New RCOG Guideline: If No Complication or Infection Deliver at 37 Weeks in PPROM

Becky McCall

June 19, 2019

LONDON – The optimal time to give birth, and greater involvement of the parents across care in cases of Preterm Prelabour Rupture of Membranes (PPROM), are central to a new guideline on PPROM from the Royal College of Obstetricians & Gynaecologists (RCOG), released this week.

Essentially, if a mother with PPROM does not go into labour, she should be offered the choice to continue with the pregnancy until 37 weeks of gestation — as long as there are no signs of infection or complications.

The revised guideline focusses on the diagnosis, assessment, care and timing of birth following PPROM from 24 +0 weeks and until 36 +6 weeks of gestation.

The guideline was launched here at the World Congress of the RCOG.

Further Detail and Recommendation for Daily Practice

Dr Andrew Thomson, consultant obstetrician and gynaecologist, at The Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, chaired the RCOG Guidelines Committee. He authored the RCOG Green-top Guideline: Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks of Gestation.

In 2015, the National Institute of Health and Care Excellence (NICE) published a guideline on preterm labour and birth (NICE NG25). The new RCOG guideline on PPROM launched this week complements that.

"Having archived many of the RCOG guidelines around preterm labour and birth after the 2015 NICE guidelines became available, it became clear that professionals needed some further detail and recommendation for daily practice, and specifically regarding PPROM," Dr Thomson explained.

Within the guideline is a recommendation on what to do if the diagnosis of PPROM is not confirmed, and for those confirmed cases, best care for mother and baby during birth.

PPROM occurs when the membranes rupture before 37 weeks of gestation, but the woman does not establish labour. "PPROM complicates 3% of pregnancies. I see one or two cases of PPROM per week in my maternity unit," asserted Dr Thomson.

Some aspects of the new guideline reinforce aspects of previous guidelines and/or the 2015 NICE guideline, for example, use of an antibiotic for 10 days or until labour has been established.

The guideline recommends that if on speculum examination, no amniotic fluid is observed, an insulin-like growth factor-binding protein 1 (IGFBP-1) or placental alpha microglobulin-1 (PAMG-1) test of vaginal fluid should be considered to guide further management. "Here in Scotland we don't have these tests, so we point out that the tests should be used in combination with the mother's history, taking all information together, these tests might be useful," said Dr Thomson.

Regarding steroid use, there is some change since the NICE guideline. "Where possible we supplement that evidence [NICE] but since publication of the NICE guideline, new studies show evidence that corticosteroids are effective if given from 24 weeks to 26 weeks. Our new guideline recommends that women who have PPROM between 24+0 and 33+6 weeks' gestation should be offered corticosteroids, and that steroids can be considered up to 35+6 weeks' gestation," said Dr Thomson. Steroid injections help to avoid respiratory problems, cerebral haemorrhage, and necrotising enterocolitis.

If in PPROM, labour becomes established or there is a decision to have a planned preterm birth within 24 hours there is a recommendation to offer intravenous magnesium sulphate between 24+0 and 29+6 weeks of gestation. Magnesium sulphate infusion into the mother reduces the chance of the baby developing cerebral palsy and motor dysfunction, with greatest effect at less than 30 weeks' gestation, explained Dr Thomson.

"The biggest change in this guideline relates to when the optimal time is to deliver a baby after PPROM," said Dr Thomson. The last version of the RCOG guideline recommended that risk of prematurity and infection balance out when the woman reaches 34-35 weeks, he added, but since then a Cochrane Review recommends that the baby has better outcomes if the pregnancy continues to 37 weeks.

"It's a key point to note that this doesn't apply to all women. In some cases, it might be better to deliver early. If there are signs of infection then the baby must be delivered because antibiotics will not stop established infection, if the mother continues to bleed, or if the baby is not growing then it is better to deliver and not wait to 37 weeks," he stressed. The guideline notes that the timing of birth should be discussed with each woman on an individual basis with careful consideration of patient preference and ongoing clinical assessment.

Dr Thomson highlighted that studies show that PPROM is associated with an increased risk of post-traumatic stress disorder (PTSD) in the mother compared to uncomplicated controls (14% vs. 2%). "PPROM can be incredibly stressful for the mother due to the uncertainty around whether the baby is okay, will she get infected, will baby need to go to the NICU. So as a result the recommendation suggests that: "Women with PPROM and their partners should be offered additional emotional support during pregnancy and postnatally," said Dr Thomson.

'Important Guideline'

Lia Brigante, quality and standards advisor at the Royal College of Midwives (RCM) commented on the new guideline: "This is important guidance that will help to improve the care and safety of pregnancies for women. We urge maternity services to use it.

"As the guidance says, emotional support for the woman and her family is vital during and after the pregnancy. It is important that our maternity services have the staff and the resources to ensure that this kind of support is available. Midwifery continuity of carer - when a woman sees the same midwife or group of midwives – has been shown to reduce preterm births. It is good to see the guidance recognising and recommending this."

Ciara Curran and Rachel Johnson, directors of the Little Heartbeats support group, also commented on the study: "Women have rarely heard of PPROM before it happens to them and understanding of the condition and how to manage it is inconsistent across the medical profession.

"When waters break early in pregnancy it can be a really emotionally challenging time for parents and the choices that need to be made can be extremely difficult. It is essential that women and their partners are provided with all the information they need to make informed decisions, and with ongoing emotional support."

Published on 17 June, 2019 in the International Journal of Obstetrics and Gynaecology (BJOG).

COI: Dr Thomson and Ms Brigante have declared no conflicts. Ciara Curran and Rachel Johnson were involved in drafting the guidelines.

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