Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks of Gestation Green-top Guideline No. 73 June 2019 Please cite this paper as: Thomson AJ, on behalf of the Royal College of Obstetricians and Gynaecologists. Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks of Gestation. BJOG 2019;126:e152–166 Tweetable abstract: #GreenTopGuideline No. 73 recommends how to diagnose & care for suspected #PPROM from 24 + 0 to 36 + 6 weeks of gestation.
DOI: 10.1111/1471-0528.15803 RCOG Green-top Guidelines Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks of Gestation AJ Thomson, on behalf of the Royal College of Obstetricians and Gynaecologists Correspondence: Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s Park, London NW1 4RG. Email:
[email protected] 1. Key recommendations The diagnosis of spontaneous rupture of the membranes is made by maternal history followed by a sterile speculum examination. [Grade D] If, on speculum examination, no amniotic fluid is observed, clinicians should consider performing an insulin-like growth factor-binding protein 1 (IGFBP-1) or placental alpha microglobulin-1 (PAMG-1) test of vaginal fluid to guide further management. [Grade B] Following the diagnosis of preterm prelabour rupture of the membranes, (PPROM) an antibiotic (preferably erythromycin) should be given for 10 days or until the woman is in established labour (whichever is sooner). [Grade A] Women who have PPROM between 24+0 and 33+6 weeks’ gestation should be offered corticosteroids; steroids can be considered up to 35+6 weeks’ gestation. [Grade A] A combination of clinical assessment, maternal blood tests (C-reactive protein and white cell count) and fetal heart rate should be used to diagnose chorioamnionitis in women with PPROM; these parameters should not be used in isolation. [Grade D] Women whose pregnancy is complicated by PPROM after 24+0 weeks’ gestation and who have no contraindications to continuing the pregnancy should be offered expectant management until 37+0 weeks; timing of birth should be discussed with each woman on an individual basis with careful consideration of patient preference and ongoing clinical assessment. [Grade A] In women who have PPROM and are in established labour or having a planned preterm birth within 24 hours, intravenous magnesium sulfate should be offered between 24+0 and 29+6 weeks of gestation. [Grade A] 2. Background and scope Preterm prelabour rupture of membranes (PPROM) complicates up to 3% of pregnancies and is associated with 30– 40% of preterm births.1 PPROM can result in significant neonatal morbidity and mortality, primarily from prematurity, sepsis, cord prolapse and pulmonary hypoplasia. In addition, there are risks associated with chorioamnionitis and placental abruption.2 The median latency after PPROM is 7 days and tends to shorten as the gestational age at PPROM advances.3,4 This guideline comprises recommendations relating to the diagnosis, assessment, care and timing of birth of women presenting with suspected PPROM from 24+0 to 36+6 weeks of gestation. It also addresses care in a subsequent pregnancy. An infographic and audio version to supplement this guideline are available online (Infographic S1, RCOG Green-top Guideline No. 73 e153 of e166 a 2019 Royal College of Obstetricians and Gynaecologists
Audio S1). It supplements NICE guideline (NG25), Preterm labour and birth (published November 2015).5 Relevant recommendations can also be found in the Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline [GTG no. 36], Early-onset of Group B Streptococcal Disease. 6 3. Identification and assessment of evidence The Cochrane Library and electronic databases (DARE, EMBASE, Trip, MEDLINE and PubMed) were searched looking for the following terms in the title or abstract ‘preterm prelabour rupture of membranes’, ‘amnioinfusion’, ‘chorioamnionitis,’ ‘intra-amniotic infection’, ‘IGFBP-1’, ‘PAMG-1’, ‘amniocentesis’, ‘antenatal corticosteroids’ and ‘tocolytics’. The search was restricted to articles published until January 2019. The full search strategy is available to view online as supporting information (Appendix S1 and S2). This guideline was developed using the methodology described in Clinical Governance Advice 1 (a-c).7 4. Diagnosis 4.1 How is the diagnosis of PPROM made? Recommendation Evidence Level Strength Rationale for the recommendation The diagnosis of spontaneous rupture of the membranes is made by maternal history followed by a sterile speculum examination demonstrating liquor 4 D Given that this is the ‘gold standard’, further trials are unlikely to add to the evidence