Chapter 31 – Premature Rupture of the Membranes

Brian M. Mercer, MD Rupture of the fetal membranes is an integral part of the normal parturition process at term and is inevitable in the process of preterm birth. Spontaneous rupture of the membranes (SROM) at term and preterm can occur any time before or after the onset of contractions. SROM before the onset of contractions is referred to as premature rupture of the membranes (PROM). Membrane rupture at term usually occurs as a result of a physiologic process of progressive membrane weakening. Preterm PROM generally results from pathologic weakening of the fetal membranes, which has several causes. Although delivery after PROM may be required by the presence of advanced labor, intrauterine infection, vaginal bleeding due to placental abruption, or non-reassuring fetal status, the physician often needs to make the decision whether to actively pursue delivery or conservatively manage the pregnancy. Management of PROM hinges on knowledge of gestational age, the neonatal risks related to immediate delivery, and an understanding of the anticipated clinical course and relative risks of intrauterine infection, abruptio placentae, and fetal distress or death from umbilical cord accident or intrauterine infection with conservative management.

Physiology and Pathophysiology of Membrane Rupture
The fetal membranes consist of the amnion, which lines the amniotic cavity, and the thicker chorion, which adheres to the maternal decidua. Initially, the amnion and chorion are separate layers. The amnionic sac is visible on first trimester ultrasound scans until it fuses with the chorion by the end of the 14th week of gestation. Subsequently, the amnion and chorion are connected by a collagen-rich connective tissue layer, with the amnion represented by a single cuboidal epithelial amnion layer and subjacent compact and spongy connective tissue layers, and a thicker chorion consisting of reticular and trophoblastic layers. Together, the amnion and chorion form a stronger unit than either layer individually. Physiologic membrane remodeling occurs with advancing gestational age, reflecting changes in collagen content and type, changes in intercellular matrix, and progressive cellular apoptosis. These changes lead to structural weakening of the membranes, which is more evident in the region of the internal cervical os.[1–8] Membrane weakening can be stimulated by exposure to local matrix metalloproteinases (e.g., MMP-1, MMP-2, MMP-9), decreased levels of membrane tissue inhibitors of matrix metalloproteinases (e.g., TIMP-1, TIMP-3), and increased poly[ADP-ribose]polymerase (PARP) cleavage.[6,9] Term or preterm uterine contractions can also lead to membrane rupture resulting from increased bursting pressure due to increased intra-amniotic pressure and from “strain hardening” with repeated uterine contractions. If the fetal membranes do not rupture before labor, the work to cause membrane rupture at the internal cervical os decreases with advancing cervical dilatation because of the lack of anchoring to the supportive decidua and enhanced ability to stretch with contractions.[1] Preterm membrane rupture can arise through a number of pathways that ultimately result in accelerated membrane weakening. Bacterial collagenases and proteases can directly cause fetal membrane tissue weakening.[10] An increase in local host cytokines or an imbalance in the interaction between MMPs and TIMPs in response to microbial colonization can have similar effects.[11] There is specific evidence linking urogenital tract infection and colonization with preterm PROM. Amniotic fluid cultures after PROM are frequently positive (25% to 35%),[12–19] and histologic evaluation in the setting of preterm birth frequently has demonstrated acute inflammation and bacterial contamination along the choriodecidual interface.[20] Although these findings may reflect ascending infection after PROM, it is likely that ascending colonization and infection are directly involved in the pathogenesis of preterm PROM in many cases. Genital tract pathogens that have been associated with PROM include Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and group B β-hemolytic streptococcus.[20–26] Although group B streptococcus (GBS) bacteriuria has been associated with preterm PROM and low-birth-weight infants[27] and an association between cervical colonization and preterm PROM is possible,[28] it does not appear that vaginal GBS carriage is associated with preterm PROM.[29,30] Although there is a well-established association between bacterial vaginosis and preterm birth, including that related to preterm PROM,[31,32] it remains unclear whether bacterial vaginosis merely identifies women with a predisposition to abnormal genital tract colonization and inflammation, facilitates ascent of other bacteria to the upper genital tract, or is directly pathogenic and causative of membrane rupture. Physical effects related to preterm contractions and prolapsing membranes with premature cervical dilatation can predispose the fetal membranes to rupture, as can the increased intrauterine pressure seen with polyhydramnios.[4,33] It is likely that certain connective tissue disorders (e.g., Ehlers-Danlos syndrome) can result in intrinsic weakening of the membranes. Clinical associations with preterm PROM include low socioeconomic status, lean maternal body mass (<19.8 kg/m2), nutritional deficiencies (e.g., copper, ascorbic acid), and prior cervical conization. During pregnancy, maternal cigarette smoking, cervical cerclage, second- and third-trimester bleeding, pulmonary disease, prior episodes of preterm labor or contractions, and uterine overdistention with polyhydramnios or multiple gestations have been linked to preterm PROM.[4,33–45] Although one or more risk factors may lead to membrane rupture, the ultimate clinical cause of PROM is often not evident at delivery. In some cases, factors leading to membrane rupture are subacute or chronic in nature. Women with a prior preterm birth have

increased risk for preterm birth due to PROM in subsequent pregnancies, especially if the prior preterm delivery resulted from PROM.[46] Asymptomatic women with a short cervical length (<25 mm) remote from delivery are also at increased risk for subsequent preterm birth due to preterm labor or PROM. Some women may have polymorphisms for inflammatory proteins that alter their inflammatory response and increase the risk for preterm birth.[47,48]

