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Preterm Premature Rupture of Membranes (PPROM)

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General Information

Description

  • rupture of amniotic membranes prior to onset of labor in pregnancy at less than 37 weeks gestation1

Also called

  • preterm PROM
  • preterm prelabor rupture of membranes (term used by American College of Obstetricians and Gynecologists [AOCG])

Definitions

  • prelabor rupture of membranes (PROM) - rupture of the chorioamniotic membranes prior to the onset of labor
  • preterm premature rupture of membranes (PPROM) - PROM which occurs at less than 37 weeks gestation
  • latency - interval between membrane rupture and the onset of labor

References

General references used

  1. Committee on Practice Bulletins-Obstetrics. American College of Obstetricians and Gynecologists Practice Bulletin No. 188: Prelabor Rupture of Membranes. Obstet Gynecol. 2018 Jan;131(1):e1-e14OpenInNew, commentary can be found in Obstet Gynecol 2018 Jun;131(6):1163OpenInNew
  2. Thomson AJ, Royal College of Obstetricians and Gynaecologists. Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24<sup>+0</sup> Weeks of Gestation: Green-top Guideline No. 73. BJOG. 2019 Aug;126(9):e152-e166OpenInNew

Recommendation grading systems used

  • American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine (ACOG/SMFM) grading system for recommendations
    • Grade 1A - strong recommendation based on high-quality evidence
      • benefits clearly outweigh risk and burdens, or vice versa
      • evidence from well-performed randomized controlled trials or overwhelming evidence of some other form
      • can apply to most patients in most circumstances with reservation
    • Grade 1B - strong recommendation based on moderate-quality evidence
      • benefits clearly outweigh risk and burdens, or vice versa
      • evidence from randomized controlled trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence of some other research design
      • applies to most patients
    • Grade 1C - strong recommendation based on low-quality evidence
      • benefits appear to outweigh risk and burdens, or vice versa
      • evidence from observational studies, unsystematic clinical experience, or from randomized controlled trials with serious flaws; any estimate of effect is uncertain
      • applies to most patients; however some of the evidence base supporting the recommendation is of low quality
    • Grade 2A - weak recommendation based on high-quality evidence
      • benefits closely balanced with risks and burdens
      • evidence from well-performed randomized controlled trials or overwhelming evidence of some other form
      • best action may differ depending on circumstances or patients or societal values
    • Grade 2B - weak recommendation based on moderate quality evidence
      • benefits closely balanced with risks and burdens; some uncertainty in estimates of benefits, risks, and burdens
      • evidence from randomized controlled trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence of some other research design
      • alternative approaches likely to be better for some patients under some circumstances
    • Grade 2C - weak recommendation based on low-quality evidence
      • uncertainty in estimates of benefits, risks, and burdens; benefits may be closely balanced with risks and burdens
      • evidence from observational studies, unsystematic clinical experience, or from randomized controlled trials with serious flaws; any estimate of effect is uncertain
      • other alternatives may be equally reasonable
    • Best practice - recommendation for which either
      • there is enormous amounts of indirect evidence that clearly justifies strong recommendation (direct evidence would be challenging) OR
      • recommendation to contrary would be unethical
    • PubMed28937572Obstetrics and gynecologyObstet Gynecol201710011304e187-e199e187 Reference - ACOG/SMFM care consensus on periviable birth (Obstet Gynecol 2017 Oct;130(4):e187OpenInNew)
  • American College of Obstetricians and Gynecologists (ACOG) grades of recommendations
  • Royal College of Obstetricians and Gynaecologists (RCOG) grades of recommendations and classification of evidence levels
    • grades of recommendations
      • Grade A
        • ≥ 1 meta-analysis, systematic review, or randomized controlled trial rated as 1++ and directly applicable to target population, or
        • systematic review of randomized controlled trials or body of evidence consisting principally of studies rated as 1+ directly applicable to target population and demonstrating overall consistency of results
      • Grade B
        • body of evidence including studies rated as 2++ directly applicable to target population and demonstrating overall consistency of results, or
        • extrapolated evidence from studies rated as 1++ or 1+
      • Grade C
        • body of evidence including studies rated as 2+ directly applicable to target population and demonstrating overall consistency of results, or
        • extrapolated evidence from studies rated as 2++
      • Grade D
        • evidence level 3 or 4, or
        • extrapolated evidence from studies rated as 2+
      • Good practice point (GPP) - recommended best practice based on clinical experience of guideline development group
    • classification of evidence levels
      • Level 1++ - high-quality meta-analyses, systematic reviews of randomized controlled trials, or randomized controlled trials with very low risk of bias
      • Level 1+ - well-conducted meta-analyses, systematic reviews of randomized controlled trials, or randomized controlled trials with low risk of bias
      • Level 1- - meta-analyses, systematic reviews of randomized controlled trials, or randomized controlled trials with high risk of bias
      • Level 2++ - high-quality systematic reviews of case-control or cohort studies or high-quality case-control or cohort studies with very low risk of confounding, bias, or chance and high probability that relationship is causal
      • Level 2+ - well-conducted case-control or cohort studies with low risk of confounding, bias, or chance and moderate probability that relationship is causal
      • Level 2- - case-control or cohort studies with high risk of confounding, bias, or chance and significant risk that relationship is not causal
      • Level 3 - nonanalytical studies, such as case reports or case series
      • Level 4 - expert opinion
    • PubMed31207667BJOG : an international journal of obstetrics and gynaecologyBJOG201908011269e152-e166e152Reference - RCOG guideline on care of women presenting with suspected preterm prelabour rupture of membranes from 24+0 weeks of gestation (BJOG 2019 Aug;126(9):e152OpenInNew)
  • World Health Organization (WHO) classification of recommendations
    • strength of recommendation
      • Strong - panel is confident that desirable effects of adherence to recommendation outweigh undesirable effects
      • Conditional - panel concludes that desirable effects of adherence to recommendation probably outweigh undesirable effects, but 1 of following conditions applies
        • recommendation only applicable to specific group, population, or setting
        • new evidence may result in changing balance of risk to benefit
        • benefits may not warrant cost or resource requirements in all settings
      • No recommendation possible - further research required before any recommendation can be made
    • quality of evidence
      • High - further research very unlikely to change confidence in estimate of effect
      • Moderate - further research likely to have important impact on confidence in estimate of effect and may change estimate
      • Low - further research very likely to have an important impact on confidence in estimate of effect and likely to change estimate
      • Very low - any estimate of effect very uncertain
    • Guidelines Development Group (GDG) consensus - insufficient evidence to make a recommendation so GDG consensus used as the basis of recommendation
    • Reference - World Health Organization (WHO) recommendations for prevention and treatment of maternal peripartum infections can be found at WHO 2015 PDFPictureAsPdf
  • European consensus grading system for recommendations
    • Grade A - at least 1 high-quality meta-analysis of randomized control trials (RCTs) or a sufficiently powered high-quality RCT directly applicable to target population
    • Grade B - other meta-analyses or RCTs or high-quality systematic review of case-control studies or low-grade RCT but with high probability that the relationship is causal
    • Grade C - well-conducted case-control or cohort study with low risk or confounding or bias
    • Grade D - evidence from case series, case reports, or expert opinion
    • Reference - European consensus guideline on management of neonatal respiratory distress syndrome in preterm infants(Neonatology 2013;103(4):353OpenInNew)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T435299, Preterm Premature Rupture of Membranes (PPROM); [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T435299. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

