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Neonatal complications in women with Article reuse guidelines:
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premature rupture of membranes DOI: 10.1177/0049475519886447
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(PROM) at term and near term and
its correlation with time lapsed since
PROM to delivery

Shruti Gupta1 , Sunita Malik2 and Shailesh Gupta3

Abstract
Premature rupture of membranes (PROM) is a common problem with controversies in its management. The aim of our
study was to find out the prevalence of neonatal complications and their correlation with the latent period in babies born
to mothers with PROM at 34–40 weeks of gestation. This prospective cohort study was performed on 200 pregnant
women with PROM at or near term. After birth, neonates were screened for sepsis. Other outcome measures included
birth asphyxia, stay in the Neonatal Intensive Care Unit (NICU) and neonatal mortality. These were correlated against
time spent from PROM. Duration after which risk of neonatal sepsis increased immensely was calculated by ROC. The
prevalence of specific neonatal complications was as follows: birth asphyxia (8%); neonatal sepsis (4%); NICU admission
(26%); and neonatal mortality (2%). Complications increased with an increasing latent period. Beyond 37 h of latency, the
rate of neonatal sepsis increases dramatically. In conclusion, pregnancies with PROM at and near term should not be
managed expectantly. All neonates born after 37 h of latent PROM should be stringently evaluated for sepsis.

Keywords
Premature rupture of membranes, PROM to delivery interval, neonatal complications

own challenges of failed induction, fetal distress and an

Introduction
Premature rupture of membranes (PROM) describes
the rupture of membranes occurring before the onset
of labour.1–3 It is a common obstetrical problem
encountered in day-to-day practice and is subdivided
into term PROM, preterm PROM and mid-trimester
PROM affecting 8%, 1–3% and <1% pregnancies,
respectively.4 The management of PROM is still a
matter of debate among obstetricians; it is related to
a wide variety of maternal, fetal, and neonatal compli-
cations, among which immediate complications are
cord prolapse, cord compression, meconium-stained
liquor, fetal distress and placental abruption, while
delayed complications include infections affecting
both mother and baby.5,6
Thus, the question arises whether such mothers
should be induced immediately or wait for spontaneous
onset of labour and, if so, for what duration. Such
delay to labour increases the risk of infection to both
mother and baby, while induction of labour provides its
increased rate of Caesarean delivery. Consequently, the
management of PROM aims to balance the aforemen-
tioned. We aimed to find out the prevalence of neonatal
and maternal complications in PROM and the effect of
the duration of latency. We aimed to calculate a cut-off
PROM interval to delivery beyond which stringent
evaluation of neonates for sepsis is mandatory.
1
Former Resident, Department of Obstetrics and Gynaecology, VMMC
and Safdarjung Hospital, Delhi, India
2
Professor, Department of Obstetrics and Gynaecology, VMMC and
Safdarjung Hospital, Delhi, India
3
Senior Resident, Department of Community Medicine, BPS GMC,
Khanpur Kalan, Sonepat, Haryana, India
Corresponding author:
Shruti Gupta, H No 32, Pocket 12, Sector 24, Rohini, Delhi 110085, India.
Email: drshrutigupta2988@gmail.com
2 Tropical Doctor 0(0)
Methods
Ours was a prospective cohort study conducted over
two years, after due clearance from the Institute of
Ethics Committee at VMMC and Safdarjung
Hospital. A total of 200 pregnant women with single
pregnancies presenting with PROM at 34–40 weeks of
gestation were included, after taking written and
informed consent. All women with multiple gestation,
ultrasonographic evidence of fetal anomalies and prior
febrile illness were excluded from the study. At admis-
sion, all women were screened for clinical signs of chor-
ioamnionitis or antepartum fever. The method of
delivery was planned for all according to obstetric indi-
cations. After delivery, all neonates were evaluated for
birth asphyxia and neonatal sepsis, recording the Apgar
score and need for resuscitation. Birth asphyxia was
defined as a 1-min Apgar score <7. Neonatal sepsis
was defined as:
1. culture negative (clinical sepsis) when the infant had
any one of the following three signs:
(a) the presence of predisposing factors such as
maternal fever, foul-smelling liquor or rupture
of membranes prolonged for >18 h, or the pres-
ence of gastric polymorphs (>5/high power
field);
(b) a positive septic screen with two of the following
parameters: leukocytopenia <5000/mm3, band
to total polymorph ratio >0.2, absolute neutro-
phil count <1800/mm3, C-reactive protein
>1 mg/dL and erythrocyte sedimentation ratio
(ESR) >10 mm/1st h;
(c) radiological evidence of pneumonia; or
2. culture positive sepsis with a clinical picture suggest-
ive of septicaemia, pneumonia or meningitis together
with the isolation of pathogens from blood, urine or
cerebrospinal fluid (CSF).7
Admission to intensive care depended on the
requirements of the baby.
After delivery the mother was also observed for the
development of postpartum fever and suture-line sepsis.
Outcome measures were: neonatal sepsis, birth
asphyxia, admission to intensive care, neonatal mortal-
ity, antepartum fever, postpartum fever and suture-line
sepsis. Statistical analysis was performed using software
version SPSS 20.0. P < 0.05 was considered statistically
significant. Statistical methods used were 2 and recei-
ver operator characteristic (ROC) curves.
Results
A total of 200 pregnant women and their newborns
were studied; 61.5% were term (37–40 weeks of gesta-
tion) and the remaining were preterm (34–36þ6 weeks).
Table 1. Prevalence of neonatal and maternal complications.
n %
Birth asphyxia 16 8
Neonatal sepsis 8 4
NICU admission 52 26
Neonatal mortality 4 2
Low birth weight (<2.5 kg) 88 44
Very low birth weight (<1.5 kg) 6 3
Antepartum fever 14 7
Postpartum fever 6 3
Postpartum stitch-line sepsis 5 2.5
NICU, Neonatal Intensive Care Unit.
The majority were nulliparous and aged 21–25 years. A
total of 76.5% underwent vaginal delivery with eight
women having instrumental delivery in view of fetal
distress in the second stage or during a prolonged
second stage of labour. The remaining 23.5% had a
Caesarean delivery for fetal distress, breach presenta-
tion or arrest of labour.
The mean birth weight was 2.49 kg (range ¼ 1–
3.7 kg). Eight neonates suffered from sepsis, of whom
four had clinical sepsis while another four had culture-
proven sepsis. Organisms grown were coagulase nega-
tive staphylococcus, Escherichia coli and acinetobacter.
The average duration of intensive care stay for the neo-
nate was 5.8  3.7 days. Table 2 demonstrates the cor-
relation between the duration of latency with various
complications.
The time from rupture of membranes was divided
into five groups. E. coli was the main organism respon-
sible for suture-line sepsis. The ROC curve drawn for
neonatal sepsis showed that the risk of neonatal sepsis
increased drastically if the duration of PROM to deliv-
ery increased beyond 37 h (Figure 1).
Discussion
The amniotic sac acts as a barrier that separates the
sterile uterine environment from outside infections.8 A
breach of membranes thus exposes the fetus and
mother to multiple infectious agents. Some obstetri-
cians recommend immediate intervention,2,9 while
others argue there is no difference in result.5,10,11
Our study was carried out on near-term and term
PROM patients because neonates of this gestation
rarely suffer from prematurity-related complications;
thus, the morbidity arising from rupture of membranes
may be studied more easily. It is clear from our results
that, as the duration from rupture of membranes to
delivery increases, so does the risk of neonatal sepsis.
Moreover, the need for intensive care also increases
Gupta et al. 3

