Modern Management of
Prolonged Rupture of
Membranes
Joseph R. Biggio Jr., M.D.
Department of Obstetrics & Gynecology
Division of Maternal-Fetal Medicine
University of Alabama at Birmingham
PROM
Premature Rupture of Membranes
Amniorrhexis prior to onset of active labor
regardless of gestational age
PPROM
Preterm Premature Rupture of
Membranes
Amniorrhexis < 37 weeks’ gestational age
prior to onset of active labor
Latency
Interval from Rupture of
Membranes to Onset of Active
Labor
Diagnosis
 History
 Avoid
digital exam
 Vaginal Pool
 Nitrazine Paper
 Ferning
 Ultrasound
 Amniocentesis/Dye Study
PROM near Term
 Management
gestational age
dependent
 Induction vs. awaiting spontaneous
labor
 Antibiotic prophylaxis per
ACOG/CDC recommendations
Induction vs. Expectant
Management
 >5,000
women randomized
 Oxytocin,
PGE2 or expectant
management up to 4 days
 No difference in cesarean section or
neonatal infection
 Less chorioamnionitis in induction
with oxytocin group
Hannah, NEJM, 1996
Epidemiology of Preterm
Birth
PPROM
28 %
Indicated
Preterm
Delivery
26 %
46 %
Spontaneous
Preterm
Delivery
Andrews, 1995
PPROM
Risk Factors
 Lower/Upper Genital
Proteases
Prostaglandins
 History
of PPROM
 Incompetent Cervix
 Abruption
 Polyhydramnios
 Multiple Gestation
 Smoking
Tract Infection
PPROM
Complications
 Maternal/Fetal
Infection
 Premature Labor and Delivery
 Umbilical Cord Prolapse
 Fetal Hypoxia 2º Cord Compression
 Increased Rate of Cesarean Section
 Intrauterine Growth Restriction
 Abruption
 Stillbirth
PPROM
Standard Management
 Confirmation
of Diagnosis
 Verification of Gestational Age
 R/O Labor/Infection/Fetal Compromise
 Avoid Digital Vaginal Examinations
 In Hospital Observation
 Bedrest
% Patients with Latency
> 1 Week
PPROM
Latency
75
50
25
0
25
25-28
29-32
33-36
Gestational Age (Weeks)
Wilson, Obstetrics & Gynecology, 1982
PPROM
Vaginal Examination
Latency Days
20
No Exam
15
10
5
Exam
2
4
2
6
2
6
2
8
2
8
3
0
3
0
3
2
3
2
3
4
3
4
3
5
Gestational Age (Weeks)
Lewis, Obstetrics & Gynecology, 1992
Previable PPROM
<
24 weeks
 Poor
prognosis for successful
outcome
 Outcome
may be different for
spontaneous vs. iatrogenic
Previable PPROM
Complications

Uterine Infection

Pulmonary Hypoplasia

Limb Compression Deformities

Intrauterine Growth Restriction
Previable PPROM
Outcomes
# of
Study
Infants Chorio.
Taylor
60
25%
Major
71
43%
Moretti
124
39%
Bengston
63
46%
Overall
318
39%
Survival
22%
65%
32%
51%
Normal
Neurological
Development
38%
31%
33%
16%
41%
30%
PPROM
Management Issues
Timing of Delivery
 Tocolysis
 Antibiotics
 Steroids
 Amniocentesis
 Observation vs. Induction
 Fetal Lung Maturity Testing
 Fetal Surveillance

Timing of Delivery
Neonatal Morbidity/Mortality
UAB (1995-1996)
R
D
S
I
V
H
N
E
C
S
e
p
s
i
s
1
0
0
S
u
r
v
i
v
a
l
7
5
% 5
0
2
5
0
2
32
52
72
93
13
33
5>
3
7
G
e
s
t
a
t
i
o
n
a
l
A
g
e
(
W
e
e
k
s
)
RNICU Survival and
Morbidity Data (1995-1996)
S
u
r
v
i
v
a
l
% Neonates
1
0
0
R
D
S
7
5
5
0
I
V
H
S
e
p
s
i
s
2
5
N
E
C
2
32
52
72
93
13
33
5>
3
7
W
e
e
k
s
Tocolysis
PPROM
Tocolysis
(n=33)
Bedrest
(n=42)
30.0
6.7
87.9%
45.4%
9.1%
18.2%
9.1%
29.4
5.2
76.2%
52.4%
7.1%
23.8%
11.9%
Tocolysis
Gestational age
Days gained
> 48 hr
RDS
Sepsis
NEC
Neonatal death
Weiner, AJOG, 1988
PPROM
Tocolysis
(n=39)
Expectant
(n=40)
27.9
11.5
77%
51%
3%
8%
47.5
27.3
12.0
75%
58%
5%
5%
57.0
Tocolysis
Gestational age
Days gained
> 48 hr
RDS
Sepsis
IVH
Hospital stay
Garite, AJOG, 1987
Antibiotics
% Patients Colonized
Preterm Labor
Chorioamnion Colonization
75
50
Spontaneous
Preterm Labor
25
Indicated
0
 30
weeks
31- 34
weeks
34- 36
weeks
 37
weeks
Cassell, 1993
PPROM
Antibiotic Therapy
 Reduction
 Prolong
Maternal/Perinatal Infection
Latency Period
 Improve
Neonatal Outcome
Antibiotic: PPROM
NIH-MFM Network Study
 PPROM
 IV
between 24 and 32 weeks
ampicillin and erythromycin for 48 h
 Oral
amoxicillin/erythromycin for 5 days
 Identification
 Tocolysis
and Rx of GBS carriers
and corticosteroids prohibited
Mercer, JAMA, 1997
Antibiotic:
NIH-MFM Network Study
Neonatal Morbidity
(n=299)
Placebo
(n=312)
40.5%
6.4%
5.4%
2.3%
6.4%
44.1%
48.7%
7.7%
6.4%
5.8%
5.8%
52.9%
Antibiotics
RDS
IVH
Sepsis <72 hr
NEC
Death
Composite
RR
0.83 *
0.82
0.83
0.40 *
1.10
0.84
*
Antibiotic: Latency Period
NIH-MFM Network Study
Duration of Latency
Antibiotics
Control
 48 hrs
27.3 %
36.6 %
 7 days
55.5 %
73.5 %
 14 days
75.6 %
87.9 %
 21 days
85.7 %
93.0 %
Median
6.1 days
2.9 days
PPROM
Antibiotic Therapy
 Optimal
Antibiotic Regimen
 Route/Duration
of Administration
Antibiotics & PPROM:
Summary
 Reduction
in maternal infectious
morbidity
 Reduction in births <48 h and <7 d
 Reduction in neonatal infectious
morbidity
 Reduction in neonates requiring NICU
and ventilation >28 d
Kenyon, Cochrane Library, 1999
Antibiotics & PPROM:
Summary
 No
clear reduction in perinatal
death
 No clear reduction in cerebral
abnormalities
Kenyon, Cochrane Library, 1999
Amniocentesis
PPROM
Amniotic Fluid Culture

