Suspected PPROM (<37 weeks)
Patient reports fluid leakage
All Pathways
Obstetrics & GynecologyManagement
Preterm PROM Management (ACOG 2020)
Preterm PROM Management (ACOG 2020): Suspected PPROM (<37 weeks) → Confirm Diagnosis → PPROM Confirmed? → PROM Not Confirmed.
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Confirm Diagnosis
Sterile speculum examination
- STERILE SPECULUM EXAM (not digital until labor)
- Pooling of fluid in posterior fornix
- Nitrazine test (blue = positive, pH >6.0)
- Ferning on dried slide
- If equivocal: AmniSure, ROM Plus, or ultrasound for AFI
- Cervical cultures: GBS, gonorrhea, chlamydia
03Decision PPROM Confirmed?
Based on clinical criteria
04Outcome PROM Not Confirmed
Discharge with precautions
- Educate on signs of ROM
- Return if continued leaking
- Follow-up as scheduled
05Action Initial Evaluation
Assess maternal and fetal status
- Gestational age confirmation
- Fetal monitoring (NST)
- Ultrasound: AFI, fetal presentation
- Labs: CBC, blood type, GBS culture
- Maternal temp, HR, uterine tenderness
- Assess for labor, infection, abruption
06Decision Contraindications to Expectant Management?
Assess for immediate delivery indications
- Chorioamnionitis (fever, tachycardia, tender uterus)
- Placental abruption
- Non-reassuring fetal status
- Advanced labor
- Cord prolapse
07Warning Immediate Delivery Indicated
Do not delay for steroids
- Chorioamnionitis: deliver, start antibiotics
- Non-reassuring FHR: expedite delivery
- Cord prolapse: emergency cesarean
- Abruption: per abruption protocol
08Decision Gestational Age
Management by GA
09Action <23 weeks (Previable)
Counseling and options
- Counsel on poor prognosis
- Options: expectant, induction, dilation/evacuation
- If expectant: outpatient monitoring possible
- High risk: infection, pulmonary hypoplasia
- No steroids or tocolysis
10Action 23+0 to 33+6 weeks
Expectant management with monitoring
- Admit to hospital
- Antenatal corticosteroids
- Latency antibiotics (extends latency ~1 week)
- MgSO4 neuroprotection if <32 wks and delivery imminent
- GBS prophylaxis in labor
- Daily fetal monitoring, serial WBC, temps
11Action Antenatal Corticosteroids
If 23+0 to 33+6 weeks
- Betamethasone 12mg IM q24h x 2 doses
- OR Dexamethasone 6mg IM q12h x 4 doses
- Single rescue course if >2 weeks and <34 weeks
12Action Latency Antibiotics
Prolong latency, reduce infection
- Ampicillin 2g IV q6h x 48h + Azithromycin 1g PO x1
- Then Amoxicillin 500mg PO TID x 5 days
- Alternative: Ampicillin-sulbactam
- Extend latency ~1 week on average
- Do not use amoxicillin-clavulanate (NEC risk)
13Decision Timing of Delivery
GA-based delivery recommendations
- 34+0 weeks: reasonable to deliver
- Chorioamnionitis: deliver regardless of GA
- Non-reassuring FHR: deliver
- Abruption: per protocol
14Outcome Delivery
Vaginal preferred if no contraindication
- GBS prophylaxis in labor
- Neonatal team present
- Cesarean for obstetric indications
15Action Ongoing Monitoring
While awaiting delivery
- Fetal monitoring 1-2x daily
- Maternal vitals q4-8h
- Daily WBC (rising = concern for infection)
- Uterine tenderness checks
- Watch for labor, infection, abruption
- Path rejoins step 13Shared downstream outcome
16Action 34+0 to 36+6 weeks
Consider delivery vs. expectant
- Delivery at 34+0 is reasonable (ACOG)
- Late preterm steroids if not previously given
- GBS prophylaxis
- If expectant: close monitoring, no latency abx
- Path rejoins step 13Shared downstream outcome
Guideline Source
ACOG Practice Bulletin No. 217: Prelabor Rupture of Membranes
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Expectant management requires close monitoring
- Latency antibiotics vary by institution
- Previable PPROM requires shared decision-making
Applicable Regions
USEUGlobal
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Preterm PROM Management (ACOG 2020)?
The Preterm PROM Management (ACOG 2020) is a management clinical algorithm for Obstetrics & Gynecology. It provides a structured decision tree to guide clinical decision-making, based on ACOG Practice Bulletin No. 217: Prelabor Rupture of Membranes.
What guideline is the Preterm PROM Management (ACOG 2020) based on?
This algorithm is based on ACOG Practice Bulletin No. 217: Prelabor Rupture of Membranes (DOI: 10.1097/AOG.0000000000003700).
What are the limitations of the Preterm PROM Management (ACOG 2020)?
Known limitations include: Expectant management requires close monitoring; Latency antibiotics vary by institution; Previable PPROM requires shared decision-making. Individual patient factors may require deviation from these recommendations.
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