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g. A history of preterm birth after PROM confers a 3. The optimal way to prevent complications from preterm PROM is to prevent its occurrence. Prevention of preterm PROM would be particularly appealing because labor and intrauterine infection or other complications necessitating delivery often ensue soon after membrane rupture occurs.[51. P = . it is unknown whether correction of these factors can avert this complication. Ancillary tests such as fetal fibronectin screening or transvaginal cervical sonography should be incorporated into routine practice only after effective interventions to prevent PROM have been identified for those with an abnormal test result.50] (see Chapter 29). Broad-based preventive strategies such as progesterone supplementation can be considered for those at risk due to less specific risk factors such as a history of spontaneous preterm birth[49. and the combination of a prior preterm birth due to PROM. work during pregnancy. clinical efforts continue to be focused on evaluation and treatment of women who present with symptoms of preterm PROM.. 95% confidence interval [CI]. and bacterial vaginosis are associated with preterm birth due to PROM.5%.3%). Although one study suggested that vitamin C supplementation had value in preventing preterm PROM (7. pulmonary disease in pregnancy).6% versus 24.1%. When assessed at 22 to 24 weeks' gestation. For problems or suggestions concerning this service. Copyright © 2010 Elsevier Inc. All rights reserved. Although most other risk factors are fixed in that they cannot be removed or remedied in a particular woman.8 kg/m2). urinary tract and sexually transmitted infections. and most preterm births due to preterm labor or PROM occur in women considered to be at low risk for these events.82). 1. nulliparas with a short cervix and a positive cervicovaginal fibronectin screening result at 22 to 24 weeks had a one-in-six chance (16.7%) of delivering a preterm infant because of PROM. low maternal body mass index (<19. and a positive fetal fibronectin screening result increased the risk of delivery at less than 35 weeks because of preterm PROM by 10.Prediction and Prevention Because PROM at term usually is part of the normal parturition process. studies in which vitamin C was given alone or with other supplements to women without prior preterm birth as a risk factor indicate a trend toward increased preterm birth with such treatments (relative risk [RR] = 1. medical complications (e. poor nutrition. please contact: online.3-fold increased risk for recurrent preterm birth due to the same cause (13. Perhaps the strongest risk factor for preterm PROM is a history of prematurity or PROM. P < .com . a short cervical length. P < . Because prior obstetric outcome has such a strong influence on subsequent pregnancy outcomes.5-fold higher risk of subsequent delivery before 28 weeks (1.02). we are able to predict only a small fraction of women destined to deliver preterm. and severe polyhydramnios.01). the focus of efforts has been on the prediction and prevention of preterm birth caused by PROM.[46] Identification of a cervical length shorter than 25 mm on transvaginal ultrasound also confers an increased risk of subsequent PROM in nulliparas and multiparas. In this study. Potentially modifiable risk factors for preterm PROM include cigarette smoking.38.01) and a 13. Because most cases of preterm PROM cannot be predicted or prevented. knowledge of risk can help to counsel women about suspicious symptoms and the importance of timely evaluation if preterm PROM occurs. it is useful to evaluate nulliparas separately from those with prior deliveries. Other than treatment of infections. Read our Terms and Conditions of Use and our Privacy Policy.5% versus 4.[46] Unfortunately. despite knowledge of a broad range of potential risk factors for preterm birth.52] Vitamin C supplementation to prevent preterm birth due to PROM thus cannot be recommended until there is solid evidence of benefit.help@elsevier.13%. acute pulmonary diseases.04 to 1.[53] Those with an early preterm birth have the highest risk for a recurrence.9-fold (25% versus 2.8% versus 0.

60% to 70% deliver within 1 week. 93% of women will deliver within 1 week.Clinical Course PROM affects approximately 8% of pregnancies at term. All rights reserved. delivery within 1 week is the most common outcome after preterm PROM at any gestational age.[54] Preterm PROM is also associated with brief latency from membrane rupture to delivery.[58] Copyright © 2010 Elsevier Inc. leakage stopped in most cases with conservative management. Read our Terms and Conditions of Use and our Privacy Policy.[55.com .[44. please contact: online. but 1 in 5 will have a latency of 4 or more weeks if they are managed conservatively. although a normal fluid volume sometimes took time to re-accumulate (in a range of 8 to 51 days).57.[35] Although the likelihood of spontaneous resealing of the membranes after preterm PROM is low (3% to 13%).56] With PROM near the limit of viability. with 86% to 94% resealing spontaneously.58] In a study of women with PROM after second-trimester amniocentesis. and 50% to 60% of those who are managed conservatively will deliver within 1 week. and 95% of these women will deliver within 28 hours of membrane rupture. When PROM occurs before 34 weeks' gestation.help@elsevier. On average. For problems or suggestions concerning this service. the prognosis for those with PROM occurring after amniocentesis is much better. latency increases with decreasing gestational age at membrane rupture.

[67] Copyright © 2010 Elsevier Inc.com . For problems or suggestions concerning this service.help@elsevier. please contact: online.8%) leading to death (0.66] Maternal sepsis (0.60–62] Conservative management of PROM provides the opportunity for subclinical deciduitis to progress to overt infection and for ascending infection to occur. Endometritis occurs in 2% to 13% of cases.14%) is a uncommon complication of preterm PROM occurring near the limit of viability.62] Chorioamnionitis can complicate 13% to 60% of cases when PROM occurs remote from term. a risk that increases to 24% with membrane rupture lasting longer than 24 hours.Complications after Premature Rupture of the Membranes Maternal Complications Chorioamnionitis complicates 9% of pregnancies with term PROM.[63.65. All rights reserved.[54. Read our Terms and Conditions of Use and our Privacy Policy.[59] The risk of intrauterine infection increases with the duration of membrane rupture and with declining gestational age.[34.55.64] Placental abruption is diagnosed in 4% to 12% of pregnancies complicated by PROM and can occur before or after the onset of membrane rupture.[20.54.55.

and placental abruption. but it may also reflect less aggressive obstetric interventions for fetal compromise before the limit of viability. Copyright © 2010 Elsevier Inc. particularly with fetal malpresentation. umbilical cord compression.8% to 22%. Fetal heart rate patterns consistent with umbilical cord compression due to oligohydramnios are commonly seen after PROM. For problems or suggestions concerning this service.com . please contact: online.69.Fetal Complications The risks to the fetus are primarily those related to intrauterine infection. All rights reserved. Read our Terms and Conditions of Use and our Privacy Policy. Fetal death occurs in 1% to 2% of cases of conservatively managed PROM.70] This particularly high risk of fetal loss may reflect increased susceptibility to umbilical cord compression and hypoxia or intrauterine infection.[68] Umbilical cord prolapse can occur after membrane rupture.help@elsevier.[36. which is more common with preterm gestations.[56] The reported incidence of fetal death after PROM at 16 to 28 weeks ranges from 3.

