I enjoyed Dr. David F. Lewis’ informative article on preterm premature rupture of membranes (PPROM) in the October issue (“PPROM: New strategies for expectant management”). What evidence, if any, supports bed rest with PPROM? And if there is evidence, what is the level of rest it supports: strict, with bathroom privileges, or a bedside commode? If strict, does Dr. Lewis advocate sequential compression stockings? Does he prefer that the patient lie flat, or in the Trendelenberg or reverse Trendelenberg position? My hospital prefers the Trendelenberg, but this seems counterintuitive to me, as I would like to see the fluid run out of the “dirty” vagina, rather than pool at the top near the cervix.
Stephen Weiss, MD
Dr. Lewis responds:
Unfortunately, clinical data do not exist to answer these important questions. When it comes to bed rest, we do know that greater activity increases the number of uterine contractions, which can be detrimental in these patients. I prescribe bed rest with bathroom privileges. I also advocate the use of compression stockings to prevent deep vein thrombosis.
As for the Trendelenberg position, I agree that it seems more likely to cause the contents of the vagina to traverse the cervix and enter the intrauterine cavity, increasing the likelihood of infection, but we lack definitive data about that, too.
The only group I am especially concerned about is women with a nonvertex fetus. There is nothing more stressful than receiving a 3 AMcall from the antenatal service about a prolapsed cord!