• PRELABOR RUPTURE OF MEMBRANES (PROM) REFERS TO MEMBRANE RUPTURE BEFORE THE ONSET OF UTERINE CONTRACTIONS (PREVIOUSLY KNOWN AS PREMATURE RUPTURE OF MEMBRANES);

• PRETERM PROM (PPROM) REFERS TO PROM BEFORE 37 WEEKS OF GESTATION.

• IT IS RESPONSIBLE FOR, OR ASSOCIATED WITH, APPROXIMATELY ONE-THIRD OF PRETERM BIRTHS

THE MANAGEMENT OF PPROM IS AMONG

• :

●ACCURATE DIAGNOSIS IN PROBLEMATIC CASES

●EXPECTANT MANAGEMENT VERSUS INTERVENTION

●USE OF TOCOLYTICS

●DURATION OF ADMINISTRATION OF ANTIBIOTIC PROPHYLAXIS

●TIMING OF ADMINISTRATION OF ANTENATAL CORTICOSTEROIDS

●METHODS OF TESTING FOR MATERNAL/FETAL INFECTION

●TIMING OF DELIVERY

INCIDENCE OF PPROM

• 3 PERCENT OF • APPROXIMATELY 0.5 PERCENT OF PREGNANCIES <27 WEEKS, • 1 PERCENT OF PREGNANCIES 27 TO 34 WEEKS, • 1 PERCENT OF PREGNANCIES 34 TO 37 WEEKS

THE STRENGTH AND INTEGRITY OF FETAL MEMBRANES DERIVE FROM EXTRACELLULAR MEMBRANE PROTEINS, • INCLUDING COLLAGENS, • FIBRONECTIN, • AND LAMININ. MATRIX METALLOPROTEASES (MMPS) DECREASE MEMBRANE STRENGTH BY INCREASING COLLAGEN DEGRADATION PATHOGENESIS

SUBCLINICAL OR OVERT INFECTION, INFLAMMATION, MECHANICAL STRESS, BLEEDING INITIATE A CASCADE OF BIOCHEMICAL CHANGES THAT CULMINATE IN PROM CLINICAL FINDINGS

RISK FACTORS • MATERNAL PHYSIOLOGIC • GENETIC • ENVIRONMENTAL FACTORS • A HISTORY OF PPROM IN A PREVIOUS • GENITAL TRACT INFECTION • ANTEPARTUM BLEEDING • CIGARETTE SMOKING HAVE A PARTICULARLY STRONG ASSOCIATION WITH PPROM

• POLYHYDRAMNIOS • ACUTE TRAUMA • SEVERAL GENETIC POLYMORPHISMS OF GENES RELATED TO INFECTION, INFLAMMATION, AND COLLAGEN DEGRADATION • FINDINGS ON PHYSICAL EXAMINATION — • DIRECT OBSERVATION OF AMNIOTIC FLUID • IF AMNIOTIC FLUID IS NOT IMMEDIATELY VISIBLE, THE WOMAN CAN BE ASKED TO PUSH ON HER FUNDUS, VALSALVA, OR COUGH TO PROVOKE LEAKAGE OF AMNIOTIC FLUID FROM THE CERVICAL OS.

FOR PATIENTS WHO ARE NOT IN ACTIVE LABOR, EXAMINATION OF THE CERVIX AND VAGINA SHOULD BE PERFORMED USING A STERILE SPECULUM. • DIGITAL EXAMINATION SHOULD BE AVOIDED BECAUSE IT MAY DECREASE THE LATENCY PERIOD (IE, TIME FROM RUPTURE OF MEMBRANES TO DELIVERY) AND INCREASE THE RISK OF INTRAUTERINE INFECTION

• FINDINGS ON ULTRASONOGRAPHY — FIFTY TO 70 PERCENT OF WOMEN WITH PPROM HAVE LOW AMNIOTIC FLUID VOLUME ON INITIAL SONOGRAPHY

OLIGOHYDRAMNIOS CAN BE DEFINED AS THE ABSENCE OF • A SINGLE POCKET OF AMNIOTIC FLUID THAT IS >2 CM IN DEPTH • AN ≤5 CM.

• APPROXIMATELY ONE-THIRD OF WOMEN WITH PPROM DEVELOP POTENTIALLY SERIOUS INFECTIONS, SUCH AS INTRA-AMNIOTIC INFECTION (CHORIOAMNIONITIS), ENDOMETRITIS, OR SEPTICEMIA. • ENDOMETRITIS IS MORE COMMON AFTER CESAREAN THAN • EARLY, SEVERE, PROLONGED OLIGOHYDRAMNIOS CAN BE ASSOCIATED WITH • PULMONARY HYPOPLASIA • FACIAL DEFORMATION • ORTHOPEDIC ABNORMALITIES •

• COMPLICATIONS ARE MOST LIKELY WHEN MEMBRANE RUPTURE OCCURS AT LESS THAN 23 WEEKS OF GESTATION.

