However, more typically with second-trimester spontaneous PPROM at a previable age, 40 to 50 percent of women will deliver within the first week, and 70 to 80 percent will do so after 2 to 5 weeks (American College of Obstetricians and Gynecologists, 2016f). Average latency is 2 weeks (Hunter, 2012; Kibel, 2016). Significant maternal complications attend previable PPROM and include chorioamnionitis, endometritis, sepsis, placental abruption, and retained placenta (Waters, 2009). With bleeding, cramping, or fever, abortion is considered inevitable, and the uterus is evacuated.
Without these complications, expectant management is an option in the well-counseled patient (American College of
Obstetricians and Gynecologists, 20 17). Many will choose ter mination due to the just-described maternal risks and tenuous neonatal outcomes. In contemporary cohorts with PPROM at <24 weeks' gestation, only approximately 20 percent of fetuses survive until hospital discharge (Esteves, 2016; Everest, 2008;
Muris, 2007). Of surviving infants, 50 to 80 percent sufer long-term sequelae (Miyazaki, 2012; Pristauz, 2008). Further stratification of outcomes by gestational age is described in
Chapter 42 (p. 806). Overall, prognosis is improved if previa ble PPROM occurred at a later gestation, latency is longer, and oligohydramnios is absent. Neonatal mortality predominantly stems from pulmonary dysfunction, which has higher rates when oligohydramnios persists (Winn, 2000). Fetal deforma tions may also result from scant amnionic luid. Amnioinfusion has been investigated but is currently investigational (Roberts, 20i14).
If expectant care is elected, management is described in
Chapter 42 (p. 807). Antibiotics are considered and given for 7 days to extend latency. Other topics include lung-maturing corticosteroids, magnesium sulfate neuroprophylaxis, group
B streptococcus antibiotic prophylaxis, tocolytics, and neo natal resuscitation eforts. After initial hospitalization, the patient may be discharged home, with instruction for careful surveillance for complications until viability, at which time readmission is usual (American College of Obstetricians and
Gynecologists, 20 16). In subsequent pregnancies, the risk for recurrent preterm birth is great, and in one cohort study, the rate neared 50 percent (Monson, 2016).
With abortion legalization, horriic infections and maternal deaths associated previously with criminal septic abortions are now rare. Still, with spontaneous or induced abortion, organisms may invade myometrial tissues and extend to cause parametritis, peritonitis, and septicemia. Most bacteria causing septic abortion are part of the normal vaginal lora. Particularly worrisome are severe necrotizing infections and toxic shock syndrome caused by group A streptococcus-S pyogenes (Daif, 2009).