The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of "Major Recommendations" field.
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
- For women with premature rupture of membranes (PROM) at term, labor should be induced at the time of presentation, generally with oxytocin infusion, to reduce the risk of chorioamnionitis.
- Patients with PROM before 32 weeks of gestation should be cared for expectantly until 33 completed weeks of gestation if no maternal or fetal contraindications exist.
- A 48-hour course of intravenous ampicillin and erythromycin followed by 5 days of amoxicillin and erythromycin is recommended during expectant management of preterm PROM remote from term to prolong pregnancy and to reduce infectious and gestational age-dependent neonatal morbidity.
- All women with PROM and a viable fetus, including those known to be carriers of group B streptococci and those who give birth before carrier status can be delineated, should receive intrapartum chemoprophylaxis to prevent vertical transmission of group B streptococci regardless of earlier treatments.
- A single course of antenatal corticosteroids should be administered to women with PROM before 32 weeks of gestation to reduce the risks of respiratory distress syndrome (RDS), perinatal mortality, and other morbidities.
The following recommendations and conclusions are based on limited and inconsistent scientific evidence (Level B):
- Delivery is recommended when PROM occurs at or beyond 34 weeks of gestation.
- With PROM at 32 to 33 completed weeks of gestation, labor induction may be considered if fetal pulmonary maturity has been documented.
- Digital cervical examinations should be avoided in patients with PROM unless they are in active labor or imminent delivery is anticipated.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- A specific recommendation for or against tocolysis administration cannot be made.
- The efficacy of corticosteroid use at 32–33 completed weeks is unclear based on available evidence, but treatment may be beneficial particularly if pulmonary immaturity is documented.
- For a woman with preterm PROM and a viable fetus, the safety of expectant management at home has not been established.
Table: Management of Premature Rupture of Membranes Chronologically
| Gestational Age |
Management |
| Term (37 weeks or more) |
- Proceed to delivery, usually by induction of labor
- Group B streptococcal prophylaxis recommended
|
| Near term (34 weeks to 36 completed) |
|
| Preterm (32 weeks to 33 completed weeks) |
- Expectant management, unless fetal pulmonary maturity is documented
- Group B streptococcal prophylaxis recommended
- Corticosteroid—no consensus, but some experts recommend
- Antibiotics recommended to prolong latency if there are no contraindications
|
| Preterm (24 weeks to 31 completed weeks) |
- Expectant management
- Group B streptococcal prophylaxis recommended
- Single-course corticosteroid use recommended
- Tocolytics—no consensus
- Antibiotics recommended to prolong latency if there are no contraindications
|
| Less than 24 weeks* |
- Patient counseling
- Expectant management or induction of labor
- Group B streptococcal prophylaxis is not recommended
- Corticosteroids are not recommended
- Antibiotics—there are incomplete data on use in prolonging latency
|
*The combination of birthweight, gestational age, and sex provide the best estimate of chances of survival and should be considered in individual cases.
Definitions:
Grades of Evidence
I Evidence obtained from at least one properly designed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled trials without randomization.
II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence.
III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Levels of Recommendations
Level A — Recommendations are based on good and consistent scientific evidence.
Level B — Recommendations are based on limited or inconsistent scientific evidence.
Level C — Recommendations are based primarily on consensus and expert opinion.
