Royal College of Obstetricians and Gynaecologists

A new guideline, which was released on the first day of the Royal College of Obstetricians and Gynaecologists (RCOG) World Congress 2019, recommends that pregnant women whose waters break from 24 weeks, but do not go into labour, should be offered the choice to continue with the pregnancy until 37 weeks of gestation if there are no signs of infection or complications.

"These updated guidelines are essential to inform best practice and improve outcomes for mothers and their babies in maternity units around the country," said Dr Andrew Thomson, Consultant Obstetrician, and author of the guideline.

Around 50% of women will go into labour within the first week after their waters break. But frequently, it is possible to continue gestation for weeks or months after membranes have ruptured.

The previous iteration of the guideline, published in 2010, advised that delivery should be considered at 34 weeks of pregnancy. Between 34 and 37 weeks, the 2010 guideline described the management of pregnancies with preterm prelabour rupture of the membranes (PPROM) as "a contentious issue"; it recommended that women managed expectantly should be advised of the risks of continuing gestation versus having a Caesarean section.

The change in recommendation in the new guideline is based on findings from a Cochrane review and meta-analysis, which included 12 trials and 3,617 women with PPROM.

The guideline also gives recommendations on diagnosis and management.

It advises that diagnosis of spontaneous rupture of the membranes should be made by maternal history followed by a sterile speculum examination. If, on speculum examination, no amniotic fluid is observed, clinicians should consider performing an insulin-like growth factor‐binding protein-1 (IGFBP-1) or placental alpha microglobulin-1 (PAMG-1) test of vaginal fluid to guide further management.

Following the diagnosis of PPROM, an antibiotic (preferably erythromycin) should be given for 10 days or until the woman is in established labour (whichever is sooner).

Other new recommendations in the guideline include:

• if possible, a baby should be born in a unit with appropriate neonatal staff and facilities
• if possible, a woman and her partner should be offered the opportunity to meet a neonatologist to discuss their baby's care
• emotional support should be offered to a woman and her partner before and after birth
• women should be cared for by an obstetrician with expertise in preterm birth in subsequent pregnancies
• the location of a woman's care (at home or in a maternity unit) should be considered on a case-by-case basis

PPROM occurs in up to 3% of pregnancies and is associated with 30-40% of premature births in the UK.