Many women whose waters break early can safely continue pregnancy
Author: Louise Prime
Many women with preterm prelabour rupture of membranes (PPROM) after 24 weeks’ gestation can safely continue their pregnancy to 37 weeks and should be offered the choice to do so as long as there are no signs of infection or complications, according to new ‘green top’ guidance from the Royal College of Obstetricians and Gynaecologists (RCOG). The College advises that some women might be cared for at home until they go into labour, although it adds that women and babies should be monitored closely for signs of infection, and recommends hospital birth in a unit with appropriate neonatal facilities and staff.
RCOG explained that PPROM, where membranes rupture before 37 weeks but labour does not start, is uncommon, only affecting up to 3% of UK pregnancies. However, PPROM is potentially serious for both mother and baby and is associated with 30-40% of premature births in the UK.
About half of women go into labour within the first week of PPROM, but the College notes that for the others, they might be able to continue their pregnancy for weeks or even months further, up to 37 weeks; continuing with the pregnancy closer to term could reduce the risk of the baby being born prematurely which is linked to problems with breathing, feeding and infection, and being admitted to a neonatal unit.
This week RCOG used new guidance on PPROM, as well as a new patient leaflet for women and their partners. Its key recommendations are that:
- The diagnosis of spontaneous rupture of the membranes is made by maternal history followed by a sterile speculum examination.
- 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.
- Following the diagnosis of PPROM, an antibiotic (preferably erythromycin) should be given for 10 days or until the woman is in established labour (whichever is sooner).
- 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.
- 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.
- 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.
- 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.
Consultant obstetrician Dr Andrew Thomson, author of the RCOG clinical guidelines on PPROM, commented: “PPROM is an uncommon, but potentially serious condition with significant health risks to a woman and her baby. Evidence shows that waiting for labour to begin may be the best option for a healthier outcome, unless there is a reason for the baby to be born immediately. Every pregnancy will be different, and each woman’s individual preferences need to be considered when deciding on the timing of birth.
“All maternity units across the country are encouraged to follow these guidelines which should improve health outcomes for both mother and baby.”