1. Expectant management
In pprom

2. Administration of antenatal corticosteroids
A course of corticosteroids should be given to pregnancies between and 34 weeks of gestation

3. Up to date:
A single course of "rescue" therapy is reasonable if the patient is clinically estimated to be at high risk of delivery within the next seven days, at least two weeks have passed since the initial course of antenatal corticosteroids, and the initial course was given at <28 weeks of gestation.
ACOG:
to administer a rescue course of corticosteroids with
PROM is controversial, and there is insufficient evi-
dence to make a recommendation for or against.

4. Antibiotic therapy
The regimen of prophylactic antibiotics is given for seven days to patients at <34 weeks of gestation at the time of membrane rupture.  

5. We recommend administering a seven-day course of antibiotic prophylaxis to all women with PPROM who are managed expectantly. Our preference is ampicillin 2 g intravenously every 6 hours for 48 hours, followed by amoxicillin (500 mg orally three times daily or 875 mg orally twice daily) for an additional five days
In addition, we recommend giving one dose of azithromycin (one gram orally) upon admission
(intravenous ampicillin 2 g every 6 hours and erythromycin 250 mg every 6 hours for 48 hours followed by oral amoxicillin 250 mg every 8 hours and erythromycin 333 mg every 8 hours for five days)

6. Chemoprophylaxis for GBS
Chemoprophylaxis specifically for GBS disease is indicated if GBS test results are positive or unknown and delivery is imminent, but is generally not given to women with recent (within five weeks) negative GBS test results.

7. after completion of this regimen, antibiotics should be discontinued
after completion of this regimen, antibiotics should be discontinued. If the patient’s GBS culture is positive, specific prophylaxis for GBS colonization should be resumed when the patient subsequently goes into labor

8. Use of tocolysis
As a general rule, tocolytics should not be administered for more than 48 hours. 

9. They also should not be administered to patients who are
in advanced labor (>4 cm dilation)
or who have any findings suggestive of subclinical or overt chorioamnionitis.
nonreassuring fetal testing,
abruptio placentae,
and significant risk of cord prolapse

10. Should magnesium sulfate for fetal neuro- protection be administered to patients with preterm PROM
maternal administration of magnesium sulfate used for fetal neuroprotection when birth is anticipated before 32 0/7 weeks of gestation reduces the risk of cerebral palsy in surviving infants

11. Supplemental progesterone
Progesterone supplementation is not beneficial in women with PPROM in the current pregnancy
In women who are on supplemental progesterone because of a prior pregnancy with preterm delivery related to preterm labor or PPROM, we discontinue the medication upon diagnosis of PPROM.

12. Hospitalization versus home care
We hospitalize women with PPROM who have a viable fetus from the time of diagnosis until delivery, with few exceptions

13. Activity is limited to using the bathroom and sitting up in a bedside chair. Thromboprophylaxis in the form of sequential compression devices should be provided to all hospitalized pregnant women at bedrest
We also administer prophylactic doses of enoxaparin (1 mg/kg/day) to patients who have additional risk factors for deep vein thrombosis. Ideally, enoxaparin should be discontinued 48 hours prior to anticipated delivery.
Activity is limited to using the bathroom and sitting up in a bedside chair. Thromboprophylaxis in the form of sequential compression devices should be provided to all hospitalized pregnant women at bedrest

14. Maternal and fetal monitoring

15. Women with PPROM should be monitored for signs of infection; however, there is no consensus as to the best approach.
maternal temperature, uterine tenderness and contractions, maternal and fetal heart rate)
Periodically monitoring white blood cell counts or other markers for inflammation/infection has not been proven useful
We do not routinely perform amniocentesis to screen for intraamniotic infection in asymptomatic women

16. Fetal monitoring 
 Some type of fetal surveillance is generally employed (eg, kick counts, NSTs, biophysical profile [BPP]) to provide the clinician and patient some assurance of fetal well-being
However, none of these tests has good sensitivity for predicting fetal infection, even when performed daily
There is no consensus among experts regarding the optimum type and frequency of testing.
Doppler surveillance is not useful for monitoring fetal status in PPROM

17. Women with HSV, HIV, or cerclage
Special situations
Women with HSV, HIV, or cerclage

18. Removal of cerclage after PPROM
the gestational age at PPROM was the most important determinant of neonatal outcome
Based on the available, limited data and our own clinical experience, we remove the cerclage in women with PPROM if
(1) there is any evidence of chorioamnionitis or
(2) the pregnancy is at least 32 weeks of gestation.