LABORATORY CONFIRMATION OF CLINICALLY SUSPECTED PPROM

NITRAZINE IF PPROM IS NOT OBVIOUS AFTER VISUAL INSPECTION NITRAZINE PAPER. AMNIOTIC FLUID USUALLY HAS A PH RANGE OF 7.0 TO 7.3 COMPARED WITH THE NORMALLY ACIDIC VAGINAL PH OF 3.8 TO 4.2 AND THE NORMAL ACIDIC PH OF URINE OF 5.0 TO 6.0.

• FALSE-NEGATIVE AND FALSE-POSITIVE NITRAZINE TEST RESULTS OCCUR IN UP TO 5 PERCENT OF CASES FALSE-NEGATIVE TEST RESULTS CAN OCCUR WHEN • LEAKING IS INTERMITTENT • THE AMNIOTIC FLUID IS DILUTED BY OTHER VAGINAL FLUIDS. FALSE-POSITIVE RESULTS CAN BE DUE TO THE PRESENCE OF ALKALINE FLUIDS IN THE VAGINA, • BLOOD • SEMINAL FLUID • SOAP • THE PH OF URINE CAN BE ELEVATED TO NEAR 8.0 IF INFECTED WITH PROTEUS SPECIES.

• FERNING FLUID FROM THE POSTERIOR VAGINAL FORNIX IS SWABBED ONTO A GLASS SLIDE AND ALLOWED TO DRY FOR AT LEAST 10 MINUTES. AMNIOTIC FLUID PRODUCES A DELICATE FERNING PATTERN, IN CONTRAST TO THE THICK AND WIDE ARBORIZATION PATTERN OF DRIED CERVICAL MUCUS • WELL-ESTROGENIZED CERVICAL MUCUS OR A FINGERPRINT ON THE MICROSCOPE SLIDE MAY CAUSE A FALSE-POSITIVE FERN TEST; • FALSE NEGATIVES CAN BE DUE TO INADEQUATE AMNIOTIC FLUID ON THE SWAB OR HEAVY CONTAMINATION WITH VAGINAL DISCHARGE OR BLOOD.

• PLACENTAL ALPHA MICROGLOBULIN-1 PROTEIN ASSAY (PAMG-1 [AMNISURE]) FOR DIAGNOSIS OF RUPTURE OF MEMBRANES PAMG-1 (AMNISURE) — AMNISURE IS A RAPID SLIDE TEST

PLACENTAL ALPHA MICROGLOBULIN-1 IS RELEASED FROM DECIDUAL CELLS.

AN ADVANTAGE OF THIS TEST IS THAT IT IS NOT AFFECTED BY SEMEN OR TRACE AMOUNTS OF BLOOD.

• GIVEN THE RELATIVELY HIGH COST OF THIS TEST, WE SUGGEST LIMITING ITS USE TO CASES WHERE THE DIAGNOSIS REMAINS UNCERTAIN AFTER PHYSICAL EXAMINATION, • NITRAZINE AND FERN TESTS, AND ULTRASOUND ASSESSMENT.

• IGFBP-1, MAY BE OF VALUE IN CONFIRMING THE DIAGNOSIS OF PPROM IN PROBLEMATIC CASES. THIS PROTEIN IS SECRETED BY DECIDUAL AND PLACENTAL CELLS AND HAS A VERY HIGH CONCENTRATION IN AMNIOTIC FLUID COMPARED TO OTHER BODY FLUIDS. • THIS TEST IS POPULAR IN EUROPE • THE TEST IS NOT AFFECTED BY THE PRESENCE OF INFECTED VAGINAL SECRETIONS, URINE, SEMEN, OR SMALL AMOUNTS OF BLOOD.

PLACENTAL PROTEIN 12 AND ALPHA-FETOPROTEIN (ROM PLUS) THE TEST IS PERFORMED BY PLACING THE ROM PLUS TEST SWAB IN THE VAGINA FOR 15 SECONDS, PLACING THE SWAB IN A DILUENT, AND THEN PLACING A SAMPLE OF THE DILUENT ON A SPECIAL TEST STRIP, WHICH DEVELOPS A LINE IF THE PROTEINS ARE PRESENT. TRACE AMOUNTS OF BLOOD DO NOT AFFECT THE TEST.

