Prelabour rupture of membranes (PROM)

Prelabour rupture of membranes (PROM)

Prelabour rupture of membranes (PROM) is the rupture of membranes (breakage of the amniotic sac) before the onset of labour. If rupture occurs before 37 weeks of gestation, it is called preterm prelabour rupture of membranes (PPROM).

Prolonged PROM occurs when more than 24 hours have passed between membrane rupture and the onset of labour. PROM lasting more than 18 hours increases the risk of ascending infection, which can lead to chorioamnionitis (infection of the chorion, amnion, and amniotic fluid).

Clinical presentation

• Leakage of watery fluid per vagina, confirmed by sterile speculum examination

Management of PROM at the dispensary and health centre

Give prophylactic antibiotics against chorioamnionitis:

• Erythromycin (PO) 500 mg every 8 hours for 7 days

AND

• Metronidazole (PO) 400 mg every 8 hours for 7 days

Referral

• Refer to the hospital for further evaluation and management

Management of PROM at the hospital

Investigations

• Ultrasound to assess fetal wellbeing, amount of amniotic fluid, and gestational age

• Perform a sterile speculum examination to confirm leakage

• Obtain a high vaginal swab (HVS) for culture and susceptibility testing

• Perform urinalysis

General management

PROM at term

• Plan delivery within 24 hours

• Assess Bishop's score and induce labour accordingly

If the cervix is unfavourable:

• Misoprostol (PO) 25 mcg every 8 hours (maximum 3 doses)

OR

If the cervix is favourable:

• Oxytocin (IV) 5 IU in 500 mL of 5% dextrose, titrated beginning at 10 drops per minute

• Monitor fetal heart rate (FHR) closely during induction of labour

• Deliver by caesarean section if vaginal delivery is contraindicated, fetal distress develops, or induction of labour fails

Preterm prelabour rupture of membranes (PPROM)

If there are no signs of infection, await fetal maturity and give:

• Dexamethasone (IM) 6 mg every 12 hours for 48 hours if gestational age is less than 34 weeks for fetal lung maturation

AND

• Nifedipine (PO) 20 mg every 8 hours for 7 days for tocolysis

• Monitor for infection using full blood picture (FBP), C-reactive protein (CRP), pulse rate, and temperature

• Monitor fetal wellbeing through fetal movements, fetal heart rate, and obstetric ultrasound

Prophylactic antibiotics

• Metronidazole (PO) 400 mg every 8 hours for 10 days

AND

• Erythromycin (PO) 500 mg every 8 hours for 10 days

OR

• Amoxicillin + clavulanic acid (FDC) (PO) 625 mg every 8 hours for 10 days

Indication for delivery

• Deliver irrespective of gestational age if infection develops

Management of chorioamnionitis

If signs of infection are present (pyrexia, foul-smelling liquor, or chorioamnionitis), give:

• Metronidazole (PO) 400 mg every 8 hours for 5–7 days

AND

• Amoxicillin + clavulanic acid (FDC) (IV) 1.2 g every 8 hours for 5–7 days

OR

• Ceftriaxone + sulbactam (FDC) (IV) 1.5 g every 12 hours for 5–7 days.