South Australian Perinatal Practice Guideline

Preterm Prelabour Rupture of

Membranes (PPROM) © Department for Health and Wellbeing, Government of South Australia. All rights reserved.

Note:
This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and
facilitate standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based
on a review of published evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site
and does not sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details of each
patient and professionally assess the applicability of the relevant guideline to that clinical situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must
document in the patient’s medical record, the decision made, by whom, and detailed reasons for the departure
from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the individual
clinicians are responsible for discussing care with consumers in an environment that is culturally appropriate
and which enables respectful confidential discussion. This includes:
• The use of interpreter services where necessary,
• Advising consumers of their choice and ensuring informed consent is obtained,
• Providing care within scope of practice, meeting all legislative requirements and maintaining
standards of professional conduct, and
• Documenting all care in accordance with mandatory and local requirements
Note: The words woman/women/mother/she/her have been used throughout this guideline as most pregnant
and birthing people identify with their birth sex. However, for the purpose of this guideline, these terms include
people who do not identify as women or mothers, including those with a non-binary identity. All clinicians should
ask the pregnant person what their preferred term is and ensure this is communicated to the healthcare team.

Explanation of the aboriginal artwork:

The Aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the Aboriginal culture. The
horse shoe shape design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant woman. The
smaller horse shoe shape in this instance represents the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and
demonstrates the need to move forward together in unison.

Australian Aboriginal Culture is the oldest living culture in the world yet
Aboriginal people continue to experience the poorest health outcomes when
compared to non-Aboriginal Australians. In South Australia, Aboriginal women are
2-5 times more likely to die in childbirth and their babies are 2-3 times more likely to
be of low birth weight. The accumulative effects of stress, low socio economic
status, exposure to violence, historical trauma, culturally unsafe and discriminatory
health services and health systems are all major contributors to the disparities in
Aboriginal maternal and birthing outcomes. Despite these unacceptable statistics,
the birth of an Aboriginal baby is a celebration of life and an important cultural
event bringing family together in celebration, obligation and responsibility. The
diversity between Aboriginal cultures, language and practices differ greatly and so
it is imperative that perinatal services prepare to respectfully manage Aboriginal
protocol and provide a culturally positive health care experience for Aboriginal
people to ensure the best maternal, neonatal and child health outcomes.

Purpose and Scope of Perinatal Practice Guideline (PPG)

Guidance for the management of Preterm Pre-labour Rupture of Membranes (PPROM).
For additional information and management of preterm labour, see the Preterm Labour
and Birth, Prevention, Diagnosis & management PPG.

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Flowchart 1 | Assessment and Management of Preterm Prelabour

Rupture of Membranes (PPROM)

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Table of Contents

Purpose and Scope of Perinatal Practice Guideline (PPG) ........................................................................ 1

Preterm Prelabour Rupture of Membranes ................................................................................................. 2
Flowchart 1 | Assessment and Management of Preterm Prelabour Rupture of Membranes (PPROM) ... 2
Preterm Prelabour Rupture of Membranes ................................................................................................. 4
Abbreviations ............................................................................................................................................. 4
Introduction ................................................................................................................................................ 4
Definition .................................................................................................................................................... 4
Associated risks of PPROM ...................................................................................................................... 4
Preterm Prelabour Rupture of Membranes ................................................................................................. 5
Initial Assessment ...................................................................................................................................... 5
Transfer or retrieval for access to specialised obstetric and neonatal services ....................................... 5
Surveillance / Fetal assessment .............................................................................................................. 5
Laboratory investigations ......................................................................................................................... 5
Antibiotic prophylaxis ................................................................................................................................ 5
Preterm Prelabour Rupture of Membranes ................................................................................................. 6
Signs of Chorioamnionitis......................................................................................................................... 6
If there are signs of chorioamnionitis ....................................................................................................... 6
Preterm Prelabour Rupture of Membranes ................................................................................................. 7
Preterm Prelabour Rupture of Membranes ................................................................................................. 8
Magnesium sulphate for neuroprotection of the fetus ............................................................................... 8
Controlled trials ........................................................................................................................................ 8
Indications ................................................................................................................................................ 8
Dosage and administration....................................................................................................................... 8
Counselling ............................................................................................................................................... 8
Preterm Prelabour Rupture of Membranes ................................................................................................. 9
Management .............................................................................................................................................. 9
PPROM < 23 weeks gestation ................................................................................................................. 9
PPROM 23-34 weeks gestation ............................................................................................................... 9
Preterm Prelabour Rupture of Membranes ............................................................................................... 10
Preterm Prelabour Rupture of Membranes ............................................................................................... 11
Preterm Prelabour Rupture of Membranes ............................................................................................... 12
References ................................................................................................................................................ 12
Preterm Prelabour Rupture of Membranes ............................................................................................... 13
Acknowledgements.................................................................................................................................... 13
Document Ownership & History ................................................................................................................ 14

