njm 3/2/02

## ANMC WOMEN'S HEALTH SERVICE

## GUIDELINES FOR THE MANAGEMENT

> **OF PRETERM LABOR**

**Goals:**

Idiopathic preterm labor cannot be inhibited for prolonged periods of
time. Therefore, the goals when treating this condition are to:

-   Delay delivery so that corticosteroids can be administered.

-   Allow safe transport of the gravida, if indicated, to a facility
    that can provide an appropriate level of neonatal care if the
    patient delivers preterm.

-   Prolong pregnancy when there are underlying, self-limited causes of
    labor, such as pyelonephritis or abdominal surgery, that are
    unlikely to cause recurrent preterm labor.

**Definitions:**

[Preterm Labor]{.underline} - regular uterine contraction after 20 weeks
or before 37

weeks GA, which occur regularly, leading to progressive cervical change.

Associations with preterm birth:

1.  Preterm premature rupture of membranes (see below)

2.  Chorioamnionitis

3.  Fetal anomalies

4.  History of prior preterm labor

5.  Multiple gestation

6.  Polyhydraminos

7.  Intrauterine fetal demise

8.  Cervical insufficiency

9.  Uterine anomalies

10. Placenta previa or abruptio placentae

11. Retained IUD

12. Serious maternal disease (e.g., preeclampsia)

13. Cervical conization or L.E.E.P.

14. Idiopathic

Preterm birth due to:

-   PROM 35% of the time

-   Maternal fetal complications 35%

-   Idiopathic preterm labor 30%

Risks of recurrent preterm birth

First Birth Second Birth Next Birth Preterm

term \-\-\-\-\-\-\-\-\-\-\-\-\-\-- 5%

preterm \-\-\-\-\-\-\-\-\-\-\-\-\-\-- 15%

term preterm 24%

preterm preterm 32%

###### Routine Antibiotics, e.,g., not just for Beta Strep prophylaxis

A Cochrane review concluded that antibiotics cannot be recommended in
the routine management of women in preterm labor with intact membranes.
A subgroup of women who have subclinical intrauterine infection
theoretically might benefit from treatment with antibiotics, but there
is no means for identifying these women at this time. It is also
possible that the infectious process may be too advanced by the time
preterm labor is clinically apparent for treatment to be effective.

A subsequent RCT confirmed the meta-analysis described above and
affirmed the recommendation against routine antibiotic administration to
women in preterm labor without evidence of infection.

**CONTRAINDICATIONS TO TOCOLYSIS** --- The general contraindications to
labor inhibition are:

-   Intrauterine fetal demise

-   Lethal fetal anomaly

-   Nonreassuring fetal assessment

-   Severe intrauterine growth restriction

-   Chorioamnionitis

-   Maternal hemorrhage with hemodynamic instability

-   Severe preeclampsia or eclampsia

Known or suspected fetal maturity is not necessarily a contraindication
to tocolysis as there are nonpulmonary morbidities associated with
preterm birth. For example, a 30 week fetus with a mature amniotic fluid
test is still at risk for intraventricular hemorrhage, sepsis,
hyperbilirubinemia, and other morbidities unrelated to hyaline membrane
disease. These fetuses could potentially benefit from prolongation of
pregnancy.

Inhibition of preterm labor is less effective when cervical dilatation
is advanced (greater than 3 cm). Tocolysis can also be considered in
these cases, especially when the goal is to administer antenatal
corticosteroids or safely transport the gravida to a tertiary care
center.

