In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Levels of evidence (Ia-IV) and grading of recommendations (A-C) are defined at the end of the "Major Recommendations" field.
How Is the Diagnosis of Preterm Prelabour Rupture of Membranes (PPROM) Best Achieved?
B - The diagnosis of spontaneous rupture of the membranes is best achieved by maternal history followed by a sterile speculum examination.
C - Ultrasound examination is useful in some cases to help confirm the diagnosis.
C - Digital examination should be avoided where PPROM is suspected.
What Antenatal Tests Should Be Performed?
C - Fetal monitoring using cardiotocography should be considered where regular fetal surveillance is required.
B - Biophysical profile scoring or Doppler velocimetry should not be considered as first-line surveillance or diagnostic tests for fetal infection.
The criteria for the diagnosis of clinical chorioamnionitis include maternal pyrexia, tachycardia, leucocytosis, uterine tenderness, offensive vaginal discharge, and fetal tachycardia. During inpatient observation, the woman should be regularly examined for such signs of intrauterine infection and an abnormal parameter or a combination of them may indicate intrauterine infection. The frequency of maternal temperature, pulse and fetal heart rate auscultation should be between 4 hours and 8 hours.
What is the Role of Amniocentesis?
B - Routine amniocentesis is not recommended for women with PPROM.
Management
Are Prophylactic Antibiotics Recommended?
A - Erythromycin (250 mg orally 6 hourly) should be given for 10 days following the diagnosis of PPROM.
A - Co-amoxiclav is not recommended for women with PPROM because of concerns about necrotising enterocolitis.
If group B streptococcus is isolated in cases of PPROM, antibiotics should be given in line with the recommendation for routine intrapartum prophylaxis in the National Guideline Clearinghouse (NGC) summary of the Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline No. 36: Prevention of Early Onset Neonatal Group B Streptococcal Disease.
What is the Role of Antenatal Corticosteroids?
A - Antenatal corticosteroids should be administered in women with PPROM.
Tocolysis: Should Tocolytic Agents Be Used?
A - Prophylactic tocolysis in women with PPROM without uterine activity is not recommended.
Amnioinfusion
Should Amnioinfusion in Labour Be Carried Out?
A - Transvaginal amnioinfusion in labour is not recommended for women with preterm rupture of membranes.
B - Transabdominal amnioinfusion is not recommended as a method of preventing pulmonary hypoplasia in very preterm PPROM.
Use of Fibrin Glue
What is the Role of Fibrin Glue in the Sealing of Chorioamniotic Membranes to Prevent Pulmonary Hypoplasia?
B - Fibrin sealants are not recommended as routine treatment for second-trimester oligohydramnios caused by PPROM.
Outpatient Monitoring
Can Patients Be Monitored at Home?
B - Women should be considered for outpatient monitoring of PPROM only after rigorous individual selection by a consultant obstetrician.
There are insufficient data to make recommendations of home, daycare and outpatient monitoring rather than continued hospital admission in women with PPROM. It would be considered reasonable to maintain the woman in hospital for at least 48 hours before a decision is made to allow her to go home. This method of management should be individualised and restricted to certain groups of women. Women should be instructed to take regular temperature recordings at home every 12 hours or to be aware of the symptoms associated with infection. (Evidence level III)
Delivery of the Fetus
When Is the Appropriate Time to Deliver?
B - Delivery should be considered at 34 weeks of gestation.
B - Where expectant management is considered beyond 34 weeks of gestation, women should be counselled about the increased risk of chorioamnionitis and its consequences versus the decreased risk of serious respiratory problems in the neonate, admission for neonatal intensive care, and caesarean section.
Definitions:
Grading of Recommendations
Grade A - Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation. (Evidence levels Ia, Ib)
Grade B - Requires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations. (Evidence levels IIa, IIb, III)
Grade C - Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality. (Evidence level IV)
Levels of Evidence
Ia: Evidence obtained from meta-analyses of randomised controlled trials
Ib: Evidence obtained from at least one randomised controlled trial
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