• IMMUNOASSAY FOR ALPHA-FETOPROTEIN EMBEDDED IN A SANITARY NAPKIN • THE TEST WAS EASY TO READ BY ALL OBSERVERS

• INSTILLATION OF DYE — IN THE PAST,, 1 ML OF INDIGO CARMINE DYE IN 9 ML OF STERILE SALINE WAS INJECTED TRANSABDOMINALLY INTO THE AMNIOTIC FLUID, AND A TAMPON WAS PLACED IN THE VAGINA. TWENTY MINUTES LATER, THE TAMPON WAS REMOVED AND EXAMINED FOR BLUE STAINING, WHICH INDICATED LEAKAGE OF AMNIOTIC FLUID

THE MANAGEMENT BASED UPON CONSIDERATION OF SEVERAL FACTORS ●GESTATIONAL AGE

●PRESENCE OR ABSENCE OF MATERNAL/FETAL INFECTION

●PRESENCE OR ABSENCE OF LABOR

●FETAL PRESENTATION

●FETAL WELL-BEING

●FETAL LUNG MATURITY

●CERVICAL STATUS (BY VISUAL INSPECTION)

●AVAILABILITY OF NEONATAL INTENSIVE CARE

• SCREENING FOR GROUP B STREPTOCOCCUS, SEXUALLY TRANSMITTED INFECTIONS, AND • POSSIBLY BACTERIAL VAGINOSIS (BV) IS USEFUL FOR GUIDING ANTIBIOTIC THERAPY

ADMINISTRATION OF ANTENATAL CORTICOSTEROIDS — A COURSE OF CORTICOSTEROIDS SHOULD BE ADMINISTERED TO PREGNANCIES THAT PRESENT WITH PPROM BETWEEN 23 AND 34 WEEKS OF GESTATION.

• NEONATAL DEATH • RESPIRATORY DISTRESS SYNDROME, • INTRAVENTRICULAR HEMORRHAGE • NECROTIZING ENTEROCOLITIS • DURATION OF NEONATAL RESPIRATORY SUPPORT WERE SIGNIFICANTLY REDUCED

• ADMINISTRATION OF ANTENATAL STEROIDS FOR PREGNANCIES THAT PRESENT WITH PPROM IN THE 22ND WEEK OF GESTATION IS ALSO REASONABLE IF DELIVERY IN THE NEXT SEVEN DAYS IS ANTICIPATED • IN PREGNANCIES THAT FIRST PRESENT WITH PPROM AT >34 WEEKS AND <37 WEEKS, THE AUTHOR ADMINISTERS A FIRST COURSE OF ANTENATAL CORTICOSTEROIDS IF AMNIOTIC FLUID TESTING SUGGESTS FETAL PULMONARY IMMATURITY.

• CHEMOPROPHYLAXIS SPECIFICALLY FOR GBS IS INDICATED IF GBS TEST RESULTS ARE POSITIVE OR UNKNOWN AND DELIVERY IS IMMINENT. • AMPICILLIN 2 G INTRAVENOUSLY EVERY 6 HOURS FOR 48 HOURS • SHOULD PROVIDE ADEQUATE TREATMENT FOR GBS-COLONIZED WOMEN WHO ARE IN LABOR AT THE TIME OF ADMISSION OR WHO GO INTO LABOR WITHIN 48 HOURS OF ADMISSION. AS NOTED, THIS REGIMEN OF INTRAVENOUS AMPICILLIN, FOLLOWED BY ORAL AMOXICILLIN, COMBINED WITH AZITHROMYCIN, IS USUALLY GIVEN FOR SEVEN DAYS.

• PROPHYLACTIC ANTIBIOTICS

• ARE INDICATED TO PROLONG LATENCY AND TO REDUCE THE RISK OF BOTH NEONATAL AND MATERNAL INFECTION. • THEREBY DELAY THE ONSET OF PRETERM LABOR (PROLONG LATENCY)

• ANTIBIOTICS FOLLOWING PPROM BEFORE 37 WEEKS OF GESTATION COMPARED WITH NO TREATMENT, • ANTIBIOTIC USE WAS ASSOCIATED WITH SIGNIFICANT REDUCTIONS IN:

●CHORIOAMNIONITIS

●NEONATAL INFECTION

●USE OF SURFACTANT

●NEONATAL OXYGEN

WE RECOMMEND ADMINISTERING A SEVEN-DAY COURSE TO ALL WOMEN WITH PPROM WHO ARE MANAGED EXPECTANTLY.