**Management:**

1.  History of Preterm Labor with preterm delivery

```{=html}
<!-- -->
```
a.  preconceptual counseling to eliminate risk factors, e.g., stop
    tobacco,

> alcohol, drugs, space pregnancies, good nutrition, normalize
> hypertension,stabilize maternal medical conditions, anticipate need
> for increased pregnancy surveillance and prophylactic rest.

b.  early pregnancy care

c.  excellent dating by exam and early ultrasound

d.  urine culture x1

e.  identify and treat cervical or vaginal infection

f.  preterm labor education by qualified personnel by 20 to 23 weeks GA.

g.  intensive monitoring for signs and symptoms of recurrent preterm
    labor and/or asymptomatic cervical change

> signs & symptons:
>
> \*increased vaginal discharge

\*blood tinged mucus

\*low backache

\*pelvic pressure

\*menstrual - like cramps

\*intestinal cramping, with or without diarrhea

\*"not feeling right"

\*precocious cervical dilations (1 cm or more)

j.  1\) lives in town: cervical exam 24-26 weeks

```{=html}
<!-- -->
```
2.  lives outside of town: travel to town at 26 weeks GA, obtain
    cervico-vaginal swab for fetal fibronectin (fFN) (no lubricant, no
    coitus, no bleeding) (excellent negative predictive value-95%, poor
    positive predictive value-15%), perform cervical exam, one
    transvaginal ultrasound for cervical length, and ultrasound for
    dating if not yet done. Serial ultrasonic cervical lengths are not
    necessary.

    -Cervix no change, in combination with negative fFN, and one
    transvaginal ultrasound cervical length\>2.5 cm- return to village,
    weekly radio monitoring for early signs and symptoms, transfer to
    town as needed

    \*\*\* consider stocking village formulary with oral indomethacin
    and SQ terbutaline when the patient is allowed to return to the
    village\*\*\*

    -Cervix changed, or transvaginal ultrasound cervical length \<2.5
    cm, or fFN positive- to remain in town for routine prenatal care,
    refer to Anchorage as needed

```{=html}
<!-- -->
```
2.  If local resources do not permit, consider counseling the patient to
    remain in town regardless of cervical findings. Time of patient
    remaining in town should be based on prior time of preterm birth.

```{=html}
<!-- -->
```
2.  History of preterm labor with Term Delivery- Same as 1.

3.  History of preterm labor due to prior maternal or fetal

Complications

a.  Reassess risk of recurrence

> -if prior preterm birth associated with nonrecurring condition, i.e.
> twins, preterm birth risk probably same as "normal" singleton
> pregnancy.

b.  Liberally consult ANMC OB-GYN to determine risk of recurrent preterm
    labor and management.

```{=html}
<!-- -->
```
4.  **Current preterm labor**

```{=html}
<!-- -->
```
a.  Obtain cervico-vaginal swab for fFN

b.  Review pregnancy dating

c.  Rule out maternal fetal complications before initiating tocolytic

> Therapy (See Contraindications)

-   obtain NST

-   repeat U/S as needed to check fetal anatomy, size, amniotic fluid

> volume, and placentation; obtain transvaginal ultrasound for cervical
> length

-   monitor maternal status for infections, hypertensive disease,
    bleeding, etc.

-   administer betamethasone 12 mg IM x2 doses 24 hrs apart, or if not
    available, then dexamethasone 6 mg IM x 4 doses 12 hours apart

d.  Liberally consult ANMC OB - GYN consultant re: management or
    transfer

e.  Although preterm labor is defined as labor prior to 37 weeks, it has
    been thecurrent practice to tocolyze and transfer patients only for
    true preterm labor at \<35 weeks GA. This has been based on nursery
    care, facilities and neonatal outcomes.

-   Preterm labour education while hospitalized

-   Outpatient management if medical compliance assured. Social Service,
    Mental Health, and Home Health Care consults may be appropriate.

-   If discharged, the patient should be seen in clinic on a weekly
    basis.

> Symptoms and compliance are re-assessed at each visit and cervical
> exam is considered at each encounter.
>
> Preterm labor recommendations are maintained until 35 weeks GA.

-   Patients referred in from outside the Anchorage Service Unit remain
    in town until preterm labor is resolved. They should not transfer
    back to their Service Unit until their delivery could be safely
    managed by their Level 1 Nursery, eg., after 36 weeks. The patient
    should return to the Service Unit Hospital and not to their village.
    Notify referring provider prior to patients return to Service Unit.

