ACOG PRACTICE BULLETIN SUMMARY

Clinical Management Guidelines for Obstetrician–Gynecologists

NUMBER 217 (Replaces Practice Bulletin Number 188, January 2018)

For a comprehensive overview of these recommendations, the full-text Scan this QR code
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Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the American College of Obstetricians
and Gynecologists’ Committee on Practice Bulletins—Obstetrics in collaboration with Robert Ehsanipoor, MD and Christian M.
Pettker, MD.

Prelabor Rupture of Membranes

Preterm birth occurs in approximately 10% of all births in the United States and is a major contributor to perinatal
morbidity and mortality (1–3). Prelabor rupture of membranes (PROM) that occurs preterm complicates approxi-
mately 2–3% of all pregnancies in the United States, representing a significant proportion of preterm births, whereas
term PROM occurs in approximately 8% of pregnancies (4–6). The optimal approach to assessment and treatment of
women with term and preterm PROM remains challenging. Management decisions depend on gestational age and
evaluation of the relative risks of delivery versus the risks (eg, infection, abruptio placentae, and umbilical cord
accident) of expectant management when pregnancy is allowed to progress to a later gestational age. The purpose
of this document is to review the current understanding of this condition and to provide management guidelines that
have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the
basis of consensus and expert opinion also are presented. This Practice Bulletin is updated to include information
about diagnosis of PROM, expectant management of PROM at term, and timing of delivery for patients with preterm
PROM between 34 0/7 weeks of gestation and 36 6/7 weeks of gestation.

Clinical Management Questions

< How is prelabor rupture of membranes diagnosed?
< What does initial management involve once prelabor rupture of membranes has been confirmed?
< What is the optimal method of initial management for a patient with prelabor rupture of membranes at
term?
< When is delivery recommended for the preterm fetus in the presence of prelabor rupture of membranes?
< What general approaches are used in cases of preterm prelabor rupture of membranes managed
expectantly?
< Should tocolytics be considered for patients with preterm prelabor rupture of membranes?

VOL. 135, NO. 3, MARCH 2020 OBSTETRICS & GYNECOLOGY 739

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
< Should antenatal corticosteroids be administered to patients with preterm prelabor rupture of
membranes?
< Should magnesium sulfate for fetal neuroprotection be administered to patients with preterm prelabor
rupture of membranes?
< Should antibiotics be administered to patients with preterm prelabor rupture of membranes?
< Should preterm prelabor rupture of membranes be managed with home care?
< How should a patient with preterm prelabor rupture of membranes and a cervical cerclage be treated?
< What is the optimal management of a patient with preterm prelabor rupture of membranes and herpes
simplex virus infection or human immunodeficiency virus?
< How does care differ for patients with prelabor rupture of membranes that occurs before neonatal
viability?
< What is the expected outcome of prelabor rupture of membranes after second-trimester amniocentesis?
< How should a patient with a history of preterm prelabor of membranes be managed in future
pregnancies?

by oral amoxicillin and erythromycin is recom-

Recommendations mended during expectant management of women
and Conclusions with preterm PROM who are at less than 34 0/7
weeks of gestation. Some centers have replaced the
The following recommendations are based on good and
use of erythromycin with azithromycin in situations
consistent scientific evidence (Level A):
in which erythromycin is not available or not toler-
< Patients with preterm PROM before 34 0/7 weeks of ated, and this is a suitable alternative.
gestation should be managed expectantly if no < Women with preterm PROM and a viable fetus who
maternal or fetal contraindications exist. are candidates for intrapartum GBS prophylaxis
< A single course of corticosteroids is recommended for should receive intrapartum GBS prophylaxis to pre-
pregnant women between 24 0/7 weeks of gestation vent vertical transmission regardless of earlier anti-
and 33 6/7 weeks of gestation and may be considered biotic treatments.
for pregnant women who are at risk of preterm birth
The following recommendations and conclusions are
within 7 days, including for those with ruptured
based on limited and inconsistent scientific evidence
membranes, as early as 23 0/7 weeks of gestation.
(Level B):
< A single course of corticosteroids is recommended for
pregnant women between 34 0/7 weeks of gestation < For women with PROM at 37 0/7 weeks of gestation
and 36 6/7 weeks of gestation at risk of preterm birth or more, if spontaneous labor does not occur near the
within 7 days and who have not received a previous time of presentation in those who do not have con-
course of antenatal corticosteroids if proceeding with traindication to labor, labor induction should be rec-
induction or delivery in no less than 24 hours and no ommended, although the choice of expectant
more than 7 days. management for a short period of time may be
< Women with preterm PROM before 32 0/7 weeks of appropriately offered.
gestation who are thought to be at risk of imminent < Either expectant management or immediate delivery
delivery should be considered candidates for fetal in patients with PROM between 34 0/7 weeks of
neuroprotective treatment with magnesium sulfate. gestation and 36 6/7 weeks of gestation is a reason-
< To reduce maternal and neonatal infections and able option, although the balance between benefit and
gestational-age-dependent morbidity, a 7-day course risk, from both maternal and neonatal perspectives,
of therapy of latency antibiotics with a combination should be carefully considered, and patients should
of intravenous ampicillin and erythromycin followed be counseled clearly. Care should be individualized

740 Practice Bulletin No. 217 Summary OBSTETRICS & GYNECOLOGY

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
 Box 1. Management of Prelabor Rupture of Membranes by Gestational Age Categories in
Patients With Normal Antenatal Testing
Term (37 0/7 weeks of gestation or more)
c GBS prophylaxis as indicated
c Treat intraamniotic infection if present
c Proceed toward delivery (induction or cesarean as appropriate/indicated)