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Abbreviations
C Celsius
CRP C- reactive protein
CTG Cardiotocography
et al. And others
g Gram(s)
> Greater than
GBS Group B Streptococcus
IM Intramuscular
IV Intravenous
kg Kilogram/s
< Less than
mL Millilitre/s
mg Milligram/s
PPROM Preterm prelabour of the membranes
i.e. That is

Introduction
 PPROM complicates only 2 % of pregnancies but is associated with 40 % of preterm deliveries and
can result in significant neonatal morbidity and mortality
 The three causes of neonatal death associated with PPROM are:
o Prematurity
o Sepsis
o Pulmonary hypoplasia
 Outcomes for preterm infants depend on place of birth and access to neonatal intensive care.
Maternal transfer is generally safer than neonatal retrieval if delivery is not imminent

Definition
 Rupture of the fetal membranes before 37+0 completed weeks of pregnancy (i.e. preterm) and
before the onset of labour (i.e. prelabour)

Associated risks of PPROM

 Preterm labour
 Cord prolapse
 Placental abruption
 Intrauterine infection / amnionitis
 Pulmonary hypoplasia
 Limb positioning defects
 Perinatal mortality

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Initial Assessment
 History and examination
 Abdominal palpation to determine fetal size and presentation
 Speculum examination to:
o Exclude cord prolapse
o Visualise pooling of liquor (note presence of vernix)
o Collect cervical and vaginal microbiological swabs (including GBS)
o Estimate cervical dilatation
Use available testing modality to confirm ROM:
o Amnicator (nitrazine yellow): a positive reaction results in a blue / purple colour on
contact (false positive rate of 17 %)
o Make a smear to look for ferning on microscopical examination
o Actim®PROM, AmniSure®, ROMPlus®

Transfer or retrieval for access to specialised obstetric and neonatal services

 In units without neonatal facilities suitable for the gestation, consult with tertiary centre. Consider
maternal transfer if delivery is not imminent or consult with neonatal retrieval service if delivery is
anticipated

Surveillance / Fetal assessment

 Cardiotocography (CTG) to assess fetal condition
 Ultrasound to assess liquor volume (and visualise presentation)
 Consider formal ultrasound for fetal number, weight, presentation, morphology and liquor volume

Laboratory investigations
 C-Reactive Protein – repeat daily for three days
 Complete blood picture – repeat daily for three days
 Low and high vaginal swabs for microscopy and culture
 Midstream specimen of urine for bacteriology

Antibiotic prophylaxis
 Studies show that prophylactic antibiotics prolong pregnancy and reduce maternal and neonatal
sepsis (Kenyon et al. 2003)

Refer to Antibiotics in the Peripartum Period PPG for guidance on most

appropriate antibiotic choice for the individual woman.

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Signs of Chorioamnionitis
 The diagnosis of chorioamnionitis relies on the clinical presentation and may be difficult in its early
manifestations
 The clinical picture may include maternal fever with two or more of the following:
 Increased white cell count (> 15 x 109 / L)

 Maternal tachycardia (> 100 bpm)

 Fetal tachycardia (>160 bpm)

 Uterine tenderness

 Offensive smelling vaginal discharge

 C-Reactive Protein > 40

 Consideration should also be given to check for any other site of infection (e.g. urinary or
respiratory tract) which could cause these changes
 If in doubt consultation with a senior obstetrician, maternal fetal medicine or infectious disease
physician should be considered
 Histological examination of placenta and membranes with evidence of acute inflammation may
confirm the diagnosis after birth

If there are signs of chorioamnionitis

 Do not inhibit labour, but consider hastening delivery under intravenous antibiotic cover
 Consider optimal mode of delivery (LSCS versus vaginal birth) on the basis of the findings and the
anticipated duration until birth

