TABLE 42-9. Management of Preterm Premature Rupture of Membranes 34 weeks or more Plan delivery: labor induction unless contraindicated Group B streptococcal
Single corticosteroid course may be considered up to 366/7 weeksb 32 weeks to 33 completed weeks Expectant management
Group B streptococcal prophylaxisa Single corticosteroid coursec Antimicrobials to prolong latency 24 weeks to 31 completed weeks Expectant management
T ocolytics: no consensus Antimicrobials to prolong latency <24 weeks Expectant management or induction of labore
Group B streptococcal prophylaxis is not recommendedf
Single corticosteroid course may be considerede,f f
Tocolytics: no consensuse,n
Antimicrobials: may be considerede,9 aFigure 64-7 (p. 1222) outlines group B streptococcal prophylaxis for preterm gestations.
bMay be considered between 34°17 and 366/7 weeks in those who have not received a previous course of antenatal corticosteroids. (Repeat, or rescue, course of corticosteroids with preterm rupture of membranes is controversial.
dMagnesium sulfate for neuroprotection in accordance with one of the larger studies.
eSee Periviable Neonatal Survival (p. 806) to aid patient counseling and decision making. flntervention not recommended before viability but may be considered as early as 23°(7 weeks of gestation. 9May be considered as early as 20°/7 weeks of gestation.
Data from American College of Obstetricians and Gynecologists 2016a, d, 2017a, e.
delivery nor expectant management were proven to be superior prolonged latency after membrane rupture was not associated for neonatal outcomes. Lieman and associates (2005) found that with a greater incidence of fetal neurological damage. n imporneonatal outcomes did not improve with expectant management tant correlate is that infection-specifically chorioamnionitisbeyond 33 weeks. McElrath and coworkers (2003) found that is recognized as a risk factor for development of neonatal neurological injury (Gaudet, 2001; Wu,r2000).
•Deaths from prematurity complications recently compared planned early 150 birth with expectant management ..Deaths from pulmonary hypoplasia for women with PPROM before 37 weeks' gestation. They evaluated women and 3628 newborns. No �90 • ..0• clinically important diferences in ..,..0. .
D • the incidence of neonatal sepsis
C .•. • between women who immediately ..0. . . • . . • delivered and those managed expec ..,..0. . tantly were identified. Although the .,incidence of chorioamnionitis was ..,:I · : lower, neonates of women random ized to early birth were more likely to be born at an earlier gestational
Gestation at amniorrhexis (weeks) perinatal sequelae. The authors con cluded that in women with rupture continuing the pregnancy, a policy of expectant management with careful monitoring was associated with better outcomes for both the mother and newborn.
he American College of Obstetricians and Gynecologists (2016d) has recognized the controversies of immediate deliv ery compared with expectant management. Clearly, gestational age is an important consideration. At 24°/7 to weeks, expectant management in the absence of nonreassuring fetal status, clinical chorioamnionitis, or placental abruption is rec ommended. At 34°/7 weeks of gestation or greater, delivery is still recommended by the College for all women with ruptured membranes. Our current practices at Parkland Hospital are consistent with these recommendations.
• Considerations with Expectant Management