[88–91] Pulmonary hypoplasia develops over weeks after membrane rupture occurs. mid-trimester PROM is no longer a relevant clinical entity. Conservative management may result in fetal or neonatal loss before viability.83.001) after controlling for other factors. and cerebral palsy. early gestational age at birth has been associated with neonatal white matter damage (P < . with resultant failure of lung growth.88] Overall. It is most accurately diagnosed pathologically based on radial alveolar counts and lung weights. when the risks of long-term sequelae are highest.[82–87] With PROM occurring during the late pseudoglandular or canalicular stage of pulmonary development. and late-onset bacterial or fungal infection. With current survival rates of about 25% to 85% after delivery at 23 to 26 weeks' gestation. Immediate delivery will result in neonatal death. please contact: online.9%) delivering after PROM at 16 to 26 weeks' gestation. Alternatively.4%) because there has been adequate alveolar development to support extrauterine life by this time.com . and a latency of 28 days.86–88.[74–76] This highlights the need for potential neonatal benefit from delayed delivery if conservative management is to be attempted because this delay offers the opportunity for intrauterine infection to develop.84. including chronic lung disease. and adverse neurologic outcomes. was considered as a separate entity from preterm PROM because neonatal death usually could be anticipated with immediate delivery. before 23 weeks' gestation) is a special circumstance that places the fetus in particular jeopardy.[67] In a review of 201 cases from 11 studies. including pneumothorax. intrauterine infection or inflammation. and the need for high ventilatory pressures because of poor pulmonary compliance. these long-term morbidities are uncommon with delivery after about 32 weeks' gestation. Early PROM before 20 weeks' gestation carries the highest potential for lethal pulmonary hypoplasia (≈50% with PROM before 19 weeks' gestation). restriction deformities can occur in up to 27% of fetuses. pulmonary hypoplasia is suggested by a small chest circumference with severe respiratory distress or persistent pulmonary hypertension and radiographic findings such as small.72.[71. Early preterm birth can lead to long-term complications.[97] Lethal pulmonary hypoplasia is uncommon with PROM after 24 to 26 weeks' gestation (0% to 1. visual or hearing difficulties. compared with 57% for rupture at 24 to 26 weeks' gestation. Respiratory distress syndrome. but there was similar survival after PROM at less than 20 weeks. Fetal lung growth and development can be especially adversely affected when PROM occurs in the early phases of development. mid-trimester PROM.98] However.72] Cerebral palsy and periventricular leukomalacia have been associated with amnionitis.[83. meningitis. sepsis. pulmonary hypoplasia becomes evident in 0% to 26.[71. For problems or suggestions concerning this service. Neonatal sepsis is twofold more common after preterm PROM than after preterm birth due to preterm labor.. and if viability is reached. periventricular leukomalacia. well-aerated lungs with a bell-shaped chest and elevation of the diaphragm. Read our Terms and Conditions of Use and our Privacy Policy. In the past. may lead to failure of the terminal bronchioles and alveoli to develop. which encompasses membrane rupture occurring at about 16 to 26 weeks' gestation. intraventricular hemorrhage.[73] and increased amniotic fluid cytokines and fetal systemic inflammation have been associated with preterm PROM.78–80] Previable PROM occurring before the limit of viability (i. the perinatal survival rate with conservative management of PROM before 23 weeks' gestation was 21%.[77] Despite the described associations between PROM.5% of infants (mean = 5. Neonatal infection can manifest as congenital pneumonia. delivery is likely at an early gestational age. developmental and motor delay. and sepsis are the most common serious acute morbidities.98. and they are common with early preterm birth.[67. it has not been shown that immediate delivery after PROM can prevent these morbidities. the risk of pulmonary hypoplasia is estimated to be 74% to 82%.99] With prolonged oligohydramnios.[83.e.[83. or both. necrotizing enterocolitis. All rights reserved. mental retardation. [92.[83. The neonatal survival rate after PROM occurring before 24 weeks has previously been reported to be approximately 30%. and cerebral palsy. tracheobronchial collapse or loss of intrinsic factors within the tracheobronchial fluid. pneumomediastinum. In general.Neonatal Complications Gestational age at delivery is the primary determinant of the frequency and severity of neonatal complications after PROM. nonlethal pulmonary hypoplasia increases the likelihood of pulmonary barotrauma.help@elsevier.[81] These reported outcomes of previable PROM may be optimistic because most studies have been retrospective and have included only patients amenable to conservative management. an amniotic fluid index of 2 cm or less.94–96] With PROM at 15 to 16 weeks.93] In surviving infants.98–101] Copyright © 2010 Elsevier Inc.

Cervical mucus should be avoided during sampling because it can also yield a ferning pattern on microscopy.Diagnosis In more than 90% of cases. the diagnosis of PROM can be confirmed by clinical assessment. and anovaginal Streptococcus agalactiae (i. However.[102–107] The diagnosis of membrane rupture is confirmed by visualization of fluid passing from the cervical canal. including endocervical Neisseria gonorrhoeae and Chlamydia trachomatis.[108. clinical examination. Blood or semen contamination. and other markers may assist in the diagnosis of PROM. passage of the mucous plug.e.0 to 6. but it can be falsely positive if there is heavy blood contamination.1 to 7. and some studies have shown it to introduce vaginal organisms into the cervical canal and to increase the risk of infection. and ferning test results. to assess cervical dilatation and effacement. and to obtain cultures. GBS). If further clarification is needed. and laboratory evaluation. Re-examination after prolonged recumbency or alternate measures can be considered if initial testing is negative. as appropriate. alkaline antiseptics. because a positive test result may reflect decidual disruption rather than membrane rupture in some cases and a negative test result cannot exclude the diagnosis unequivocally. which turns blue at a pH above 6.3. Because optimal clinical care requires an accurate diagnosis. . Digital examination can shorten latency between membrane rupture and delivery. Amniotic fluid usually has a pH of 7.109] Prolonged leakage with minimal residual fluid can lead to false-negative clinical.. including the combination of history. prolactin. Initially. human chorionic gonadotropin (hCG). If the diagnosis is not confirmed on initial inspection. Nitrazine. these tests usually are not more helpful than the initial measures listed previously. whereas normal vaginal secretions have a pH of about 4. attention should be paid to confirming the diagnosis when a suspicious history or ultrasound finding of oligohydramnios is identified. Ferning results from the interaction of amniotic fluid proteins and salts. microscopic inspection can be performed for the presence of arborized crystals (i. The fern test is unaffected by meconium and vaginal pH. Other potentially confounding findings such as urine leakage. 31-1) in an air-dried sample collected from the vaginal side walls or pooled vaginal fluid. increased vaginal discharge with cervical dilatation or membrane prolapse. digital cervical examination should be avoided unless imminent delivery is anticipated because the needed information usually can be obtained with visualization of the cervix..0. and bacterial vaginosis can cause false-positive Nitrazine test results. Assessment of cervicovaginal secretions for fetal fibronectin. ferning) (Fig. A sterile speculum examination should be performed to provide confirmatory evidence of membrane rupture and to inspect for cervicitis and for umbilical cord or fetal prolapse.e. the pH of the vaginal side walls or pooled vaginal fluid can be evaluated using Nitrazine paper. and the presence of semen or vaginal douching should be considered.5.5 to 6. cervical infection.