Tocolytics
 Where contractions are present, nifedipine may be commenced (for further information see
‘nifedipine for preterm labour’ in the A to Z index at www.sahealth.sa.gov.au/perinatal) to prolong
pregnancy for 48 hours while corticosteroid cover is established if there are no other signs of
chorioamnionitis
 Give stat oral dose nifedipine 20 mg

 Give second oral dose nifedipine 20 mg 30 minutes after first dose (maximum is 40
mg in the first hour)

 Do not give any further nifedipine until 3 hours after the 2 nd dose

 Administer oral nifedipine 20 mg every 3 hours until contractions cease or the woman
establishes in labour. Prescribe as written (do not prescribe as prn)
 After 24 hours, medical review is required to determine the dose of maintenance
treatment with controlled release nifedipine (Adalat® Oros) 2-3 times per day
 For further information see ‘nifedipine for preterm labour’ in the A to Z index at
www.sahealth.sa.gov.au/perinatal

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Corticosteroids22,23
 Corticosteroids are effective in preventing adverse perinatal outcomes, most notably
respiratory distress syndrome, and in increasing the likelihood of neonatal survival 22
 Repeated doses of corticosteroids reduce the occurrence and severity of neonatal lung
disease and the risk of serious health problems in the first few weeks of life 22

Indications
Single course
 Gestational age is between 23+0 and 34+6 weeks and in PTL
 Risk of preterm imminent birth
 Preterm birth is planned or expected within the next seven days
Dosage
 Administer IM betamethasone in two doses of 11.4 mg (5.7 mg x 2)
24 hours apart to the woman
 If betamethasone is unavailable, give IM dexamethasone in two
doses of 12 mg, 24 hours apart22
 Where appropriate, estimate the risk of preterm birth by considering
the use of adjunct prediction tests including fetal fibronectin and
assessment of cervical length

Repeat Indications
course(s)  When the gestational age is 32+6 days or less, a repeat antenatal
corticosteroid dose may be given 7 days or more after the first course
in women still considered at risk of early preterm birth
Dosage
 Either: A single repeat dose of IM betamethasone 11.4 mg IM (5.7
mg x 2)
 OR A single repeat course of IM betamethasone in two doses of 11.4
mg (5.7 mg x 2) 24 hours apart
 If betamethasone is unavailable, give IM dexamethasone 12 mg
 Seven days after the first, single, repeat dose (and less than 14 days
Further repeat since the first repeat dose), if the woman is still considered to be at
single dose(s) risk of preterm birth within the next seven days, a further, single,
repeat dose of antenatal corticosteroids ( IM betamethasone 11.4 mg
IM [5.7 mg x 2]) can be given
 Use up to a maximum of three, single, repeat doses only
 NB: Do not give any further repeat courses if a single repeat course
(11.4 mg, as two intramuscular doses, 24 hours apart) of
betamethasone has been given already

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Magnesium sulphate for neuroprotection of the fetus

Controlled trials
 Show that fetal exposure to magnesium sulphate given before preterm birth has a neuroprotective
role. The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is
63 (Doyle et al. 2009)
 This systematic review also showed a significant reduction in the rate of gross motor dysfunction in
early childhood (Doyle et al. 2009)

Indications
 Neuroprotection of the fetus for women at risk of preterm birth who are at least 24 +0 weeks of
gestation and < 30+0 weeks of gestation
 When birth is anticipated within 24 hours or in cases of expected planned delivery as close to four
hours before expected delivery time and regardless of;
 plurality
 why the woman is at risk of preterm birth
 parity
 anticipated mode of birth
 whether antenatal corticosteroids have been given or not

Dosage and administration

 See Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus in the A
to Z index at www.sahealth.sa.gov.au/perinatal

Counselling
 The woman and her partner should be counselled by a member of the management team, which
includes: obstetrician, neonatologist, midwife, and others as appropriate

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Management
PPROM < 23 weeks gestation
 Outcomes for extremely preterm infants depend on place of birth and access to neonatal intensive
care
 It is important to consult with neonatologists for up to date data to inform clinical decision making
 Parental attitudes must be taken into account in formulating a management plan
 Continue antibiotic prophylaxis (as above)

Active management (i.e. allow / encourage birth to proceed) when

 In established labour
 Signs of chorioamnionitis are present
 Significant antepartum haemorrhage is present
 The woman requests it

