and consistent scientific evidence
Level B - recommendations based on limited or inconsistent scientific evidence
Level C - recommendations based primarily on consensus and expert opinion
Reference - ACOG practice bulletin 160 on premature rupture of membranes (Obstet Gynecol 2016
Jan;127(1):192)
World Health Organization (WHO) classification of recommendations
strength of recommendation

13/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

Strong - panel is confident that desirable effects of adherence to recommendation outweigh

undesirable effects
Conditional - panel concludes that desirable effects of adherence to recommendation probably
outweigh undesirable effects, but 1 of following conditions applies
recommendation only applicable to specific group, population, or setting
new evidence may result in changing balance of risk to benefit
benefits may not warrant cost or resource requirements in all settings
No recommendation possible - further research required before any recommendation can be
made
quality of evidence
High - further research very unlikely to change confidence in estimate of effect
Moderate - further research likely to have important impact on confidence in estimate of
effect and may change estimate
Low - further research very likely to have an important impact on confidence in estimate of
effect and likely to change estimate
Very low - any estimate of effect very uncertain
Guidelines Development Group (GDG) consensus - insufficient evidence to make a
recommendation so GDG consensus used as the basis of recommendation
Reference - World Health Organization (WHO) recommendations for prevention and treatment of
maternal peripartum infections can be found at WHO 2015 PDF

Synthesized Recommendation Grading System for DynaMed Plus

DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid
relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
Guideline recommendations summarized in the body of a DynaMed topic are provided with the
recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see
where guidelines agree and where guidelines differ from each other and from the current evidence.
In DynaMed Plus (DMP), we synthesize the current evidence, current guidelines from leading authorities,
and clinical expertise to provide recommendations to support clinical decision-making in the Overview &
Recommendations section.
We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify
synthesized recommendations as Strong or Weak.
Strong recommendations are used when, based on the available evidence, clinicians (without
conflicts of interest) consistently have a high degree of confidence that the desirable consequences
(health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs,
burdens).
Weak recommendations are used when, based on the available evidence, clinicians believe that
desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about
the magnitude of expected consequences (benefits and harms). Weak recommendations are used
when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in
their judgments. Weak recommendations are also used when the range of patient values and
preferences suggests that informed patients are likely to make different choices.
DynaMed Plus (DMP) synthesized recommendations (in the Overview & Recommendations section) are
determined with a systematic methodology:
Recommendations are initially drafted by clinical editors (including 1 with methodological
expertise and 1 with content domain expertise) aware of the best current evidence for benefits and
harms, and the recommendations from guidelines.
Recommendations are phrased to match the strength of recommendation. Strong recommendations
use "should do" phrasing, or phrasing implying an expectation to perform the recommended action
for most patients. Weak recommendations use "consider" or "suggested" phrasing.
Recommendations are explicitly labeled as Strong recommendations or Weak recommendations
when a qualified group has explicitly deliberated on making such a recommendation. Group

14/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

deliberation may occur during guideline development. When group deliberation occurs through
DynaMed-initiated groups:
Clinical questions will be formulated using the PICO (Population, Intervention, Comparison,
Outcome) framework for all outcomes of interest specific to the recommendation to be
developed.
Systematic searches will be conducted for any clinical questions where systematic searches
were not already completed through DynaMed content development.
Evidence will be summarized for recommendation panel review including for each outcome,
the relative importance of the outcome, the estimated effects comparing intervention and
comparison, the sample size, and the overall quality rating for the body of evidence.
Recommendation panel members will be selected to include at least 3 members that together
have sufficient clinical expertise for the subject(s) pertinent to the recommendation,
methodological expertise for the evidence being considered, and experience with guideline
development.
All recommendation panel members must disclose any potential conflicts of interest
(professional, intellectual, and financial), and will not be included for the specific panel if a
significant conflict exists for the recommendation in question.
Panel members will make Strong recommendations if and only if there is consistent
agreement in a high confidence in the likelihood that desirable consequences outweigh
undesirable consequences across the majority of expected patient values and preferences.
Panel members will make Weak recommendations if there is limited confidence (or
inconsistent assessment or dissenting opinions) that desirable consequences outweigh
undesirable consequences across the majority of expected patient values and preferences. No
recommendation will be made if there is insufficient confidence to make a recommendation.
All steps in this process (including evidence summaries which were shared with the panel,
and identification of panel members) will be transparent and accessible in support of the
recommendation.
Recommendations are verified by 1 editor with methodological expertise, not involved in
recommendation drafting or development, with explicit confirmation that Strong recommendations
are adequately supported.
Recommendations are published only after consensus is established with agreement in phrasing and
strength of recommendation by all editors.
If consensus cannot be reached then the recommendation can be published with a notation of
"dissenting commentary" and the dissenting commentary is included in the topic details.
If recommendations are questioned during peer review or post publication by a qualified individual,
or reevaluation is warranted based on new information detected through systematic literature
surveillance, the recommendation is subject to additional internal review.

DynaMed editorial process

DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
All editorial team members and reviewers have declared that they have no financial or other competing
interests related to this topic, unless otherwise indicated.
DynaMed provides Practice-Changing DynaMed Updates, with support from our partners, McMaster
University and F1000.

Special acknowledgements

Andrea Chisholm, MD, FACOG (Clinical Instructor in Obstetrics and Gynecology, Harvard Medical
School; North Shore Medical Center; Massachusetts, United States)

Allen Shaughnessy, PharmD, M Med Ed, FCCP (Professor of Family Medicine and Director of Master
Teacher Fellowship, Tufts University Family Medicine Residency; Cambridge Health Alliance;

15/16
2/10/2017 DynaMed Plus: Premature rupture of membranes at term (term PROM)

Massachusetts, United States)

Dr. Shaughnessy declares financial relationships with Essential Evidence Plus, American Family
Physician, British Medical Association, and Tufts Healthcare Institute.

Alan Ehrlich, MD (Executive Editor; Clinical Associate Professor of Family Medicine, University of
Massachusetts Medical School; Massachusetts, United States)

How to cite
National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):
DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No.
115900, Premature rupture of membranes at term (term PROM); [updated 2015 Jul 13, cited place
cited date here]; [about 10 screens]. Available from http://www.dynamed.com/login.aspx?
direct=true&site=DynaMed&id=115900. Registration and login required.

16/16