Preterm Premature Rupture of Membranes (PPROM)

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

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

• 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

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-e14, commentary can be found in Obstet Gynecol 2018 Jun;131(6):1163
2. Thomson AJ, Royal College of Obstetricians and Gynaecologists. Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24⁺⁰ Weeks of Gestation: Green-top Guideline No. 73. BJOG. 2019 Aug;126(9):e152-e166

• 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):e187)

• American College of Obstetricians and Gynecologists (ACOG) grades of recommendations
  • Level A - recommendations based on good and consistent scientific evidence
  • Level B - recommendations based on limited or inconsistent scientific evidence
  • Level C - recommendations based primarily on consensus and expert opinion
  • References -
    • ACOG Practice Bulletin 188 on prelabor rupture of membranes (Obstet Gynecol 2018 Jan;131(1):e1)
    • ACOG Practice Bulletin 171 on management of preterm labor (27661654Obstet Gynecol 2016 Oct;128(4):e155), reaffirmed 2018
    • ACOG Practice Bulletin 130 on prediction and prevention of preterm birth (22996126Obstet Gynecol 2012 Oct;120(4):964), reaffirmed 2018, commentary can be found in Obstet Gynecol 2013 Aug;122(2 Pt 1):390
• 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):e152)
• 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 PDF
• 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):353)

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