Expectant management
 Is acceptable when the risk of amnionitis and pulmonary hypoplasia is less than the risk of extreme
preterm birth and neonatal death
 If delivery does not occur, further benzylpenicillin prophylaxis is indicated when labour recurs
 Repeat high vaginal swab at weekly intervals; results may guide use of antibiotics in any
subsequent labour
 Complete blood picture and C-Reactive Protein twice weekly

PPROM 23-34 weeks gestation

 Continue antibiotic prophylaxis (as above)
 Expectant management until 34 weeks of gestation if GBS positive

Active management (i.e. allow / encourage birth to proceed) when

 In established labour
 Signs of chorioamnionitis are present
 Significant antepartum haemorrhage is present
 Signs of fetal compromise
 Consider caesarean section if birth is not imminent

Expectant management
 May be appropriate in the absence of the above. This management should include:
 Daily medical clinical assessment of the woman
 Clinical observations twice daily

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 Temperature, maternal pulse, fetal heart rate

 PV loss

 Assessment of uterine activity (abdominal pain or tenderness)

 Involving a neonatologist
 If delivery does not occur, further benzylpenicillin prophylaxis is indicated when labour recurs
 Facilitating education including:
 Neonatology review

 Neonatal intensive care tour

 Appropriate preterm birth DVD / video

Surveillance / fetal assessment

 CTG daily for the first 3-6 days, then twice per week if low risk inpatient or at home
 CTG should be reconsidered where regular fetal surveillance is required (RCOG 2006)
 Recommence CTG in the presence of:
 Regular abdominal pains or tenderness

 change in amount, colour of liquor

 Antepartum haemorrhage

Investigations
 Complete blood picture (CBP), C- reactive protein (CRP) daily for 3 days
 Consecutive daily CRP values > 20 mg / L or isolated values > 40 mg / L are suggestive of
infection
 Twice weekly after initial assessment
Vaginal swabs

 Repeat high vaginal swab at weekly intervals; results may guide use of antibiotics in any
subsequent labour

PPROM at 34-37 weeks gestation

 Continue antibiotic prophylaxis (see above)
 Studies are currently in progress to establish whether to recommend expectant or active
management for women with PPROM between 34 to 36 completed weeks of gestation

Active management (i.e. allow / encourage birth to proceed) when

 In established labour
 Signs of chorioamnionitis are present
 Significant antepartum haemorrhage is present

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 If GBS positive, active management after 36 completed weeks of gestation

 Signs of fetal compromise
 Consider caesarean section if birth is not imminent

Expectant management consists of

 Await spontaneous onset of labour until 36 completed weeks of gestation
 Continue prophylactic antibiotic treatment
 Home care may be considered

Surveillance / fetal assessment

 CTG daily for the first 3-6 days, then twice per week if low risk inpatient or at home
 CTG should be reconsidered where regular fetal surveillance is required (RCOG 2006)
 Recommence CTG in the presence of:
 Regular abdominal pains or tenderness

 change in amount, colour of liquor

 Antepartum haemorrhage

Home care
 May be considered for all women after 72 hours of initial hospitalisation if:
 Singleton pregnancy

 Cephalic presentation > 23 weeks

 Easy access to the hospital

Continue
 Daily temperature
 Twice weekly follow up CTG and investigations as an outpatient
 Return to hospital if reduced fetal movements