is suggestive of membrane rupture. This pattern may reflect initial transudation of a small amount of fluid across a weakened membrane or minimal leakage around a firmly applied presenting fetal part. All rights reserved. Ultrasonographically guided amniocentesis with infusion of indigo carmine dye (1 mL of dye in 9 mL of sterile normal saline). Amniocentesis in the setting of oligohydramnios can be difficult. and particular attention should be paid to avoidance of the umbilical cord vessels. can confirm or disprove the diagnosis of membrane rupture. A typical ferning appearance is seen after a swab from the posterior vaginal fornix was smeared on glass slide and the specimen allowed to air dry.FIGURE 31-1 Ferning. The sample was obtained from a patient with premature rupture of the membranes. Women with a suspicious history and initially negative testing should be encouraged to return for reevaluation if symptoms are persistent or recurrent. Orange.) If the diagnosis remains unclear after initial evaluation. please contact: online.help@elsevier. documentation of oligohydramnios by ultrasound. in the absence of fetal urinary tract malformations or significant growth restriction. followed by observation for passage of blue fluid from the vagina onto a perineal pad. University of California at Irvine. Some women with a history suspicious for membrane rupture but a negative speculum examination result and a normal amniotic fluid volume on ultrasound subsequently return with gross membrane rupture.com . which can have the appearance of a thin. linear fluid space under this circumstance. Copyright © 2010 Elsevier Inc. For problems or suggestions concerning this service. Read our Terms and Conditions of Use and our Privacy Policy. (Image courtesy of Thomas Garite. California.

especially under the circumstance of previable PROM. Fetal well-being is assessed by continuous heart rate monitoring if the . and significant vaginal bleeding. and the patient is evaluated for labor. National Institute of Child Health and Human Development.) Initial Evaluation After the diagnosis of membrane rupture is confirmed. Fetal presentation is assessed. (Adapted from Mercer BM: Preterm premature rupture of the membranes. clinical findings of intrauterine infection. Obstet Gynecol 101:178-193. and ultrasound findings. FIGURE 31-2 Algorithm for management of premature rupture of the membranes (PROM).Management of Premature Rupture of the Membranes Management of PROM is based primarily on the estimated risks for fetal and neonatal complications with immediate delivery weighed against the potential risks and benefits of conservative management to extend the pregnancy after membrane rupture (Fig. as appropriate. 2003. The risks of maternal morbidity should also be considered. Gestational age is established based on the combination of menstrual dates. prostaglandin E2. PGE2. NICHD. The algorithm includes several alternatives for the approach to term and preterm PROM. 31-2). the duration of membrane rupture should be estimated to assist the pediatric caregivers with subsequent management decisions. clinical history.

Although narrowing of the biparietal diameter (i. All rights reserved. dolichocephaly) due to oligohydramnios or breech presentation can result in underestimation of gestational age and fetal weight.help@elsevier. outpatient management usually is not recommended when PROM occurs after the limit of viability. Prenatal maternal transfer should be undertaken early in the course of management if these resources are not available. it is important to evaluate fetal growth and residual amniotic fluid volume by ultrasound..limit of viability has been reached. please contact: online. For problems or suggestions concerning this service. Read our Terms and Conditions of Use and our Privacy Policy. Copyright © 2010 Elsevier Inc. After preterm PROM. the patient should be cared for in a facility with the ability to provide emergent delivery for placental abruption. and the need for intrapartum prophylaxis should be determined. and the potential of fetal abnormalities that can lead to polyhydramnios should be considered.e.[110] Tables using fetal head circumference rather than biparietal diameter can be consulted as needed. Because of the potential for acute complications.com . ultrasound usually is as reliable after PROM as it is with intact membranes. In the absence of available culture results. because conservative management usually is undertaken only if there is a significant risk of neonatal morbidity and mortality with immediate delivery. fetal malpresentation. or fetal distress. a risk factor–based approach should be used for prevention of vertical transmission.[111] If conservative management is planned. GBS carrier status should be ascertained if available from culture results within 6 weeks or there has been a positive urine culture in the current pregnancy. The facility should also have neonatal intensive care facilities and offer acute neonatal resuscitation.

3 hours. available data indicate that women with PROM at term who are not in labor on arrival at the hospital should have labor induced.1%) or neonatal infections (2. decreased rates of chorioamnionitis. given similar efficacy for labor induction. In summary.9% versus 3.0% versus 8.0% versus 2. without increasing the risk of cesarean delivery (13.008). four large studies have since found that induction with oxytocin after term PROM does not increase the risks of maternal or neonatal infections.help@elsevier.001) and the frequencies of chorioamnionitis (4.[54] Neonatal antibiotic therapy was less common with immediate induction (7.2 versus 33.116–118] In the largest study. this choice is somewhat more appealing.5% versus 13. P = . please contact: online. Expectant management of PROM at term was practiced in the 1980s and early 1990s based on studies suggesting that immediate induction after term PROM might increase the risks of infection and cesarean delivery. likely because of a lower concern regarding the potential for neonatal infection with less frequent prolonged rupture of the membranes and less chorioamnionitis. and less frequent neonatal intensive care unit (NICU) admissions with no increase in cesarean delivery rates with prostaglandin administration. usually with an oxytocin infusion.8%).7%.001).[119] Because oxytocin can more easily be discontinued.001) and postpartum febrile morbidity (1. Copyright © 2010 Elsevier Inc.6%. Read our Terms and Conditions of Use and our Privacy Policy. For problems or suggestions concerning this service.com . Meta-analysis of studies comparing prostaglandin induction and conservative management in this setting has found shorter latency.[112–115] However. nor does it make cesarean delivery more likely.7% versus 14.6%. Caregivers should allow an adequate time for the latent phase of labor and minimize digital vaginal examinations until the active phase of labor. to reduce the risk of maternal and neonatal complications. oxytocin induction after term PROM reduced the duration of membrane rupture (17. All rights reserved. P < .Term Premature Rupture of the Membranes There is no substantial fetal benefit to expectant management of pregnancy after membrane rupture at 37 weeks' gestation or later. P < . P < .[54.