    • Definitions

  • KeyboardArrowRight

    Epidemiology

    • Who is most affected

    • Incidence/Prevalence

    • Risk factors

    • Factors not associated with increased risk

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

    • KeyboardArrowRight

      Physical

      • General physical

      • Abdomen

      • Pelvic

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • Blood tests

    • Imaging studies

    • Other diagnostic testing

  • KeyboardArrowRight

    Management

    • Management overview

    • KeyboardArrowRight

      Recommendations

      • American College of Obstetrics and Gynecology (ACOG) guideline

      • Royal College of Obstetricians and Gynaecologists (RCOG) guideline

    • Treatment setting

    • KeyboardArrowRight

      Delivery vs. expectant management

      • Delivery and induction

      • Expectant management to prolong pregnancy

    • KeyboardArrowRight

      Medications

      • Medications for labor induction

      • KeyboardArrowRight

        Corticosteroids

        • Corticosteroids for gestations up to 34 completed weeks gestation

        • Corticosteroids after 34 weeks gestation

      • Antibiotics

      • Progesterone

      • Tocolytics

      • Magnesium sulfate

    • KeyboardArrowRight

      Other management

      • Amnioinfusion

      • Cerclage removal

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • Prognosis

  • KeyboardArrowRight

    Prevention and Screening

    • Prevention

    • Screening

  • KeyboardArrowRight

    Quality Improvement

    • Choosing Wisely

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Michael S. Warren MD, MA
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Affiliations

Attending Hospital-Based Physician, OB/GYN, William Beaumont Hospital; Michigan, United States

Conflicts of Interest

Dr. Warren declares no relevant financial conflicts of interest.

Recommendations Editor
Amir Qaseem MD, PhD, MHA, FACP
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Affiliations

Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network; Germany

Conflicts of Interest

Dr. Qaseem declares no relevant financial conflicts of interest.

Deputy Editor
Alan Ehrlich MD, FAAFP
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Affiliations

Executive Editor, DynaMed; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Ehrlich declares no relevant financial conflicts of interest.

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