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References

1. Royal College of Obstetricians and Gynaecologists (RCOG). Preterm prelabour rupture of

membranes. RCOG guideline No. 44, October 2010. Available from URL:
https://www.rcog.org.uk/
2. Kenyon S, Boulvain M, Neilson JP. Antibiotics for preterm rupture of membranes. Cochrane
Database of Systematic Reviews 2013, Issue 12. Art. No.: CD001058. DOI:
10.1002/14651858.CD001058.pub3. (Level I). Available from URL:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001058/pdf_fs.html
3. Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for
women at risk of preterm birth. Cochrane Database of Systematic Reviews 2006, Issue 3.
Art. No.: CD004454. DOI: 10.1002/14651858.CD004454.pub2 (Level I). Available form
URL:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004454/pdf_fs.html
4. Crowther CA, McKinlay CJD, Middleton P, Harding JE. Repeat doses of prenatal
corticosteroids for women at risk of preterm birth for improving neonatal health outcomes.
Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD003935. DOI:
10.1002/14651858.CD003935.pub3. (Level I). Available from URL:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003935/pdf_fs.html
5. Antenatal Corticosteroid Clinical Practice Guidelines Panel. Antenatal corticosteroids given
to women prior to birth to improve fetal, infant, child and adult health: Clinical Practice
Guideines. 2015. Liggins Institute, The University of Auckland, Auckland. New Zealand.
Available from URL: www.ligginstrials.org/ANC_CPG
6. Doyle LW, Crowther CA, Middleton P, Marret S, Rouse D. Magnesium sulphate for women
at risk of preterm birth for neuroprotection of the fetus. Cochrane Database of Systematic
Reviews 2009, Issue 1. Art. No.: CD004661. DOI: 10.1002/14651858.CD004661.pub3
(Level I). Available from URL:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004661/pdf_fs.html
7. The Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel.
Antenatal magnesium sulphate prior to preterm birth for neuroprotection of the fetus, infant
and child: National clinical practice guidelines. Adelaide: The University of Adelaide, 2010.
ISBN Print: 978-0-86396-720-7. Available from URL: http://www.adelaide.edu.au/arch/
8. MIMS Online. MIMS Pharmaceutical Product Information. [online database] Full product
information Adalat® tablets data version August 2010 [cited 2010 Aug 16]. Available: MIMS
Online. (Level I).
9. Enkin M, Keirse MJNC, Neilson J, Crowther C, Duley L, Hodnett E, Hofmeyr J. A guide to
effective care in pregnancy and childbirth. 3rd ed. Oxford: Oxford University Press; 2000
(Level I).
10. Ryan G, Oskamp M, Seaward PGR, Kitch T, Barrett T, Brennan B, Salenieks ME, O’Brien K.
Randomized controlled trial of inpatient vs. outpatient management of PPROM. Am J Obstet
Gynecol 1999; 180: S95 (Level II).
11. Segal S, Miles A, Clothier B, Parry S, Macones G. Optimal duration of antibiotic therapy after
PPROM [abstract]. Am J Obstet Gynecol 2002; 187: S72 (Level II).

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Acknowledgements
The South Australian Perinatal Practice Guidelines gratefully acknowledge the contribution of
clinicians and other stakeholders who participated throughout the guideline development process
particularly:

SAPPG Management Group Members

Sonia Angus
Lyn Bastian
Dr Elizabeth Beare
Elizabeth Bennett
Dr Feisal Chenia
John Coomblas
Dr Danielle Crosby
Dr Scott Morris
Dr Ray Farley
Allison Waldron
Dr Charlotte Taylor
Rosina Gergis
Dr Anupam Parange
Marnie Aldred
Dr Michael McEvoy

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Document Ownership & History

Developed by: SA Maternal, Neonatal & Gynaecology Community of Practice
Contact: [email protected]
Endorsed by: Domain Custodian, Clinical Governance, Safety and Quality
Next review due: 07/09/20
ISBN number: 978-1-76083-573-6
PDS reference: PPG022
Policy history: Is this a new policy (V1)? N
Does this policy amend or update and existing policy? Y
If so, which version? 10
Does this policy replace another policy with a different title? N
If so, which policy (title)?

Approval Who approved New/Revised

Version Reason for Change
Date Version
New template
Change in Antibiotic
Domain Custodian, Clinical
3/08/22 V10.1 Prophylaxis. Removed and
Governance, Safety and Quality
referred to Peripartum
Antibiotics PPG.
SA Health Safety and Quality Strategic
7/09/15 V10 Reviewed
Governance Committee
SA Health Safety and Quality Strategic
20/05/14 V9 Reviewed
Governance Committee
SA Maternal and Neonatal Clinical
22/05/12 V8 Reviewed
Network
SA Maternal and Neonatal Clinical
18/10/10 V7 Reviewed
Network
SA Maternal and Neonatal Clinical
25/05/10 V6 Reviewed
Network
SA Maternal and Neonatal Clinical
30/12/08 V5 Reviewed
Network
SA Maternal and Neonatal Clinical
20/09/07 V4 Reviewed
Network
SA Maternal and Neonatal Clinical
19/03/07 V3 Reviewed
Network
SA Maternal and Neonatal Clinical
26/02/07 V2 Reviewed
Network
SA Maternal and Neonatal Clinical
10/05/04 V1 Original approved version.
Network

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