increased amnionitis. Amniotic fluid can be collected from the vaginal pool at initial sterile speculum examination or by amniocentesis if vaginal fluid is not available.8%.[130] Based on these findings. This limited benefit was offset by a 2. Specific attention to those enrolled at 32 to 33 weeks' gestation revealed similar trends regarding brief latency. However. P =. Concurrent antibiotic treatment should be given to reduce the risk of intrauterine infection during conservative management (discussed later). but the likelihood of survival is high. and neither group suffered any significant noninfectious neonatal morbidities. consideration should be given to the potential benefits of expeditious delivery unless conservative management to extend latency for 1 or more weeks will be attempted. If antenatal corticosteroids are not to be given to accelerate fetal pulmonary maturity after PROM at 32 to 33 weeks. For problems or suggestions concerning this service.25.06).7% versus 34.7% versus 10. gestational age–dependent neonatal morbidities. controlled trial of conservative management versus immediate induction after PROM at 32 to 36 weeks' gestation. Read our Terms and Conditions of Use and our Privacy Policy.5-fold increased risk of chorioamnionitis (27.[71. With delivery at 32 to 33 weeks' gestation. severe acute morbidities and mortality are uncommon.[121. and reduces umbilical cord pH (7. P = . significantly increases the risk of chorioamnionitis (16% versus 2%.help@elsevier. documented fetal pulmonary maturity was a requirement for enrollment. Abbott Park.001).9%.122] For these reasons. can occur.Preterm Premature Rupture of the Membranes at 32 to 36 Weeks' Gestation Although infants born at 34 to 36 weeks' gestation (i. women presenting with late preterm PROM at 34 to 36 weeks should be actively delivered.[129] The potential for occult umbilical cord compression during conservative management of PROM is highlighted by the high incidence of recurrent variable decelerations found during intermittent monitoring (19. including respiratory distress syndrome. late preterm birth) have a higher risk of complications than term infants.[122] Alternatively. All rights reserved. P = . P = . IL). suspected neonatal sepsis.003) and increased neonatal antibiotic treatment for suspected infection (78.35 versus 7.com . These decisions should take into consideration local population-based risks of infection and neonatal morbidities. conservative management prolonged pregnancy only briefly (36 versus 14 hours. conservative management with antenatal corticosteroid administration for fetal maturation is an appropriate choice.4%) among conservatively managed women. the lecithin-to-sphingomyelin ratio (L/S ratio). P < .[123–128] Modest reductions in the duration of neonatal hospital stay and hyperbilirubinemia with conservative management of PROM at 32 to 33 weeks' gestation have been reported. There are no data regarding optimal management after antenatal corticosteroid treatment is completed. because conservative management increases the risks of chorioamnionitis and prolonged hospitalization and because it is unlikely that conservative management for less than 1 week will result in further significant spontaneous fetal maturation. Each of the TDx/TdXFLx FLM II assay (Abbott Laboratories. P < .3%. In this study.6% versus 28.001) in a randomized. and antibiotic treatment with conservative management. increased neonatal sepsis workups (59.001). delivery should be considered if elective delivery is planned within 7 days after antenatal corticosteroid benefit has been achieved.e. and antenatal corticosteroids for fetal maturation are not typically recommended in this gestational age range. Copyright © 2010 Elsevier Inc. Amniotic fluid studies documenting pulmonary maturity in this gestational age range are useful to identify women who should be offered expeditious delivery. and chronic morbidities are uncommon.. please contact: online. and the phosphatidylglycerol (PG) test can predict pulmonary maturity when performed on vaginal pool specimens.009). the woman with PROM and documented fetal pulmonary maturity at 32 to 33 weeks' gestation is at low risk for complications after immediate delivery and increased risk with conservative management. and it has not been shown to improve neonatal outcomes. If fetal pulmonary testing reveals an immature result or if amniotic fluid cannot be obtained for assessment.120] Conservative management of PROM at 34 to 36 weeks prolongs pregnancy by only days.