for this recommendation If, on speculum examination, no amniotic fluid is observed, clinicians should consider performing an IGFBP-1 or PAMG-1 test of vaginal fluid to guide further management 2++ B Recommended in NG25.5 Studies have reported high levels of sensitivity and specificity for these markers The role of ultrasound assessment of amniotic fluid volume is unclear 4 U No specific studies identified in the role of liquor volume in supporting the diagnosis of PPROM The presence of a pool of fluid in the vagina at sterile speculum examination is highly suggestive of membrane rupture, and when this is clearly observed no further diagnostic tests are required.5 Some clinicians recommend that the woman lies flat or in the left lateral for a period of time before speculum examination to allow the amniotic fluid to accumulate, though no evidence was identified to support these practices. Based on clinical evaluation, the diagnosis of PPROM can be equivocal in 10–20% of cases. When a pool of amniotic fluid is not clearly observed, consideration should be given to testing for IGFBP- 1 or PAMG-1 if these tests are available, and further management undertaken as per NG25.5 Several studies investigating these biochemical markers have found high levels of sensitivity and specificity.8,9 NG 25 emphasises that the test results for IGFBP-1 or PAMG-1 should not be used alone to decide what care to offer the woman and that clinical condition, medical and pregnancy history, and gestational age Evidence level 4 RCOG Green-top Guideline No. 73 e154 of e166 a 2019 Royal College of Obstetricians and Gynaecologists
should be taken in to account. Testing for nitrazine is not recommended, and no further tests are required if the woman is in established labour.5 No studies were identified specifically addressing ultrasound to determine amniotic fluid volumes in women presenting with suspected PPROM. Ultrasound examination demonstrating oligohydramnios may be useful to support the clinical diagnosis of PPROM. If PPROM is not confirmed, the woman can return to her previous schedule of antenatal care; NG25 recommends that women should be advised to return if they have any further symptoms suggestive of PPROM or preterm labour.5 Evidence level 4 It is routine practice in the UK to obtain a vaginal swab for microbiological testing while diagnosing PPROM, although evidence to support this practice is lacking. Group B streptococcus colonization may be identified, which would influence the timing of birth (section 7.1). A prospective cohort study assessed the vaginal microbiome in women following PPROM; this concluded that following PPROM the vaginal microbiome was abnormal but the profile did not correlate with latency duration.10 Evidence level 2+ 5. Assessment 5.1 What is required antenatally to identify infection? Recommendation Evidence Level Strength Rationale for the recommendation A combination of clinical assessment, maternal blood tests (C-reactive protein and white cell count) and fetal heart rate should be used to diagnose chorioamnionitis in women with PPROM; these parameters should not be used in isolation 4 D Recommended by NG255 Women should be advised of, and observed for, symptoms of clinical chorioamnionitis (lower abdominal pain, abnormal vaginal discharge, fever, malaise and reduced fetal movements) 4 D Recommended by NG255 One of the risks associated with PPROM is ascending infection leading to chorioamnionitis, and subsequent fetal and neonatal infection. NG255 recommends that a combination of clinical assessment (pulse, blood pressure, temperature and symptoms), maternal blood tests (C-reactive protein and white cell count) and fetal heart rate using cardiotocography, should be employed to diagnose clinical infection. If the results of the clinical assessment or any of the tests are not consistent with each other, it is recommended that the woman should continue to be observed and consideration should be given to repeating the tests as per NG25.5 Evidence level 4 The white cell count will rise 24 hours following administration of corticosteroids and should return to baseline 3 days following administration.11 While a study investigating several maternal serum markers for predicting histological chorioamnionitis after PPROM concluded that a raised C-reactive protein was most informative,12 a systematic review and meta-analysis of 13 observational studies found that Evidence level 2++ RCOG Green-top Guideline No. 73 e155 of e166 a 2019 Royal College of Obstetricians and Gynaecologists
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