Late Preterm (34 0/7–36 6/7 weeks of gestation)

c Expectant management or proceed toward delivery (see text) (induction or cesarean as appropriate/indicated)
c Single-course of corticosteroids, if steroids not previously given, if proceeding with induction or delivery in no less
than 24 hours and no more than 7 days, and no evidence of chorioamnionitis*
c GBS screening and prophylaxis as indicated
c Treat intraamniotic infection if present (and proceed toward delivery)

Preterm (24 0/7–33 6/7 weeks of gestation)

c Expectant management
c Antibiotics recommended to prolong latency if there are no contraindications
c Single-course of corticosteroids; insufficient evidence for or against rescue course
c Treat intraamniotic infection if present (and proceed to delivery)
c A vaginal–rectal swab for GBS culture should be obtained at the time of initial presentation and GBS prophylaxis
administered as indicated.
c Magnesium sulfate for neuroprotection before anticipated delivery for pregnancies ,32 0/7 weeks of gestation,
if there are no contraindications†

Periviable (Less than 23–24 weeks of gestation)z,§

c Patient counseling; consider neonatology and maternal–fetal medicine consultation
c Expectant management or induction of labor
c Antibiotics may be considered as early as 20 0/7 weeks of gestation
c GBS prophylaxis is not recommended before viabilityǁ
c Corticosteroids are not recommended before viabilityǁ
c Tocolysis is not recommended before viabilityǁ
c Magnesium sulfate for neuroprotection is not recommended before viability†,ǁ
Abbreviation: GBS, group B streptococci.
*Do not delay delivery for steroids; steroids should not be administered for an imminent cesarean birth.
†Magnesium sulfate for neuroprotection in accordance with one of the larger studies.
zThe combination of birth weight, gestational age, and sex provide the best estimate of chances of survival and should be

considered in individual cases.

§Periviable birth. Obstetric Care Consensus No. 6. American College of Obstetricians and Gynecologists. 2017;130:187–99.
ǁMay be considered for pregnant women as early as 23 0/7 weeks of gestation.

through shared decision making, and expectant PROM between 34 0/7 weeks of gestation and 36 6/7
management should not extend beyond 37 0/7 weeks weeks of gestation.
of gestation. Latency antibiotics are not appropriate in < Given the potential benefit of progesterone therapy,
this setting. women with a single gestation and a prior spontaneous
< In the setting of ruptured membranes with active preterm birth (due to either labor with intact mem-
labor, although tocolytic therapy has not been shown branes or preterm PROM) should be offered pro-
to prolong latency or improve neonatal outcomes, gesterone supplementation as clinically indicated to
data are limited. Tocolytic agents can be considered reduce the risk of recurrent spontaneous preterm birth.
in preterm PROM for steroid benefit to the neonate, The following conclusions are based primarily on con-
especially at earlier gestational ages, or for maternal sensus and expert opinion (Level C):
transport but should be used cautiously and avoided if
there is evidence of infection or abruption. Tocolytic < The diagnosis of membrane rupture typically is con-
therapy is not recommended in the setting of preterm firmed by conventional clinical assessment, which

VOL. 135, NO. 3, MARCH 2020 Practice Bulletin No. 217 Summary 741

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
 includes the visualization of amniotic fluid passing 2. Martin JA, Hamilton BE, Osterman MJ, Driscoll AK,
from the cervical canal and pooling in the vagina; Drake P. Births: final data for 2017. Natl Vital Stat Rep
2018B;67(8):1–49. (Level II-3)
a simple pH test of vaginal fluid; or arborization
(ferning) of dried vaginal fluid, which is identified 3. Matthews TJ, MacDorman MF, Thoma ME. Infant mor-
under microscopic evaluation. tality statistics from the 2013 period linked birth/infant
death data set. Natl Vital Stat Rep 2015;64:1–30. (Level
< The outpatient management of preterm PROM with II-3)
a viable fetus has not been studied sufficiently to
establish safety and, therefore, is not recommended. 4. Mercer BM. Preterm premature rupture of the mem-
branes: current approaches to evaluation and manage-
Periviable PROM may be considered for home care ment. Obstet Gynecol Clin North Am 2005;32:411–28.
after a period of assessment in the hospital. (Level III)
5. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menac-
ker F, Munson ML. Births: final data for 2003. Natl Vital
Stat Rep 2005;54(2):1–116. (Level II-3)
References 6. Middleton P, Shepherd E, Flenady V, McBain RD,
1. Martin JA, Hamilton BE, Osterman MJ. Births in the Crowther CA. Planned early birth versus expectant man-
United States, 2017. NCHS Data Brief No. 318. Hyatts- agement (waiting) for prelabour rupture of membranes at
ville (MD): National Center for Health Statistics; 2018A. term (37 weeks or more). Cochrane Database of System-
Available at: https://www.cdc.gov/nchs/data/databriefs/ atic Review 2017, Issue 1. Art. No.: CD005302. (System-
db318.pdf. Retrieved April 16, 2019. (Level III) atic Review and Meta-Analysis)

742 Practice Bulletin No. 217 Summary OBSTETRICS & GYNECOLOGY

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
 Studies were reviewed and evaluated for quality
according to the method outlined by the U.S.
Preventive Services Task Force. Based on the highest
level of evidence found in the data, recommendations are
provided and graded according to the following
categories:
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.

Full-text document published online on February 20, 2020.

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Official Citation
Prelabor rupture of membranes. ACOG Practice Bulletin No.
217. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2020;135:e80–97.

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