generating several meta-analyses. delivery should be pursued and broad-spectrum antibiotics should be initiated because treatment before delivery has been shown to decrease the incidence of neonatal sepsis. A nonreactive result for a nonstress test and a biophysical profile score of 6 or less within 24 hours of delivery have been associated with perinatal infection. a vaginal pool glucose value below 5 mg/dL had a 74.[143] In this promising study. Conservative management includes initial prolonged continuous fetal heart rate and maternal contraction monitoring to assess fetal well-being and identify occult contractions and evidence of umbilical cord compression. a later meta-analysis concluded that antenatal glucocorticoids significantly reduce the risks of respiratory distress syndrome (20% versus 35.[131] Despite this.[136.[15. abruptio placentae. without increasing the risks of maternal (9. fetal heart rate monitoring can identify variable and late decelerations in addition to uterine activity.1%) or neonatal (7.5% versus 15. fetal transverse lie and back up with coexisting advanced cervical dilatation. If initial testing results are reassuring. these results are not likely to be available before the diagnosis is clarified. human immunodeficiency virus infection. Antenatal Corticosteroids Respiratory distress syndrome is the most common acute morbidity after conservatively managed preterm PROM. and long-term sequelae.4%). the counts can be artificially elevated within 5 to 7 days of antenatal corticosteroid administration. intraventricular hemorrhage (7.Preterm Premature Rupture of the Membranes at 23 to 31 Weeks' Gestation Because delivery before 32 weeks' gestation is associated with a high risk for perinatal death. and intrauterine infection.4 °F) with uterine tenderness or with maternal or fetal tachycardia in the absence of another evident source of infection. and it is diagnosed clinically by the presence of maternal fever above 38. particularly remote from term when the fetal heart rate pattern is less likely to be reactive.9%). Because of the high risk of heart rate abnormalities due to umbilical cord compression (32% to 76%). severe neonatal morbidities. In women with conservatively managed PROM remote from term.0% versus 6.[132–134] The latest study of cervical length in women with preterm PROM found that 83% of women delivered within 7 days if the initial cervical length was 1 to 10 mm.2% versus 5. primary herpes simplex virus infection). the patient can be transferred to an inpatient unit or transferred to a facility capable of emergent delivery and acute neonatal resuscitation for modified bed rest. Biophysical profile testing may also be confounded by the presence of oligohydramnios but can be helpful if the nonstress test is equivocal.8% versus 4. amniocentesis may yield helpful results. The presence of leukocytes alone in amniotic fluid after PROM is not well correlated with intrauterine infection. [138–140] Although evaluation of the maternal white blood cell count can be helpful if clinical findings are equivocal. a low initial amniotic fluid volume (amniotic fluid index <5. but only 41 women were evaluated. advanced labor. If the diagnosis of chorioamnionitis is suspected but additional confirmation is needed. currently available studies of initial amniotic fluid volume and cervical length assessment in women with preterm PROM have insufficient power and consistency to guide management. women with PROM between 23 and 31 weeks' gestation usually should be managed expectantly to prolong pregnancy unless there is evidence of intrauterine infection.[132] However.[147] Multivariate analysis of .0 cm or maximum vertical fluid pocket <2. suspected placental abruption. and necrotizing enterocolitis (0.[17] One study suggested that determination of glucose levels from vaginally collected amniotic fluid may be a simple and noninvasive method for identification of intra-amniotic infection. fetal assessment should be performed at least daily for those with initially reassuring test results.137] A nonreactive nonstress test subsequent to an initially reactive result should be considered suspicious.142] A glucose concentration below 16 to 20 mg/dL (sensitivity and specificity of 80% to 90% for a positive culture) and a Gram stain positive for bacteria (sensitivity of 36% to 80% and specificity of 80% to 97% for a positive culture) support the presence of intrauterine infection. Under certain additional circumstances.0 cm) is associated with shorter latency to delivery and increased neonatal morbidity (including respiratory distress syndrome) but not with increased maternal or neonatal infection after PROM.[141] such testing is not available in most clinical laboratories. Although a positive amniotic fluid culture supports clinical suspicion of chorioamnionitis (sensitivity of 65% to 85% and specificity of 85%).0 °C (100. Conservative management requires surveillance for the development of labor..g. compared with 18% for a cervical length more than 30 mm. or a non-reassuring fetal heart rate pattern. the predictive value of a low amniotic fluid volume for adverse outcomes is poor. Chorioamnionitis confers increased risks of perinatal mortality and intraventricular hemorrhage.[144] Antenatal corticosteroid administration after preterm PROM has been extensively studied. delivery may be appropriate despite an early gestational age at membrane rupture (e.2% accuracy rate for identifying women with a positive amniotic fluid culture.135] Continuous monitoring may be appropriate for women with intermittent fetal heart rate decelerations but otherwise reassuring findings. Although the nonstress test and biophysical profile have the ability to confirm fetal well-being in the setting of preterm PROM.141.[63] After the diagnosis of chorioamnionitis is made.6%) infections in women with preterm PROM.6%). A short cervical length on endovaginal ultrasound after preterm PROM has been associated with shorter latency to delivery.[145–147] Although early reviews produced conflicting conclusions about the utility of antenatal corticosteroid treatment after PROM. Although research has found elevated amniotic fluid interleukin levels to be associated with early delivery and perinatal infectious morbidity.[68.

and reduced infant morbidities. In a clinical trial with adequate power to evaluate antibiotic therapy during conservative management of women with preterm PROM before 32 weeks' gestation.9% versus 7. [148] Three studies in which prophylactic antibiotics were given concurrent to antenatal corticosteroids found treatment to reduce respiratory distress syndrome (18. chronic lung disease (bronchopulmonary dysplasia: 20. including death. P = .05). Oral amoxicillin-clavulanic acid treatment was associated with increased necrotizing enterocolitis (RR = 4. The antibiotic study group had less neonatal GBS sepsis (0% versus 1. and severe necrotizing enterocolitis. Benefit persisted for 3 weeks after randomization despite discontinuation of antibiotics at 7 days. patent ductus arteriosus (11.57).009) and pneumonia (2.88) was also reduced.[56.56 to 1. 0.9% versus 6.5% among controls). but oral erythromycin therapy was not (RR = 1.66 to 1. less overall maternal infection and chorioamnionitis.3%.14.05 or less for each.2%) without an increase in neonatal sepsis (9.161] In summary. The benefits and risks of a single rescue course remote from initial corticosteroid administration remain to be determined.0%).71) and within 7 days (RR = 0.3% versus 8.3% versus 48.98 to 10.60.7%). delivery within 48 hours (RR = 0.5%. and there was a trend toward less sepsis. and they were analyzed separately. 95% CI.01).05).[149–151] The National Institutes of Health Consensus Development Panel recommended a single course of antenatal corticosteroids for women with PROM before 30 to 32 weeks' gestation in the absence of intra-amniotic infection. P < . Antibiotic treatment increased the likelihood of continued pregnancy after 7 days of treatment by twofold. respiratory distress syndrome.2%). the study authors recommended erythromycin as a better choice. P < ..5% versus 13.[144] An alternative conclusion from the latest meta-analysis is that penicillins other than .[154] Respiratory distress syndrome was less common in another retrospective review of repeated courses of antenatal corticosteroids (34. CI. Antibiotic therapy also significantly reduced individual gestational age–dependent morbidities. a single course of antenatal corticosteroids should be considered when PROM occurs before 32 weeks' gestation and for women with documented pulmonary immaturity at 32 to 33 weeks' gestation. there was no reduction in respiratory distress syndrome.3% versus 2% for a single course or 1.04) were reduced for those who were not GBS carriers. the National Institutes of Child Health and Human Development Maternal Fetal Medicine Units (NICHD-MFMU) Research Network assigned women with PROM to initial aggressive intravenous therapy for 48 hours (2 g of ampicillin IV every 6 hours and 250 mg of erythromycin IV every 6 hours) followed by oral therapy for 5 days (250 mg of amoxicillin PO every 8 hours and 333 mg of enteric-coated erythromycin base PO every 8 hours) to provide limited-duration. severe intraventricular hemorrhage.156.03).5% versus 48.[144. given 12 hours apart) is considered appropriate.157] In the latest one.03) perinatal mortality (1.8%).6%.[153] In another retrospective analysis of repeated antenatal corticosteroids. but intraventricular hemorrhage and amnionitis were less common. including respiratory distress syndrome (40. broad-spectrum antibiotic (ampicillin-amoxicillin plus erythromycin) therapy for women with preterm PROM before 32 weeks' gestation prolongs pregnancy sufficiently to reduce neonatal gestational age–dependent morbidities and reduce the frequencies of maternal and neonatal infections.[160.[157] The need for surfactant administration (RR = 0.6%. P = . P = . In a retrospective study that controlled for gestational age and other factors.68). antibiotic treatment after preterm PROM significantly reduced chorioamnionitis (relative risk [RR] = 0.2%).82) compared with placebo therapy.4% versus 15. Repeated weekly antenatal corticosteroids are not recommended after preterm PROM. Because of the increased risk of neonatal necrotizing enterocolitis with amoxicillin-clavulanate.7% versus 20.159] GBS screening was performed.72) in this analysis. including neonatal infection (RR = 0. P = .[157] The study that dominated this meta-analysis included women with PROM up to 36 weeks' gestation and included a population at low risk for necrotizing enterocolitis overall (i. early sepsis.e. with no increase in perinatal infections.[158] The meta-analysis found treatment with “all penicillins” (excluding amoxicillin-clavulanic acid) versus placebo to be associated with fewer births within 48 hours and 7 days of PROM. given 24 hours apart) or dexamethasone (four doses of 6 mg IM. P = . fewer positive neonatal blood cultures. and composite morbidities (29. even though benefits were limited to reduction in delivery at 48 hours.9% versus 45.[152] Data regarding repeated weekly courses of antenatal corticosteroids after preterm PROM are conflicting.05).prospective observational trials suggested a benefit of antenatal corticosteroid use regardless of membrane rupture. two or more courses of antenatal corticosteroids were associated with increased early neonatal sepsis (15.00.5%. 1. and major cerebral abnormalities on ultrasound before discharge (RR = 0.3% versus 5.4% versus 43. Betamethasone (two doses of 12 mg IM. P = . but the studies lacked size and power to demonstrate equivalent effectiveness.83) and oxygen therapy (RR = 0. and it was the only one of 10 studies that found a significant increase in necrotizing enterocolitis with antibiotic therapy. 0. and a reduced need for oxygen therapy. Babies born to women treated with ampicillin plus erythromycin had a reduced incidence of one or more major infant morbidities (53% versus 44% rate of composite morbidity. Two other studies have attempted to determine whether antibiotic therapy of shorter duration could provide similar benefit.001). CI.80). fewer positive neonatal blood cultures. and fewer major intracranial cerebral ultrasound abnormalities. and stage 3 or 4 necrotizing enterocolitis (2. broad-spectrum antimicrobial coverage before delivery. More than two dozen randomized clinical trials have been summarized in several metaanalyses. Chorioamnionitis was reduced with the study's antibiotics (23% versus 32. less neonatal infection. Antibiotics did not influence the risk of necrotizing enterocolitis (RR = 1. 0. with P values of 0. and neonatal sepsis (8.[155] Based on current evidence that antenatal corticosteroids are effective for induction of fetal pulmonary maturity without increasing the risk of infection and that most women will remain pregnant for the 24 to 48 hours needed to achieve corticosteroid benefit after PROM.0%. GBS carriers were treated with ampicillin for 1 week and again in labor. Adjunctive Antibiotics Antibiotic therapy is given during conservative management of preterm PROM to treat or prevent ascending decidual infection to prolong pregnancy and to reduce gestational age–dependent morbidity while limiting the risk of neonatal infection.6%.97).5% for no courses.80). P < .