**[if GA \<32 weeks]{.underline}** and true preterm labor (cx change)
and no oligohydramnios (AFI \<8.0 or no pocket \>2.0 cm)

#### 

#### Then initiate tocolysis with indomethacin

Indomethacin 100 mg rectally or 50 mg po initially, followed by 50 mg po
q6h. Re-evaluate with an ANMC OB/GYN afte a maximum of 400 mg total.

If
[indomethacin](../../../../../../../../application/topic.asp%3Ffile=Drug_A_K/131224&drug=true)
is continued for longer than 48 hours, sonographic evaluation for
oligohydramnios and narrowing of the fetal ductus arteriosus is
warranted at least weekly. Evidence of oligohydramnios or ductal
constriction should prompt discontinuation of this therapy.

**Contraindications** --- Maternal contraindications to cyclooxygenase
inhibitors include platelet dysfunction or bleeding disorder, hepatic
dysfunction, gastrointestinal ulcerative disease, renal dysfunction, and
asthma (in women with hypersensitivity to
[aspirin](../../../../../../../../application/topic.asp%3Ffile=Drug_A_K/21595&drug=true)).

**[If GA 32-34 weeks]{.underline}**

-bolus with 500 mL lactated Ringer's and

-initiate group B strep prophylaxis with ampicillin 2g IV initially
followed by 1g IV q6h thereafter for 48 hrs (if not allergic to
penicillin). If penicillin allergic, then consider clindamycin 900 mg q
8 hours IV.

-may use indomethacin for transport or for other selected cases

##### Second line therapy

[**Magnesium
sulfate**](../../../../../../../../application/topic.asp%3Ffile=Drug_L_Z/150634&drug=true)
is usually administered as a 4 to 6 g intravenous load over 20 minutes,
followed by a continuous infusion of 2 to 4 g/hour. The infusion rate is
titrated based upon assessment of contraction frequency and maternal
toxicity. Serial serum magnesium concentrations may be helpful in
titrating the dose

**Contraindications** --- [Magnesium
sulfate](../../../../../../../../application/topic.asp%3Ffile=Drug_L_Z/150634&drug=true)
tocolysis is contraindicated in women with myasthenia gravis. . It also
should not be used in women with known myocardial compromise or cardiac
conduction defects because of its antiinotropic effects.

Magnesium is eliminated by the kidneys, therefore women with impaired
renal function may develop magnesium toxicity at the usual doses of
administration. These women should receive the maintenance phase of
treatment only if a patellar reflex is present (loss of reflexes being
the first manifestation of symptomatic hypermagnesemia), respirations
exceed 12 per minute, and the urine output exceeds 100 mL per four
hours. Urine output and deep tendon reflexes should be closely
monitored. Evaluation of serum magnesium concentration should be
performed as needed. [Calcium
gluconate](../../../../../../../../application/topic.asp%3Ffile=Drug_A_K/40369&drug=true)
(1 g intravenously) may be administered to counteract magnesium
toxicity.

#### Beta agonists 

-For the management of [acute preterm \< 24 hours]{.underline} labor,
[terbutaline](../../../../../../../../application/topic.asp%3Ffile=Drug_L_Z/255495&drug=true)
can also be administered subcutaneously by intermittent injection. The
dose for intermittent injections is variable: 0.25 mg SQ and repeat q4h
prn not to exceed 4 doses or until tocolysis is achieved. The drug
should be withheld if the maternal heart rate is exceeds 120 beats/min.

-For [anticipated 24 hour therapy]{.underline} it is typically
administered as a continuous intravenous infusion beginning at 2.5 to 5
µg/min and increasing the dose by 2.5 to 5 µg/min every 20 to 30 minutes
to a maximum of 25 µg/min, or until the contractions have abated. At
this point, the infusion may be reduced by decrements of 2.5 to 5 µg/min
to the lowest dose that maintains uterine quiescence.

