Clinical Review

PPROM: New strategies for expectant management

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References

Corticosteroids beneficial if infection is treated

In 1998, the National Institutes of Health issued a Consensus Statement5 recommending corticosteroid therapy to accelerate fetal lung maturity and decrease neonatal morbidity in PPROM patients. Many authorities questioned the wisdom of this recommendation, since earlier studies had suggested an increased risk of maternal morbidity when corticosteroids are given as therapy for PPROM.16 However, these early studies did not use antibiotics to treat infection—the primary cause of PPROM—and many patients underwent digital vaginal exams, which probably contributed to unfavorable maternal and neonatal outcomes.

I recently began treating PPROM patients with antibiotics for 12 hours prior to administering corticosteroids and noted a considerable benefit for steroid therapy.17 I therefore recommend that PPROM patients who are treated expectantly receive corticosteroids unless there is evidence of an infection.

Tocolysis: jury still out

The use of tocolytics also is controversial. Many original studies reported no overall benefit and a significant increase in maternal morbidity when tocolytic therapy was given for ruptured membranes.18 However, many patients in these trials underwent digital vaginal exams and were not given antibiotics, and many received corticosteroids.

In my practice, I give magnesium sulfate and corticosteroids for the first 48 hours to women at or beyond 23 weeks’ gestation, provided there is no evidence of infection.19 However, additional data is needed before this management protocol can be considered the standard of care.

Assess fetal well-being frequently

Initial recommendations for antepartum testing were based on the high perinatal morbidity and mortality associated with PPROM. Nonstress testing was the foundation of therapy, and many authorities advocated daily nonstress testing even in the absence of definitive proof of its benefit.4

In the late 1980s, Vintzileos20 and other experts recommended daily biophysical profiles, suggesting that this strategy could identify patients with subclinical infection.

Daily biophysical profiles: No benefit beyond that of daily nonstress test

My colleagues and I7 conducted the only reported prospective, randomized trial comparing daily biophysical profiles to daily nonstress testing with backup biophysical profiles for abnormalities. We concluded that daily biophysical profiles provide no benefit beyond that achieved with daily nonstress testing. Whether a less intense testing protocol would produce the same benefit is unclear.

Important to recognize high risk of poor perinatal outcome

The important point in managing patients with PPROM is recognizing the high risk of poor perinatal outcome. For this reason, frequent evaluation of fetal well-being is an essential element of any management plan.

Determine mode of delivery as usual, but monitor fetus

In PPROM cases, the fetus often is intolerant of labor, primarily because of oligohydramnios and subclinical infection. For this reason, monitor the fetus very closely in the intrapartum period. Amnioinfusion decreases variable decelerations and improves pH in these patients and should be considered when it is clinically indicated.21

Determine the mode of delivery using routine obstetrical indications. Deliver viable breech infants by cesarean section.

Few data exist on the benefit of cesarean for the very premature neonate; use of routine obstetrical indicators is advisable.

Special situations

Four conditions may affect management of the patient with PPROM:

Cerclage in place

Numerous early studies suggested that this foreign body is a focus of infection and recommended removal. However, recent reports have not substantiated these findings.22 A large, multicenter, prospective, randomized trial is underway, which compares expectant management with cerclage removal when membranes rupture. It should provide a definitive answer.

Herpes simplex infection

If the patient with PPROM has a clinical outbreak of herpes simplex virus, weigh the risk of early delivery against the risk of herpes simplex infection. Major et al23 compiled a case series showing that infants did not become infected with herpes simplex virus when women were managed expectantly. Still, consider prophylactic therapy with antiviral agents in expectantly managed patients. At later gestational ages, most experts recommend delivery.

Bleeding

Placental abruptions occur in about 5% of PPROM pregnancies.24 Some authorities contend that the cause of abruption is placental shearing following leakage of amniotic fluid and decreased intrauterine volume. However, bleeding is rarely substantial enough to warrant delivery. Even so, monitor women with active bleeding in the labor suite, remaining vigilant for evidence of fetal compromise.

Outpatient management

Only 1 study has evaluated outpatient management of women with PPROM.25 Until more definitive information is available, the American College of Obstetricians and Gynecologists recommends that outpatient management be limited to approved study protocols.6

The author reports no financial relationships relevant to this article.

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