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Preterm Labour and Preterm Prelabour Rupture of Membranes (PPROM)

NICE Guideline [NG25] Preterm Labour and Birth. Last Updated: Jun 2022 RCOG Green-top Guideline No. 73 Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks of Gestation

Background Information

Preterm birth: birth <37 weeks of gestation

  • Preterm birth may or may not be preceded by preterm prelabour rupture of membranes (PPROM)

PPROM and preterm labour are separate entities and should be approached differently. 
  • PPROM: rupture of membranes before 37 weeks of pregnancy and before the start of labour. 
  • Preterm labour: progressive dilatation from 4cm with regular contractions in <37 weeks of gestation.

P-PROM Guidelines

If P-PROM is suspected:
  • 1st line: speculum examination - look for pooling of amniotic fluid
  • If conclusive → vaginal fluid testing for IGFBP-1 / PAMG-1
  • If conclusive → P-PROM unlikely

There are 3 main domains in the management of PPROM:
  • Prophylactic antibiotic - ALL patients 
  • Maternal corticosteroid - selected patients
  • Maternal magnesium sulfate - selected patients
 

 Tocolysis is NOT recommended in PPROM, as it does not significantly improve perinatal outcome and might be associated with an increased risk of chorioamnionitis

Tocolysis only has a role in preterm labour with INTACT membrane.

Prophylaxis for intrauterine infection is indicated for ALL patients with PPROM:
  • 1st line: erythromycin 250mg PO QDS until labour / maximum of 10 days (whichever is sooner)
  • 2nd line: penicillin PO

Purpose:
  • Mainly stimulate surfactant production in the fetal lung → reduce risk of respiratory distress syndrome
  • Also reduces risk of intraventricular haemorrhage and necrotising enterocolitis

Choice of agent:
  • IM betamethasone 
  • Do not give more than 2 courses of maternal corticosteroids for preterm birth

Indications:
  • In short, indicated in <36 weeks of gestation
  • Exact recommendation
    • Offer if 24 - 33+6 weeks
    • Consider if 34 - 35+6 weeks

Purpose:
  • Fetal neuroprotection - reduces risk of cerebral palsy
  • Magnesium stabilises neuronal membrane, reduces excitotoxic injury 

Choice of agent:
  • IV magnesium sulfate (4g bolus over 15 min, followed by 1g / hour until birth or for 24 hours)

Indications:
  • In short, indicated if <34 weeks
  • Exact recommendation
    • Offer if 24 - 29+6 weeks
    • Consider if 30 - 33+6 weeks

NICE recommends monitoring for clinical signs of magnesium toxicity for at least 4 hourly:
  • Deep tendon reflex (reduced deep tendon reflex) - earliest and most sensitive indicator
  • Blood pressure (hypotension)
  • Respiratory rate (respiratory depression)

Use a combination of clinical assessment and:
  • CRP
  • White blood cell count
  • Cardiotocography

Preterm Labour with Intact Membrane Guidelines

Individauls at risk of preterm labour:
  • History of spontaneous preterm birth or loss
  • TVUS shows cervical length ≤25 mm (carried out 16-24 weeks)
  • P-PROM in previous pregnancy
  • History of cervical trauma 

Prophylactic options:
  • Vaginal progesterone - start between 16-24 weeks, until at least 34 weeks
  • Cervical cerclage 
 

Disclaimer: this section provides a simplified version underpinning the rationale of the guideline instead of the exact recommendations. 

Exact NICE recommendations (depending on the 4 outlined risk factors):

  • Point 1 + 2 → offer either option
  • Point 1 or 2 → consider vaginal progesterone
  • Point 2 + 3 or 4 → consider cervical cerclage

First, perform clinical assessment and speculum examination
  • Regular contractions reported by patient
  • Progressive cervical dilation from 4cm

If clinical assessment suggests preterm labour:
  • <30 weeks → clinical diagnosis with no further 
 
  • >30 weeks → additional tests to predict chance of entering labour in the next 48 hours
    • 1st line: TVUS - cervical length ≤15mm is diagnostic
    • 2nd line: swab for fetal fibronectin testing (swab before digital vaginal examination)
      • >50 ng/mL (positive) is diagnostic
      • Ensure swab taken before digital vaginal examination

There are 3 main domains in the management of preterm labour with intact membranes:
  • Tocolysis
  • Maternal corticosteroids
  • Maternal magnesium sulfate 

Purpose:
  • Suppress uterine contractions
  • Delays preterm delivery, usually up to 48 hours so that other interventions (e.g. steroids and magnesium sulfate) or transfer to a higher-level facility can be arranged

Choice of agent:
  • 1st line: nifedipine PO
  • 2nd line: oxytocin receptor antagonist)

Indications:
  • In short, indicated in <34 weeks of gestation and intact membrane
  • Exact recommendation
    • Offer if 26 - 33+6 weeks
    • Consider if 24 - 25+6 weeks

Purpose:
  • Mainly stimulate surfactant production in the fetal lung → reduce risk of respiratory distress syndrome
  • Also reduces risk of intraventricular haemorrhage and necrotising enterocolitis

Choice of agent:
  • IM betamethasone 
  • Do not give more than 2 courses of maternal corticosteroids for preterm birth

Indications:
  • In short, indicated in <36 weeks of gestation
  • Exact recommendation
    • Offer if 24 - 33+6 weeks
    • Consider if 34 - 35+6 weeks

Purpose:
  • Fetal neuroprotection - reduces risk of cerebral palsy
  • Magnesium stabilises neuronal membrane, reduces excitotoxic injury 

Choice of agent:
  • IV magnesium sulfate (4g bolus over 15 min, followed by 1g / hour until birth or for 24 hours)

Indications:
  • In short, indicated if <34 weeks
  • Exact recommendation
    • Offer if 24 - 29+6 weeks
    • Consider if 30 - 33+6 weeks

NICE recommends monitoring for clinical signs of magnesium toxicity for at least 4 hourly:
  • Deep tendon reflex (reduced deep tendon reflex) - earliest and most sensitive indicator
  • Blood pressure (hypotension)
  • Respiratory rate (respiratory depression)

Only consider if all the following are present:
  • <28 weeks of gestation
  • Dilated cervix
  • Exposed and unruptured fetal membrane

Delivery of Preterm Babies

If PPROM <34 weeks:
  • Expectant management until 37 weeks (unless there are additional indications)

If PPROM 34-37 weeks:
  • Offer option of expectant management until 37 weeks or induction of labour
 
  • If +ve GBS during current pregnancy → immediate induction of labour or caesarean birth

  • Discuss general benefits and risks of caesarean birth and vaginal birth
    • NICE particularly mentions the increased risk of classical incision while performing a caesarean birth of preterm birth
 
  • Explain that risks are specific to gestational age, not mode of birth


 

In short, PPROM / preterm labour on their own don't really influence planning the mode of birth.

RCOG recommends IAP with benzylpenicillin to all established preterm labour to prevent GBS disease

  • This is irrespective of maternal GBS carrier status

NICE recommends:

  • Position the baby at / below the level of placenta before cord clamping
 
  • Delayed cord clamping is recommended (wait at least 60 seconds)
    • Unless there are specific indications for earlier clamping

References

Author: Adams Lau
Reviewer:
Last Edited: 19/03/25