Group B Streptococcus
20 %

Gardnerella vaginalis
17 %

Peptostreptococcus
11 %

Fusobacteria
10 %

Bacteroides fragilis
9%

Other Streptococci
9%

Bacteroides sp.
5%
Utility of Amniocentesis
 Confirm/Refute
diagnosis of
chorioamnionitis
Glucose
<15 mg/dL
Culture
Gram
 Lung
stain
maturity testing
Corticosteroids
Corticosteroids for FLM
 Betamethasone
 Dexamethasone
PPROM
Corticosteroids
Author
Block
Taeusch
Papageorgiou
Young
Garite
Collaborative
Iams
Nelson
Simpson
Morales
Number of Patients
Steroids Control
43
26
17
24
17
19
38
37
80
80
153
135
38
35
22
46
112
105
121
124
Effect on
RDS
PPROM
Corticosteroids
Treatment
Control
OR
RDS
83 / 456
149 / 421
0.44 *
Neonatal
Infection
18 / 200
20 / 188
0.82
Crowley, Ob/Gyn Clinics, 1992
PPROM
Corticosteroids + Antibiotics
Gestation at ROM
EGA at delivery
RDS
IVH
NEC
Sepsis
Death
Hospital days
Steroids
No Steroids
(n=38)
(n=39)
29.3
31.4
18% *
--------3%
3%
24.8
29.7
32.0
44%
8%
8%
5%
3%
29.2
Lewis, Obstetrics & Gynecology, 1996
1994 NIH Consensus Conference:
Corticosteroids in PPROM
 Corticosteroids
reduce
incidence/severity of RDS, IVH
 Benefits in PPROM up to 30-32 weeks
 No significant adverse outcomes for
corticosteroid use in PPROM
 Impact less than with intact
membranes
Observation vs. Induction
Neonatal Morbidity/Mortality
UAB (1995-1996)
1
0
0
S
u
r
v
i
v
a
l
7
5
%
5
0
R
D
S
2
5
N
E
C
I
V
H
3
0
3
2
3
4
W
e
e
k
s
S
e
p
s
i
s
3
6
PPROM
Observation vs. Induction
Cesarean delivery
Chorioamnionitis
Survival
Oxygen >24 hr
IVH
NEC
Sepsis - W/U
Sepsis - Confirmed
Induction
Expectant
(n=46)
(n=47)
8.7%
10.9%
100%
4.4%
--------28.3%
6.8%
6.4%
27.7% *
100%
2.1%
--------59.6% *
4.3%
Mercer, AJOG, 1993
PPROM
Observation vs Induction
Cesarean delivery
Chorioamnionitis
Stillbirth
Neonatal Death
RDS
IVH
NEC
Sepsis
Delivery
(n=61)
23%
2%
0
5%
37%
6%
1.6%
3%
Expectant
(n=68)
12%
15%
1.4%
0
33%
4.3%
1.4%
7%
Cox, Obstetrics & Gynecology, 1995
Fetal Lung Maturity Testing
8
10
6
8
PI
6
4
L:S
2
0
4
PG
20
24
28
32
36
Gestational Age (weeks)
40
2
0
% Phospholipid
L:S Ratio
Fetal Lung Maturation
Biologic Markers
Fetal Lung Maturity
Evaluation in Vaginal Pool
Specimen
 L:S
Ratio
 TDX:FLM
 PG
Not Reliable
Assay
Not Validated
Useful
Fetal Surveillance
PPROM
Fetal Surveillance
 Daily
Non-Stress Test (NST)
Variables
Tachycardia
Loss
of reactivity
 Biophysical
Profile (BPP)
 Contraction Stress Test (CST)
Summary
UAB Management of PPROM
•PPROM 34 weeks
•Deliver
•Previable PROM
•Outpatient observation
•Antibiotic prophylaxis
•Option of termination <22wk
•Admission at viability
UAB Management of PPROM
•PPROM 23 weeks, <34 weeks
•Antibiotic prophylaxis: Amoxicillin 500
tid x 10d, Azithromycin 1gm d1 & d5
•1 course Betamethasone if
<32weeks
•Test for pool PG weekly beginning at
32 weeks
•Deliver at 34-35 weeks