Premature rupture of membranes — MSF Essential obstetric and newborn care

What this guideline says

GMJ summary

This MSF clinical guideline addresses premature rupture of membranes (PROM), defined as discharge of amniotic fluid before labour onset. Diagnosis is confirmed by speculum examination showing pooled or leaking fluid. Key risks include intrauterine infection, cord prolapse and preterm birth if rupture occurs before 37 weeks.

Management depends on gestational age, presence of infection and labour status. Prophylactic antibiotics are indicated for preterm PROM without infection (amoxicillin 1 g three times daily for 7 days), during labour at term if membranes ruptured ≥12 hours (ampicillin IV), and therapeutically if infection present (triple therapy with ampicillin, metronidazole and gentamicin). Tocolytics are contraindicated when infection is suspected and after 34 weeks.

Induction of labour is recommended 12–24 hours after membrane rupture at term if labour has not started spontaneously, and immediately if infection develops. For preterm PROM without complications, expectant management until 37 weeks is advised, with corticosteroids for lung maturation between 26–34 weeks. Transfer to facilities with neonatal intensive care capability is recommended for preterm cases.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Confirm diagnosis with speculum examination: look for fluid pooling in vagina or leaking from cervical os when patient coughs
2. For preterm PROM (<37 weeks) without infection or labour: amoxicillin 1 g orally three times daily for 7 days (do not use amoxicillin/clavulanic acid)
3. For term PROM (≥37 weeks) with membrane rupture ≥12 hours: ampicillin IV 2 g loading dose, then 1 g every 4 hours during labour until delivery
4. If infection present: ampicillin IV 2 g every 8 hours plus metronidazole IV 500 mg every 8 hours plus gentamicin IM 5 mg/kg once daily
5. Administer dexamethasone IM 6 mg every 12 hours for 48 hours for lung maturation between 26–34 weeks gestation
6. Use tocolytics only before 34 weeks and never when intrauterine infection is suspected
7. At term with no infection: induce labour 12–24 hours after rupture if labour does not start spontaneously
8. For preterm PROM without complications: expectant management until induction at 37 weeks; transfer to facility with neonatal intensive care if possible

Antibiotic therapy for premature rupture of membranes

Table extracted from the guideline

Source: Médecins Sans Frontières, Premature rupture of membranes — MSF Essential obstetric and newborn care. Reproduced in summary form.

From the guideline

Verbatim

“Never administer a tocolytic agent, no matter what the gestational age, when intra-uterine infection is suspected.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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