Therapeutic tocolysis administered only after contractions occur has not been shown to be effective in prolonging latency. the risks and benefits of this approach have not been determined. but hematogenous transmission can occur to the fetus in utero in some cases. and antiviral therapy was inconsistent in this series.5 days. After latencies ranging from 1 to 35 days.177] and infection can result in mortality rates of 50% to 60% and serious sequelae in up to 50% of survivors. Women with a diagnosis of chorioamnionitis should receive broad-spectrum intrapartum antibiotic therapy. and it remains plausible that prophylactic tocolysis could delay delivery long enough to allow antibiotic suppression of subclinical decidual infection and for corticosteroid effects on the fetus. Cesarean delivery was performed for women with active lesions at the time of delivery.[173–175] No study has found cerclage retention after PROM to reduce the frequency or severity of infant morbidities after preterm PROM.amoxicillinclavulanic acid are an acceptable treatment for preterm PROM and that the benefits of erythromycin are limited to brief pregnancy prolongation.[162–167] After preterm PROM. Tocolysis Evidence from prospective studies of tocolysis after PROM is similar to that from studies of tocolysis for preterm labor with intact membranes. tocolytic therapy should not be considered an expected practice after preterm PROM. none of the 26 infants developed neonatal herpes infection (CI. a case series of women with conservatively managed PROM before 32 weeks' gestation coincident to active recurrent herpes simplex virus lesions suggests that conservative management may be considered.[43.169. but the biologic mechanism for this association is unclear. Based on these data.179] Based on two case series including a total of 35 women with an active maternal genital herpesvirus infection. and fewer positive neonatal blood cultures.[174] Because cerclage retention after PROM has not been shown to improve perinatal outcomes and there are potential risks related to leaving the cerclage in situ.[167] A report from the Collaborative Study on Antenatal Steroids suggested tocolytic use after PROM was associated with subsequent neonatal respiratory distress syndrome. Pending further study in this area.[180–182] However. Shortages in intravenous and oral antibiotics have led to the need for alternative antibiotic choices. 0% to 10.[168] Overall. In a retrospective comparison of aggressive tocolysis with limited treatment for contractions only during the first 48 hours.170] Because no prospective studies have been performed regarding management of preterm PROM with a cerclage in situ. but it may be appropriate in pregnancies at high risk for neonatal complications with early preterm birth. and each has demonstrated statistically insignificant trends toward increased maternal infectious morbidity with only brief pregnancy prolongation. the available prospective studies have not found tocolytic treatment after PROM to increase or prevent neonatal morbidities after PROM. provided the cerclage is removed on admission after PROM. Maternal Herpes Simplex Virus Infection Neonatal herpes simplex infection most commonly results from direct maternal-fetal transmission at delivery.[178. aggressive therapy was not associated with longer latency (3. P = . regardless of prior antibiotic treatments. Neonatal infection rates after primary and secondary maternal infections occur in 34% to 80% and 1% to 5% of cases. erythromycin. The risk of adverse perinatal outcomes does not appear to be different when PROM occurs with a cerclage or without one. Tocolytic therapy has not been studied when antenatal corticosteroids and antibiotics were administered concurrently.[111] Known GBS carriers and those who deliver before carrier status can be determined should receive intrapartum prophylaxis to prevent vertical transmission. While deferred removal might enhance pregnancy prolongation for corticosteroid administration. One study found increased infant mortality and mortality due to sepsis with cerclage retention after PROM. conservative management of PROM complicated by recurrent maternal herpes simplex virus infection may be .[176. prophylactic tocolysis with β-agonists before the onset of contractions can prolong pregnancy briefly.[171–172] Several small studies comparing pregnancies of preterm PROM in which the cerclage was retained or removed have yielded consistent patterns. removal is recommended when PROM occurs.[173] One study that compared different practices at two institutions found longer latencies with cerclage retention. particularly if the indication for initial cerclage placement was not strong. Oral ampicillin.8 versus 4. Cervical Cerclage Preterm PROM complicates about one fourth of pregnancies with a cervical cerclage and one half of pregnancies requiring an emergent cerclage.4%).[183] Antenatal corticosteroids and antibiotics were not administered. less need for oxygen therapy. it has been generally accepted that increasing latency after membrane rupture of more than 4 to 6 hours increases risk of neonatal infection and that cesarean delivery should be performed expeditiously to prevent fetal infection in this setting. recommendations reflect the data available from retrospective cohorts. respectively.16). and azithromycin are likely appropriate alternatives if needed. Up to a 7-day course of parenteral and oral therapy using ampicillin-amoxicillin and erythromycin is recommended for women undergoing conservative management of preterm PROM remote from term. but this finding could reflect population or practice differences at these institutions rather than the effect of cerclage retention. Adjunctive antibiotic administration to prolong latency must be distinguished from intrapartum prophylaxis to prevent vertical transmission of GBS from mother to baby.[157] This is not inconsistent with the NICHD-MFMU approach.