**Contraindications** --- Labor inhibition with a beta-adrenergic
receptor agonist is relatively contraindicated among women with cardiac
disease because of potent chronotropic effects. It can unmask
undiagnosed CHD. Women with poorly controlled hyperthyroidism or
diabetes mellitus should likewise not receive this class of labor
inhibiting agents. Well-controlled diabetes mellitus is not a
contraindication to beta-adrenergic receptor agonist therapy, as long as
glucose and potassium concentrations are followed carefully and
regulated. Beware of pulmonary edema.

Beta-adrenergic receptor agonists have important metabolic effects as
well, including hypokalemia, hyperglycemia, and lipolysis. Glucose and
potassium concentrations should be monitored during drug administration
since hyperglycemia (140 to 200 mg/dL) and hypokalemia occur in 20 to 50
percent and 40 to 60 percent of patients, respectively.

**[Nifedipine]{.underline}**: An optimal
[nifedipine](../../../../../../../../application/topic.asp%3Ffile=Drug_L_Z/181147&drug=true)
dosing regimen for treatment of preterm labor has not been defined. A
common approach is to administer an initial loading dose of 30 mg
orally, followed by an additional 20 mg orally in 90 minutes. An
alternative regimen is to administer 10 mg orally every 20 minutes for
up to 4 doses, followed by 20 mg orally every four to eight hours.

The half-life of
[nifedipine](../../../../../../../../application/topic.asp%3Ffile=Drug_L_Z/181147&drug=true)
is approximately two to three hours and the duration of action of a
single orally administered dose is up to six hours. Nifedipine is almost
completely metabolized in the liver and excreted by the kidney.

**Contraindications** --- Calcium channel blockers are contraindicated
in women with known hypersensitivity to the drug and should be used with
caution in women with left ventricular dysfunction or congestive heart
failure. The concomitant use of a calcium-channel blocker and magnesium
could act synergistically to suppress muscular contractility, which
could result in respiratory paralysis. This agent has been associated
with hypotension and headache.

**[CAUTION Please note:]{.underline}**

It is reasonable to consider beta-adrenergic agonists or
[indomethacin](../../../../../../../../application/topic.asp%3Ffile=Drug_A_K/131224&drug=true)
(in gestations less than 32 weeks) as first line agents for treatment of
preterm labor. However, beta-adrenergic agents should [not]{.underline}
be the first choice in women with cardiac disease, diabetes mellitus, or
hyperthyroidism.

By comparison, indomethacin should be [avoided]{.underline} in the
setting of maternal platelet dysfunction or bleeding disorder, hepatic
dysfunction, gastrointestinal ulcerative disease, renal dysfunction, or
asthma (in women with hypersensitivity to
[aspirin](../../../../../../../../application/topic.asp%3Ffile=Drug_A_K/21595&drug=true)).
In these cases consider second line therapy.

**[If tocolysis doesn't work at first]{.underline}**

If the first tocolytic agent chosen does not successfully inhibit
preterm labor consult an ANMC OB/GYN.

It may be reasonable to discontinue the first agent and begin therapy
with a second agent. It is important to exclude intrauterine infection
before beginning a second agent as amniotic fluid cultures can be
positive in almost 61 percent of women in whom tocolysis with a single
agent is not successful. The presence of clinical criteria for
chorioamnionitis (maternal fever, fundal tenderness, maternal
leukocytosis, maternal/fetal tachycardia) is a contraindication to
further tocolytic therapy. In the absence of clear clinical criteria of
infection, amniocentesis for gram stain, glucose, and culture can be
performed in women with single agent tocolytic failure to help exclude
occult intraamniotic infection before switching to a second agent.

