RCOG Green-top Guideline
MRCOG Part 2
Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks
Scope
Covers suspected preterm prelabour rupture of membranes (PPROM) from 24+0 to 36+6 weeks of gestation. PPROM complicates up to 3% of pregnancies and is associated with 30-40% of preterm births; it carries risk of neonatal morbidity/mortality from prematurity, sepsis, cord prolapse and pulmonary hypoplasia. Care before 24+0 weeks is covered by a separate guideline (periviable PPROM).
Diagnosis
- Diagnosis of spontaneous rupture of membranes is made by maternal history followed by a sterile speculum examination looking for pooling of amniotic fluid — this remains the first-line diagnostic step.
- If no fluid is visualised on speculum examination but PPROM is still suspected, clinicians should consider an IGFBP-1 (insulin-like growth factor-binding protein-1) or PAMG-1 (placental alpha microglobulin-1) test of vaginal fluid to guide further management.
- Digital vaginal examination should be avoided unless the woman is in established labour or delivery is imminent, as it increases infection risk and adds little diagnostic value over speculum assessment.
Chorioamnionitis Assessment
- No single test reliably diagnoses chorioamnionitis. A combination of clinical assessment, maternal blood tests (CRP and white cell count), and fetal heart rate should be used together — these parameters should not be relied on in isolation, as each has limited sensitivity and specificity alone.
Antibiotic Prophylaxis
- An antibiotic — preferably erythromycin — should be given for 10 days, or until the woman is in established labour, whichever is sooner.
- Co-amoxiclav should be avoided. The ORACLE 1 trial found co-amoxiclav use after PPROM was associated with a significantly increased incidence of neonatal necrotising enterocolitis compared with other antibiotics, which is why erythromycin (or, in confirmed penicillin allergy, erythromycin alone) is preferred over amoxicillin/clavulanic acid.
Corticosteroids and Magnesium Sulphate
- Antenatal corticosteroids should be considered/offered where birth is anticipated, in line with RCOG Green-top Guideline No. 74, which recommends a single course of corticosteroids for women at risk of preterm birth up to 34+6 weeks of gestation.
- Magnesium sulphate for fetal neuroprotection should be offered where birth is considered likely within 24 hours, consistent with national (NICE NG25/BAPM-aligned) practice for very preterm birth.
Tocolysis
- Tocolysis is not recommended in the presence of confirmed PPROM.
Timing of Birth: Expectant vs Active Management
- Women with PPROM and no contraindications (e.g. chorioamnionitis, abruption, non-reassuring fetal status) should be offered expectant management until 37+0 weeks of gestation, as this is associated with better neonatal outcomes than routine early delivery.
- Where there is evidence of infection, fetal compromise, or other obstetric complication, active management (expedited birth) should be pursued irrespective of gestation, guided by individualised multidisciplinary assessment rather than a fixed threshold.
- This guideline supplements NICE guideline NG25 (Preterm labour and birth), which should be consulted alongside it for overall preterm labour management.
High-Yield Exam Points
- Diagnosis = history + sterile speculum first; IGFBP-1/PAMG-1 testing is reserved for cases where no fluid is seen on speculum.
- Chorioamnionitis is a clinical + laboratory (CRP, WCC) + fetal heart rate composite diagnosis — no single test is definitive.
- Erythromycin for 10 days (or until established labour) is the antibiotic of choice; avoid co-amoxiclav (ORACLE 1 — increased necrotising enterocolitis risk).
- Tocolysis is contraindicated once PPROM is confirmed.
- Default management is expectant until 37+0 weeks in the absence of infection or fetal compromise — know this as the guideline's key gestational anchor, distinct from the corticosteroid cut-off (34+6 weeks, per GTG 74) and magnesium sulphate neuroprotection criteria.
- This guideline replaced the archived Green-top Guideline No. 44 and should be cited as GTG No. 73, not GTG 44, in current answers.
Source: RCOG Green-top Guideline No. 73 (Last reviewed October 2024 (extended for 2 years; next full review scheduled to commence 2026). Originally replaced the archived GTG No. 44 in 2019; a June 2022 update aligned corticosteroid advice with GTG No. 74.)
Read the original on rcog.org.uk
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