For problems or suggestions concerning this service. All rights reserved.help@elsevier. Read our Terms and Conditions of Use and our Privacy Policy.. please contact: online.g.appropriate if membrane rupture occurs remote from term and the potential for mortality or serious sequelae with delivery is considered to be high. Copyright © 2010 Elsevier Inc. acyclovir) during conservative management can reduce viral shedding and the frequency of recurrence.com . Antiviral therapy (e.

severe oligohydramnios after PROM before 20 weeks is the strongest predictor of subsequent lethal pulmonary hypoplasia.g. Serial fetal biometric evaluation (e. Discharged patients are typically readmitted to hospital after the limit of viability has been reached to allow early intervention for infection. including a realistic appraisal of potential fetal and neonatal outcomes according to the available information for gestational age–appropriate outcomes. and the physician's experience with these techniques. please contact: online. Copyright © 2010 Elsevier Inc. and deep venous thrombosis can also occur with prolonged bed rest.e. suspicious vaginal discharge. labor. and there are inadequate data to recommend that any of these approaches be incorporated into routine clinical practice.184] In addition to the maternal risks of conservative management previously delineated. the available facilities. or the degree of neonatal pulmonary hypoplasia at the time of initial presentation with PROM.g. previable PROM in a pregnancy complicated by persistent second-trimester bleeding. These methods are described in a review. the ultimate gestational age at delivery. After an initial ultrasound assessment. For women who decide that the risks of conservative management exceed the potential benefits.help@elsevier.[191] The maternal risks and fetal benefits of these interventions have not been adequately evaluated. cryoprecipitate. repeated evaluation can be performed every 1 to 2 weeks to determine whether there is re-accumulation of amniotic fluid and to evaluate lung growth. Prediction of specific neonatal outcomes after previable PROM is extremely difficult because it is not possible to predict extended latency. Membrane rupture after amniocentesis is associated with cessation of leakage and subsequent successful pregnancy outcomes in most cases. prior cesarean delivery) and preference. Administration of antenatal corticosteroids for fetal maturation at this time is appropriate. Read our Terms and Conditions of Use and our Privacy Policy.72. Data to guide the management for women who choose conservative management of previable PROM are lacking. abdominal pains. Women who are discharged should be advised to abstain from intercourse and limit physical activity. lung length.[88. misoprostol).96. or by dilatation and evacuation. There is no consensus about the advantages of inpatient versus outpatient management. bone demineralization.Previable Premature Rupture of the Membranes before 23 Weeks' Gestation Although the cause is often not apparent. delivery can usually be accomplished with vaginal prostaglandin E2. with a high-dose oxytocin infusion.[71. which carries a poor prognosis... For problems or suggestions concerning this service. and there are significant financial and social implications of prolonged hospitalization. The patient with previable PROM and no other indication for immediate delivery should be counseled regarding the risks and benefits of expectant management. oral or vaginal prostaglandin E1 (i. oligohydramnios.com . clinical antecedents can be helpful in determining the likely outcomes in some cases of previable PROM. the patient may choose to reconsider her decision regarding ongoing expectant management.. Treatments to seal the membrane defect or restore normal amniotic fluid volume include transabdominal amnioinfusion and membrane sealing with fibrin. severe oligohydramnios. or any vaginal bleeding. Persistent.185–190] If pulmonary hypoplasia becomes evident before the limit of viability or there is persistent. or gel-foam plugs. muscle wasting. They should return immediately in case of fever. chest circumference). evident amnionitis. gestational age. and non-reassuring fetal heart rate patterns. platelet. or an elevated level of maternal serum α-fetoprotein more likely reflects an abnormality of placentation. Initial inpatient evaluation may include strict bed and pelvic rest to enhance the opportunity for resealing and for early identification of infection and placental abruption. ratios to adjust for overall fetal size (thoracic to abdominal circumference. Hospitalization for the duration of amniotic fluid leakage may be appropriate in some circumstances. All rights reserved. thoracic circumference to femur length) and Doppler studies of fetal pulmonary artery and ductus arteriosus waveform modulation with fetal breathing movements can demonstrate whether fetal pulmonary growth has occurred over time. Alternatively. The optimal approach depends on the patient's characteristics (e. placental abruption. These results have a high predictive value for neonatal mortality due to pulmonary hypoplasia.

All rights reserved. Attention to early diagnosis and management of complications that occur after PROM can lead to good perinatal outcomes in many cases. please contact: online.com . there is the potential for significant perinatal morbidity and mortality. Conservative management of PROM remote from term can reduce infectious and gestational age–dependent morbidities.Summary When term or preterm PROM occurs. infants delivered after early preterm or previable PROM are at high risk for perinatal complications. Expeditious delivery of the patient with term and late preterm PROM can reduce the risk of perinatal infections without increasing the likelihood of operative delivery. which can be reduced by considered and timely obstetric interventions. Read our Terms and Conditions of Use and our Privacy Policy. many of which cannot be avoided with current technologies and management algorithms. For problems or suggestions concerning this service.help@elsevier. Regardless of management approach. Copyright © 2010 Elsevier Inc.

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