**[PLEASE NOTE:]{.underline}**

Concurrent use of multiple tocolytic agents should be undertaken with
caution. In a study of the concurrent use of
[ritodrine](../../../../../../../../application/topic.asp%3Ffile=Drug_L_Z/223926&drug=true)
and magnesium, for example, there were significantly more cardiovascular
effects in the group that received ritodrine plus [magnesium
sulfate](../../../../../../../../application/topic.asp%3Ffile=Drug_L_Z/150634&drug=true)
(11/24) than in the group that received ritodrine alone (1/17). The
predominant side effect was chest pain, frequently associated with
electrocardiogram changes indicative of myocardial ischemia. In
addition, there was no improvement in efficacy with concurrent
administration of magnesium and ritodrine therapy.

**[Summary of recommendations]{.underline}**

***The following recommendations are based on good and consistent
scientific evidence (Level A):***

-   The beta-adrenergic receptor agonists, and
    [indomethacin](../../../../../../../../application/topic.asp%3Ffile=Drug_A_K/131224&drug=true)
    are the only agents that have been shown to be more effective than
    placebo in prolonging pregnancy in randomized controlled trials.

-   Therefore, it is reasonable to consider beta-adrenergic agonists or
    [indomethacin](../../../../../../../../application/topic.asp%3Ffile=Drug_A_K/131224&drug=true)
    (in gestations less than 32 weeks) as first line agents for
    treatment of preterm labor.

-   There is good evidence against routine antibiotic administration to
    women in preterm labor without evidence of infection.

-   There are no current data to support the use of salivary estriol,
    HUAM, or BV screening as strategies to identify or prevent preterm
    birth.

-   Corticosteroids given prior to preterm birth (as a result of either
    preterm labour or elective preterm delivery) are effective in
    preventing respiratory distress syndrome and neonatal mortality.
    However there is not enough evidence to evaluate the use of repeated
    doses of corticosteroids in women who remain undelivered, but who
    are at continued risk of preterm birth.

-   Multiple doses of corticosteroids should not be administered.

-   Intrapartum antibiotic treatment of women colonized with group B
    streptococcus appears to reduce neonatal infection. Effective
    strategies to detect maternal colonization with group B
    streptococcus and better data on maternal risk factors for neonatal
    group B streptococcus infection in different populations are
    required.

The following recommendations are based on evidence that may be limited
or inconsistent (Level B):

> -Screening for risk of preterm labor by means other than historic risk
> factors is not beneficial in the general obstetric population.
>
> -Ultrasonography to determine cervical length, fFN testing, or a
> combination of both may be useful in determining women at high risk
> for preterm labor. However, their clinical usefulness may rest
> primarily with their negative predictive value given the lack of
> proven

treatment options to prevent preterm birth.

> -Fetal fibronectin testing may be useful in women with symptoms of
> preterm labor to identify those with negative values and a reduced
> risk of preterm birth, thereby avoiding unnecessary intervention.

The following recommendations are based primarily on consensus and
expert opinion (Level C):

-   Evidence from comparative trials, many of which are underpowered,
    show that magnesium and calcium-channel blockers appear to have
    comparable efficacy to the beta-adrenergic agonist, but with a more
    favorable side-effect profile and ease of administration.

-   Therefore [magnesium
    sulfate](../../../../../../../../application/topic.asp%3Ffile=Drug_L_Z/150634&drug=true)
    and beta agonists reasonable second-line agents in women with
    intolerance of side effects or other obvious contraindication to a
    first-line agent.

-   To reduce the risk of pulmonary oedema, beta-agonists should be
    administered intravenously with the minimum volume of fluid.
    Beta-agonists should also be used with caution in a woman with
    multiple pregnancy.

-   Beta-agonists should be administered via a controlled infusion
    device. The infusion rate should be increased at regular intervals
    until contractions have ceased or until the maternal pulse reaches
    120 per minute.

**[References:]{.underline}**

\- ACOG Practice Bulletin. Assessment of Risk Factors for Preterm Birth.
No. 21 October 2001. American College of Obstetricians and Gynecologist.
Washington, D. C.

-Brocklehurst P, Hannah M, McDonald H. Interventions for treating
bacterial vaginosis in pregnancy (Cochrane Review). In: *The Cochrane
Library,* Issue 4, 2001. Oxford: Update Software.

