Evaluation and management of preterm premature rupture of membranes

The largest and most strictly conducted trial was reported by Mercer et al⁸ on behalf of the Maternal-Fetal Medicine Units Network. Participants—all women with PPROM between 24 and 32 weeks gestation—were randomly assigned to treatment with placebo or IV ampicillin plus erythromycin for 48 hours, followed by oral amoxicillin plus erythromycin for an additional 5 days. The main outcome measure was composite morbidity—at least 1 of the following complications: fetal or infant death, RDS, IVH, NEC, or sepsis within 72 hours of birth. (Researchers also looked at these morbidities individually.) Antibiotic prophylaxis significantly reduced the risk of composite morbidity (44.1% versus 52.9%, P = .04), RDS (40.5% versus 48.7%, P = .04), and NEC (2.3% versus 5.8%, P = .03). Among women who tested negative for group B streptococci, prophylactic antibiotics also significantly prolonged the latent period between PPROM and onset of labor (P .001>

• Monitoring. Patients selected for expectant management should be observed for evidence of maternal infection. Although a variety of laboratory tests have been proposed for the early diagnosis of infection (white blood cell count, C-reactive protein, nonstress test, biophysical profile, amniotic fluid glucose, or Gram stain), probably the most cost-effective method is monitoring maternal temperature and heart rate and fetal heart rate.
  

Patients also should be evaluated for signs of fetal cord compromise, best accomplished by serial nonstress tests. If signs of maternal infection or fetal compromise appear, delivery is indicated.

• Outpatient versus inpatient. With rare exceptions, expectant management should take place in the hospital. Carlan et al⁹ reported a randomized trial of outpatient management of PPROM, in which patients were included if they were judged to be compliant and met all of the following criteria: no evidence of cervical or intra-amniotic infection, minimal cervical dilation, stable fetal presentation, no sign of labor, reassuring heart-rate tracing, and easy access to the hospital. Patients initially were observed for 72 hours in the hospital.
  

Interestingly, only 67 of 349 patients (18%) fulfilled all criteria and therefore were considered for the trial. Compared to women who remained hospitalized, discharged patients hospital did not experience an increase in maternal infection or cesarean delivery rates. Infant outcomes also were similar.

Dr. Duff reports no affiliations or financial arrangements with any of the manufacturers of products mentioned in this article.