Table 2. Correlation between complications and duration of latency.

0–12 h (n ¼ 48) 13–24 h (n ¼ 71) 25–36 h (n ¼ 40) 37–48 h (n ¼ 14) >48 h (n ¼ 27)
PROM to delivery Pearson
interval (h) n % n % n % n % n % 2 (P)

Birth asphyxia 4 8.3 2 2.8 4 10 2 14.3 4 14.8 0.261

Neonatal sepsis 0 0 0 0 2 5 2 14.3 4 14.8 0.002
NICU admission 5 10.4 8 11.3 17 42.5 6 42.9 16 59.3 0.000
Neonatal mortality 0 0 1 1.4 2 5 1 7.1 0 0 0.250
Antepartum fever 0 0 1 1.4 3 7.5 2 14.3 8 29.6 0.000
Postpartum fever 0 0 0 0 2 5 1 7.1 3 11.1 0.025
Postpartum 0 0 0 0 2 5 1 7.1 2 7.4 0.092
stitch-line sepsis
NICU, Neonatal Intensive Care Unit; PROM, premature rupture of membranes.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.

ORCID iD
Shruti Gupta https://orcid.org/0000-0002-5418-9545

References
Figure 1. Receiver operator characteristic (ROC) curve of
neonatal sepsis against time lapsed from PROM to delivery.
Area under the curve is 0.862.
significantly. Further, the occurrence of maternal infec-
tion likewise increased, as noted in other studies.12,13
We showed a rising trend of neonatal mortality with
increasing duration of latency, although no deaths were
reported in babies born to mothers with PROM > 48 h.
An increase in study population size would show even
more significant results.
The ROC curve (Figure 1) drawn for newborn sepsis
gives a clear cut-off at 37 h.
We recommend that women with PROM at or near
term should not be managed expectantly. All neonates
born after 37 h of membrane rupture must be rigor-
ously evaluated for sepsis.
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