-Crowley P. Prophylactic corticosteroids for preterm birth (Cochrane
Review). In: *The Cochrane Library,* Issue 4, 2001. Oxford: Update
Software.

-Crowther CA, Moore V. Magnesium for preventing preterm birth after
threatened preterm labour (Cochrane Review). In: *The Cochrane Library,*
Issue 4, 2001. Oxford: Update Software.

-King J, Flenady V. Antibiotics for preterm labour with intact membranes
(Cochrane Review). In: *The Cochrane Library,* Issue 4, 2001. Oxford:
Update Software.

-National Guidelines Clearinghouse <http://www.guidelines.gov/index.asp>

-Singapore: Ministry of Health (Singapore); Management of Preterm Labor.
2001 May. 28 p. (Ministry of Health Singapore clinical practice
guidelines; no. 3/01).

-Smaill F. Intrapartum antibiotics for Group B streptococcal
colonisation (Cochrane Review). In: *The Cochrane Library,* Issue 4,
2001. Oxford: Update Software.

-UpToDate. [Biochemical and biophysical predictors of
prematurity](../topicText.asp%3Ffile=pregcomp/6957#top). Lockwood CJ.

<http://www.uptodateonline.com/application/topic.asp?file=pregcomp/6957>

-UpToDate. [Inhibition of preterm
labor](../topicText.asp%3Ffile=pregcomp/11591#top). Hyagriv Simhan H,
Caritis S.

<http://www.uptodateonline.com/application/topic.asp?file=pregcomp/11591>

-U.S. Preventive Services Task Force (USPSTF) Screening for bacterial
vaginosis in pregnancy: recommendations and rationale. Am J Prev Med
2001 Apr;20(3 Suppl):59-61

Revised 3/2/02 gjg/njm

10/26/98

7/31/97

10/11/95

October 1994

January 1988

June 1980

### ANMC WOMEN'S HEALTH SERVICE

# PRETERM PREMATURE RUPTURE OF MEMBRANES

> **1. Definition:**
>
> Rupture of the membranes prior to 37 weeks gestation and prior to the
> onset of labor.
>
> (To be distinguished from "premature rupture of membranes" prior to
> the onset of labor at term, and from premature rupture of membranes
> without labor prior to viability at 23-24 weeks, which is most
> commonly associated with "hour-glassing" of the membranes secondary to
> cervical insufficiency.)
>
> a\. Associations with PPROM:
>
> -same as for preterm birth above, current theory is that PPROM is the
> result of occult infection at the choriodecidual interface with
> production of microbial collagenases resulting in membrane rupture.

####### Midtrimester PPROM: KEY POINTS

-   Midtrimester PPROM is associated with the same risk factors at PPROM
    later in gestation

-   Mean latency is 17 days, median latency is 7 days because the
    majority of pregnancies deliver soon after rupture of membranes

-   The frequency of chorioamnionitis is higher early in the latency
    period and at lower residual amniotic fluid volumes

-   Abruptio placentae and cord prolapse are more common in pregnancies
    complicated by PPROM

-   Neonatal survival is primarily related to gestational age at
    delivery, and is comparable to that in preterm deliveries matched
    for gestational age without PPROM.

-   The neonatal risk of both pulmonary hypoplasia and musculoskeletal
    deformation decrease with advancing gestational age, shorter
    latency, and greater residual amniotic fluid volume.

-   Maternal risks from midtrimester PPROM are lower than fetal/neonatal
    risks and include infection, need for cesarean delivery, and need
    for classical hysterotomy.

-   Absence of amniotic fluid leakage associated with resealing of
    membranes and reaccumulation of amniotic fluid confers a prognosis
    comparable to that of pregnancies without PPROM.

