PROM dilemmas: Choosing a strategy, knowing when to call it quits

CASE continued: Patient is apprised of the risks

After a frank discussion of the risks involved in continuing her pregnancy, J.S. chooses expectant management. Given the early gestational age and absence of any sign of infection, she is sent home for bed rest and instructed to check her temperature twice daily. She is told to return for evaluation if fever (>100°F) or symptoms of infection develop. Because of the very early gestational age, no steroid or antibiotic will be given until 24 weeks’ gestation, when she will be admitted for inpatient care.

PROM at 24 to 32 weeks’ gestation

Selecting a management strategy for a pregnancy at this gestational age means weighing the potential morbidity and mortality of immediate delivery against the morbidity and mortality of expectant management. At this gestational age, the principal source of fetal morbidity is prematurity itself. As many as 40% of infants delivered before 26 weeks’ gestation experience some type of long-term morbidity such as intraventricular hemorrhage (IVH), retinopathy of prematurity, necrotizing enterocolitis (NEC), or, most commonly, respiratory distress syndrome (RDS).^16,17 It is true that fetal morbidity increases when chorioamnionitis is present, but the potential benefit of prolonging the pregnancy by 7 to 14 days is believed to outweigh the risk of infection at these gestational ages. Therefore, in the absence of contraindications, expectant management is the usual course of action.

Select patients carefully for expectant management

Consider expectant management only when fetal well-being can be documented, without evidence of infection. Abruption is a contraindication to expectant management, although the clinical nature of this diagnosis can make it difficult to identify. If abruption is diagnosed, aggressive management with labor augmentation or cesarean section and intravenous (IV) antibiotics is appropriate.

Repetitive fetal heart decelerations in the presence of active vaginal bleeding and uterine tenderness indicate placental insufficiency and are an indication for delivery.

More than 50% of patients deliver within the first week after PROM is diagnosed.¹⁸ At least 30% experience chorioamnionitis some time after the diagnosis of PROM, and 1% to 2% suffer cord prolapse.^10,18,19 As many as 4% to 12% of cases of PROM will also be complicated by abruption,^20,21 and a rate of intrauterine fetal demise as high as 1% has been documented.¹⁸ Therefore, if expectant management is selected, it should include close monitoring for these complications.

Hospitalization is warranted. Women who are stable and being managed expectantly should probably be hospitalized. One prospective trial comparing outcomes between women managed at home and women who were hospitalized found no significant difference in latency period or the rate of infection.²² However, the strict inclusion criteria for this study make it difficult to generalize the results. Only 18% of the 349 women screened for enrollment met these criteria.

The high rate of precipitous labor, frequent onset of infection, and need for frequent maternal and neonatal evaluation at this gestational age make hospitalization a prudent choice.

Fetal surveillance is mandatory

Most investigators would agree that a regular schedule of fetal surveillance is necessary during expectant management. But there is no clear evidence indicating which type, and what timing, of surveillance are best. It is clear that changes in the FHR pattern and BPP precede the onset of chorioamnionitis and intrauterine demise due to cord accidents.^23-25 However, no studies have demonstrated a significant improvement in neonatal outcomes with daily or even twice-daily antenatal surveillance.

At our institution, we follow a regimen of daily surveillance, which consists of a nonstress test and/or BPP to confirm fetal well-being.

Tocolysis won’t prolong gestation beyond 48 hours…

There is no evidence that prolonged tocolysis with any therapy significantly increases long-term latency or improves any type of neonatal morbidity in pregnancies complicated by PROM. Tocolysis may prolong pregnancy over the short term (<48 hours),^26,27 but its widespread use is not supported by the evidence.

Tocolysis is appropriate to achieve safe maternal transport or administer steroids.

…but corticosteroids are highly beneficial

Antenatal corticosteroids clearly improve neonatal outcomes when PROM occurs before 32 weeks’ gestation. Two large meta-analyses have found such benefits to be a decrease in the rates of RDS, IVH, NEC, and neonatal death.^28,29 A recent prospective study confirmed these findings.³⁰ The rate of RDS declined 26%—from 44% to 18%.

A consensus panel of the National Institutes of Health (NIH) recommended use of corticosteroids in cases of PROM between 24 and 32 weeks’ gestation in which there is no clinical evidence of infection.³¹ Any of the standard steroid regimens is appropriate. At our institution, we give an intramuscular injection of 12 mg of betamethasone and repeat this one time in 24 hours.