DOI 10.1515/jpm-2013-0127J. Perinat. Med.

2013; 41(6): 651652

Amos Grunebaum*

Reply to Management of prelabour rupture of

membranes (PROM) at term
*Corresponding author: Amos Grunebaum, Department of
Obstetrics, New York Weill Medical College of Cornell University,
525 East 68th Street, Suite J-130, New York 10065, USA,
E-mail: amosgrune@yahoo.com

Term prelabour rupture of fetal membranes (PROM),

also known as term premature rupture of membranes, is
defined as the rupture of fetal membranes prior to labour
beyond 37 weeks of gestation and happens in about 8%
of pregnancies [1]. Term PROM is associated with an
increased risk of infections, such as chorioamnionitis and
neonatal sepsis, a risk that increases with the length of
time between PROM and delivery [5, 6].
The two options of managing term PROM commonly
include expectant management and awaiting sponta
neous labour versus active management and delivery
with induction inducing agents, such as oxytocin or other
agents.
In the UK, the National Institute for Health and Care
Excellence (NICE) guidelines of term PROM recommend
expectant management for 24 h [4], while in the USA,
the American College of Obstetricians and Gynecolo
gists (ACOG) advises active management of term PROM to
reduce the risk of infectious complications [1].
Ismail and Tahiri [3] believe that detection of
developing infections could be enhanced by using a com
bination of investigations (at presentation, 12 and 24 h)
as well as current advice to self-monitor temperature and
vaginal loss. However, by the time clinical infection has
been detected, the chances are that subclinical infection
has been ongoing for some time and there will be a likeli
hood of a delay in treatment and delivery. There is no evi
dence that this approach of expectant management and
self-monitoring of temperature is safe.
The TERMPROM study by Hannah etal. in 1996 com
pared expectant management with induction of labour
with oxytocin or prostaglandin in 5042 women with term
PROM and was the largest prospective randomised study
done on term PROM [2]. They showed a similar rate of cae
sarean deliveries but a significantly increased risk of clini
cal chorioamnionitis, antibiotic use, longer maternal hos
pital stay, and postpartum fever in women with expectant

management when compared to those with labour induc

tion. They concluded that there was a lower risk of mater
nal infection with oxytocin induction, and that women
view induction of labour more positively than expectant
management.
In the technical bulletin on term PROM, ACOG recom
mended that: for women with PROM at term, labour
should be induced at the time of presentation, generally
with oxytocin infusion, to reduce the risk of chorioam
nionitis (level A recommendation), and delivery is
recommended when PROM occurs at or beyond 34 weeks
of gestation (level B recommendation). These recom
mendations are based on the fact that there are presently
not enough data supporting the safety of expectant man
agement of term PROM, and that in the absence of a safe
expectant management, delivery is in the best interest of
mother and newborn.
In conclusion, expectant management of term pre
labour PROM delays delivery without evidence that it is
safe, and if the patient is admitted to hospital, expectant
management unnecessarily increases length of stay.
The right answer to the management of term PROM is
not to wait for any signs of infection but instead to recom
mend to women with term prelabour PROM to proceed
with delivery and to actively induce labour in the absence
of a contraindication to vaginal delivery. PROM should
not be managed at home because of the increased risk of
cord prolapse and intrauterine cord compression from oli
gohydramnios. Neither self-monitoring of temperature or
vaginal loss (whatever that means) have been found to be
effective or safe in term PROM.
Hannah et al. have shown conclusively that delays
in term PROM increases the risk for infections, such as
chorioamnionitis, neonatal infection, admission to the
neonatal intensive care unit, and that women view active
management more positively than expectant manage
ment [2]. Therefore, the best and safest approach to term
prelabour PROM is to recommend active management
and expeditious delivery.
Received June 5, 2013. Accepted June 5, 2013. Previously published
online July 4, 2013.

652Grunebaum, Reply to Management of PROM at term

References
[1] ACOG Practice Bulletin. Premature rupture of membranes.
Number 80; 2007.
[2] Hannah ME, Ohlsson A, Farine D, Hewson SA, Hodnett ED,
Myhr TL, etal. Induction of labor compared with expectant
management for prelabor rupture of the membranes at term.
N Engl J Med. 1996;334:100510.
[3] Ismail AQT, Lahiri S. Management of prelabour rupture of
membranes (PROM) at term. J Perinat Med. 2013;41:6479.
[4] NICE. Intrapartum care. Secondary intrapartum care 2009.
http://www.nice.org.uk/nicemedia/live/11837/36275/36275.
pdf. Accessed XX Month, 20XX.

[5] Novak-Antolic Z, Pajntar M, Verdenik I. Rupture of the

membranes and postpartum infection. Eur J Obstet Gynecol
Reprod Biol. 1997;71:1416.
[6] Wagner MV, Chin VP, Peters CJ, Drexler B, Newman LA.
A comparison of early and delayed induction of labor with
spontaneous rupture of membranes at term. Obstet Gynecol.
1989;74:937.

The author stated that there are no conflicts of interest regarding

the publication of this article.

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