> **2. Management:**

a.  Review pregnancy dating criteria

b.  Perform sterile speculum examination for fern and nitrazine testing

c.  Refrain from performing a digital examination unless absolutely
    necessary to document advanced labor prior to transport. (Remember
    that if you can visualize a portion of the presenting part, the
    cervix is most likely significantly effaced and dilated at least 4
    cm, but if it appears "closed" it may be any dilation \<4cm...)
    Digital examination "winds the clock of infection" and significantly
    decreases the latency period for the onset of labor, and increases
    the risk of infection, and is to be avoided in this setting if at
    all possible!

d.  Confirm presentation by Leopold's and/or ultrasound

e.  Perform level I ultrasound to assess GA, EFW, AFI, presentation, and
    anatomy

f.  A sample of vaginal pool amniotic fluid for fetal lung maturity
    testing may be appropriate if the patient is between 34 and 36 weeks
    gestation

g.  Obtain fetal monitor strip and maternal vital signs

h.  Administer betamethasone 12 mg IM and repeat the dose in 24 hours,
    or if not available, then dexamethasone 6 mg IM x 4 doses 12 hours
    apart

i.  Administer group B strep prophylaxis with ampicillin 2g IV initially
    and then 1g IV q6h for 48 hrs (if not allergic to penicillin) If
    penicillin allergic, then consider clindamycin 900 mg q 8 hours IV.

j.  Tocolysis (see above) may be appropriate to facilitate transport,
    but is otherwise not indicated

k.  Consult with ANMC OB-GYN is advised for further management and
    transport

l.  **At ANMC** PPROM is managed as an in-patient

m.  Daily NST should be carried out

n.  After 48 hours of group B strep prophylaxis with IV ampicillin, the
    latency period has been shown to be prolonged by administration of
    erythromycin 250 mg po q6h for 10 days or until delivery. See ANMC
    GBBS Guidelines for alternative agents.

o.  Maternal temperature and fetal heart rate are monitored q4h, but the
    onset of uterine contractions is the most common sign of incipient
    infection. Overt chorioamnionitis mandates delivery.

p.  Labor may be induced at 34 weeks documented gestation, or sooner
    with consultation with the Pediatrics service

q.  Patients may be induced with either vaginal or oral misoprostol or
    IV oxytocin

r.  Group B strep prophylaxis with IV ampicillin should be re-instituted
    in labor

s.  If chorioamnionitis is suspected, gentamicin 2 mg/kg IV q8h should
    also be administered to cover gram negative pathogens

t.  Patients \<32 weeks should be delivered at a level III nursery
    facility

u.  Patients with rupture of membranes **[at term]{.underline}** who are
    not in labor have a better outcome without an increase in their
    cesarean birth rate if induced as soon as they present.

######## Summary of recommendations

***The following recommendations are based on good and consistent
scientific evidence (Level A):***

-   With term PROM, labor may be induced at the time of presentation or
    patients may be observed for up to 24-72 hours for the onset of
    spontaneous labor.

-   Antibiotics prolong the latency period and improve perinatal outcome
    in patients with preterm PROM and should be administered according
    to one of several published protocols if expectant management is to
    be pursued prior to 35 weeks of gestation.

-   There are sufficient data to recommend routine prescription of
    macrolide antibiotics in this clinical situation. The routine
    prescription of macrolide antibiotic (erythromycin) is recommended
    as beta lactum antibiotics (augmentin) is associated with a
    statistically significant increase in neonatal necrotising
    enterocolitis.

-   Antenatal corticosteroids should be administered to gravidas with
    PROM before 32 weeks of gestation to reduce the risks of respiratory
    distress syndrome, neo-natal intraventricular hemorrhage,
    necrotizing entero-colitis, and neonatal death.

-   Digital cervical examinations should not be performed in patients
    with PROM who are not in labor and in whom immediate induction of
    labor is not planned.

-   Patients with PROM prior to 30-32 weeks of gestation should be
    managed conservatively if no maternal or fetal contraindications
    exist.