19. HSV and Preterm premature rupture of membranes
Recurrent HSV infection and PPROM
Limited evidence supports expectant management for PPROM in the second trimester in women with active recurrent genital herpes. In the third trimester, the risk associated with prematurity (which varies by gestational age) must be balanced with the risk for in utero infection on a case-by-case basis. If delay of delivery is appropriate because of concerns about gestational age remote from term, we suggest administering intravenous acyclovir (5 mg/kg every 8 hours) to shorten the duration of active lesions in the mother and to decrease viral burden. However, the ability of acyclovir to prevent maternal-fetal transmission has not been proven.

20. Primary or first episode genital HSV infection and PPROM
Given the absence of data to inform decision-making, it is difficult to weigh the risks of in utero infection against the risks associated with preterm delivery, which vary significantly by the week of gestation. In light of the high risk for fetal transmission during primary infection [9] and the high risk for neonatal morbidity/mortality in infected fetuses, some authors suggest prompt cesarean delivery of pregnancies ≥28 weeks of gestation in an attempt to minimize the risk for fetal infection; others use a threshold of ≥32 weeks. The neonate is then treated with acyclovir and surfactant.

21. The risk of vertical transmission with delivery in primary HSV is reported to be between 30% and 50%, compared with only 3% in cases of recurrent HSV
The risk of prematurity should be weighed against
the potential risk of neonatal HSV infection. In the set-
ting of PROM with recurrent active infection, expectant
management is recommended before 34 0/7 weeks of
gestation. Herpes simplex virus therapy should be initi-
ated, and corticosteroids, antibiotics, and magnesium
sulfate for neuroprotection should be provided as clini-
cally indicated. If active disease or prodromal symptoms
are present at the onset of labor or when delivery is indi-
cated, cesarean delivery is recommended.
ACOG

22. HIV and PPROM
The presence of HIV infection of the mother should not change management.
Administration of antenatal corticosteroids
 When the decision is made to deliver, route of delivery should be according to obstetrical indications.

23. Twin pregnancy  
The management of PPROM in twin pregnancies is similar to that in singletons.
Delayed-interval delivery in multifetal pregnancy

24. We believe the best candidates for delayed-interval delivery are pregnancies at an early gestational age (<24 weeks) in which only the first (presenting) fetus delivers due to preterm labor, cervical insufficiency, premature rupture of membranes, or intrauterine demise
We do not offer delayed-interval delivery to women with pregnancy complications associated with a high risk of serious maternal or fetal injury (eg, severe preeclampsia, abruptio placentae, intraamniotic infection of the nonpresenting fetus) or gestational age ≥28 weeks.

25. The counseling and consent process should address the risks and benefits of delayed-interval delivery, including the possibility and consequences of extending the pregnancy from a previable to a periviable gestational age; the risk of maternal, fetal, and/or neonatal infection, as well as potential sequelae of infection; and the option of not attempting delayed-interval delivery. ●Prior to an attempt at delayed-interval delivery, we perform amniocentesis to exclude subclinical microbial invasion of the amniotic fluid of the proposed retained sibling

26. What is the expected outcome of PROM after second-trimester amniocentesis?
the risk of PROM is approximately 1% .
In contrast to patients with spontaneous PROM in the second trimester, re accumulation of normal amniotic fluid volume and favorable outcomes are expected.
After appropriate counseling, patients with PROM after genetic amniocentesis typically are managed expectantly as outpatients. Precautions regarding symptoms of chorio amnionitis and miscarriage should be given. Regular follow-up visits with ultra sonographic examinations to assess amniotic fluid volume are recommended

27. How should a patient with a history of preterm PROM be managed in future pregnancies?
Patients with prior preterm PROM have an increased risk of recurrent PROM and preterm birth, and a detailed medical history should be taken.
However, given the potential benefit of progesterone therapy, women with a single gestation and a prior spontaneous preterm birth (due to either labor with intact membranes or PROM) should be offered progesterone supplementation starting at 16 weeks to 24 weeks of gestation to reduce the risk of recurrent spontaneous preterm birth.

28. Although vaginal ultrasonographic measurement of the cervix is a safe and reliable means of evaluating the risk of preterm birth related to cervical length, there have been no well- designed trials of cervical surveillance in women with a history of PROM.
Similar to the progesterone studies, women with prior PROM were included in trials that evaluated cervical assessment, vaginal progesterone,
and cerclage but their specific data were not reported