-   Corticosteroids given prior to preterm birth (as a result of either
    preterm labour or elective preterm delivery) are effective in
    preventing respiratory distress syndrome and neonatal mortality.
    However there is not enough evidence to evaluate the use of repeated
    doses of corticosteroids in women who remain undelivered, but who
    are at continued risk of preterm birth and should not be used

-   Intrapartum antibiotic treatment of women colonized with group B
    streptococcus appears to reduce neonatal infection. Effective
    strategies to detect maternal colonization with group B
    streptococcus and better data on maternal risk factors for neonatal
    group B streptococcus infection in different populations are
    required.

-   Induction of labour with prostaglandins for prelabour rupture of
    membranes at or near term appears to decrease the risk of maternal
    infection (chorioamnionitis) and admission to neonatal intensive
    care. Induction of labour with prostaglandins does not appear to
    increase the rate of caesarean section, although it is associated
    with more frequent maternal diarrhoea and pain relief.

-   Women with prelabour rupture of membranes [at or near
    term]{.underline} having their labour induced with prostaglandins
    versus oxytocin appear to have a lower risk of epidural analgesia
    and fetal heart rate monitoring. However there appears to be an
    increased risk of chorioamnionitis and nausea/vomiting with
    prostaglandins compared to oxytocin.

-   Women with prelabour rupture of membranes [at term]{.underline}
    having their labour induced with prostaglandins appear to have a
    lower risk of epidural analgesia and fetal heart rate monitoring.
    However there appears to be an increased risk of chorioamnionitis
    and neonatal infections after prostaglandin induction compared to
    oxytocin.

***The following recommendations are based primarily on consensus and
expert opinion (Level C):***

-   Tocolysis may be utilized in patients with preterm PROM to permit
    administration of antenatal cortico-steroids and antibiotics.

-   Antenatal corticosteroids may be administered to gravidas with PROM
    up to 34 weeks of gestation.

**[References:]{.underline}**

-American College of Obstetricians and Gynecologists. Premature Rupture
of Membranes ACOG Practice Bulletin No. 1 June 1998. Washington, D.C.
(Level III)

-Crowley P. Prophylactic corticosteroids for preterm birth (Cochrane
Review). In: *The Cochrane Library,* Issue 4, 2001. Oxford: Update
Software.

-Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm premature
rupture of membranes (Cochrane Review). In: *The Cochrane Library,*
Issue 4, 2001. Oxford: Update Software. (Level III)

-National Guidelines Clearinghouse <http://www.guidelines.gov/index.asp>

-Smaill F. Intrapartum antibiotics for Group B streptococcal
colonisation (Cochrane Review). In: *The Cochrane Library,* Issue 4,
2001. Oxford: Update Software.

-Tan BP, Hannah ME. Oxytocin for prelabour rupture of membranes at or
near term (Cochrane Review). In: *The Cochrane Library,* Issue 4, 2001.
Oxford: Update Software.

-Tan BP, Hannah ME. Prostaglandins for prelabour rupture of membranes at
or near term (Cochrane Review). In: *The Cochrane Library,* Issue 4,
2001. Oxford: Update Software.

-Tan BP, Hannah ME. Prostaglandins versus oxytocin for prelabour rupture
of membranes [at or near term]{.underline} (Cochrane Review). In: *The
Cochrane Library,* Issue 4, 2001. Oxford: Update Software.

-Tan BP, Hannah ME. Prostaglandins versus oxytocin for prelabour rupture
of membranes [at term]{.underline} (Cochrane Review). In: *The Cochrane
Library,* Issue 4, 2001. Oxford: Update Software.

UpToDate. [Midtrimester preterm premature rupture of
membranes](../topicText.asp%3Ffile=pregcomp/11274#top). McElrath T.
<http://www.uptodateonline.com/application/topic.asp?file=pregcomp/11274>

-U.S. Preventive Services Task Force (USPSTF) Screening for bacterial
vaginosis in pregnancy: recommendations and rationale. Am J Prev Med
2001 Apr;20(3 Suppl):59-61

Revised 3/2/02 gjg/njm

10/26/98

7/31/97

10/11/95

October 1994

January 1988

June 1980