AZITHROMYCIN ONE GRAM ORALLY UPON ADMISSION, PLUS

●AMPICILLIN 2 G INTRAVENOUSLY EVERY 6 HOURS FOR 48 HOURS, FOLLOWED BY

●AMOXICILLIN 500 MG ORALLY THREE TIMES DAILY OR 875 MG ORALLY TWICE DAILY FOR AN ADDITIONAL FIVE DAYS

• AZITHROMYCIN SPECIFICALLY TARGETS UREAPLASMAS, WHICH CAN BE IMPORTANT CAUSES OF CHORIOAMNIONITIS IN THIS SETTING • AZITHROMYCIN ALSO PROVIDES COVERAGE OF CHLAMYDIA TRACHOMATIS, WHICH IS AN IMPORTANT CAUSE OF NEONATAL CONJUNCTIVITIS AND PNEUMONITIS. • AMPICILLIN AND AMOXICILLIN SPECIFICALLY TARGET GROUP B STREPTOCOCCUS (GBS), MANY AEROBIC GRAM-NEGATIVE BACILLI, AND SOME ANAEROBES.

• NETWORK TRIAL ON ANTIBIOTIC THERAPY FOR REDUCTION OF INFANT MORBIDITY AFTER PPROM (INTRAVENOUS AMPICILLIN 2 G EVERY 6 HOURS AND ERYTHROMYCIN 250 MG EVERY 6 HOURS FOR 48 HOURS FOLLOWED BY ORAL AMOXICILLIN 250 MG EVERY 8 HOURS AND ERYTHROMYCIN 333 MG EVERY 8 HOURS FOR FIVE DAYS PROPHYLAXY

• WOMEN WITH PENICILLIN ALLERGY — IF THE PATIENT'S HISTORY SUGGESTS A "LOW RISK" FOR ANAPHYLAXIS (EG, ISOLATED MACULOPAPULAR RASH WITHOUT URTICARIA OR PRURITUS), THEN WE SUGGEST CEFAZOLIN 1 G INTRAVENOUSLY EVERY 8 HOURS FOR 48 HOURS, FOLLOWED BY CEPHALEXIN 500 MG ORALLY FOUR TIMES DAILY FOR FIVE DAYS. • THESE DRUGS PROVIDE COVERAGE FOR BOTH GBS AND ESCHERICHIA COLI, THE TWO MAJOR CAUSES OF NEONATAL INFECTION. WE ALSO GIVE A SINGLE ORAL DOSE OF AZITHROMYCIN 1 G. (SEE "PENICILLIN ALLERGY: IMMEDIATE REACTIONS".)

IF THE PATIENT'S HISTORY SUGGESTS A "HIGH RISK" FOR ANAPHYLAXIS (EG, ANAPHYLAXIS, ANGIOEDEMA, RESPIRATORY DISTRESS, URTICARIA, PARTICULARLY IF THESE SYMPTOMS OCCURRED WITHIN 30 MINUTES OF DRUG ADMINISTRATION), WE SUGGEST INTRAVENOUS CLINDAMYCIN 900 MG EVERY 8 HOURS FOR 48 HOURS PLUS INTRAVENOUS GENTAMICIN 5 MG/KG ACTUAL BODY WEIGHT EVERY 24 HOURS FOR TWO DOSES. SUBSEQUENTLY, THE PATIENT SHOULD RECEIVE ORAL CLINDAMYCIN 300 MG EVERY EIGHT HOURS FOR FIVE DAYS. WE ALSO GIVE A SINGLE DOSE OF AZITHROMYCIN 1 G • INDICATIONS FOR TOCOLYSIS — THE PRINCIPAL INDICATION FOR TOCOLYSIS IN THE SETTING OF PPROM IS TO DELAY DELIVERY FOR 48 HOURS TO ALLOW ADMINISTRATION OF CORTICOSTEROIDS. i. AS A GENERAL RULE, TOCOLYTICS SHOULD NOT BE ADMINISTERED FOR MORE THAN 48 HOURS. ii. THEY ALSO SHOULD NOT BE ADMINISTERED TO PATIENTS WHO ARE IN ADVANCED LABOR (>4 CM DILATION) iii. OR WHO HAVE ANY FINDINGS SUGGESTIVE OF SUBCLINICAL OR OVERT CHORIOAMNIONITIS. iv. NONREASSURING FETAL TESTING, v. ABRUPTIO PLACENTAE vi. SIGNIFICANT RISK OF CORD PROLAPSE 1. DILATED CERVIX 2. FETAL MALPRESENTATION

• AVOIDANCE OF SUPPLEMENTAL PROGESTERONE — PROGESTERONE SUPPLEMENTATION IS NOT BENEFICIAL IN WOMEN WITH PPROM IN THE CURRENT PREGNANCY.

• THE HOSPITAL AND HOME CARE GROUPS • , THE POSSIBILITY AND RISKS OF A DELAY IN DIAGNOSIS OF MATERNAL INFECTION, • CORD PROLAPSE, • PRECIPITOUS LABOR • DELIVERY NEED TO BE ADDRESSED

MATERNAL MONITORING — FOR SIGNS OF • MATERNAL TEMPERATURE • , UTERINE TENDERNESS • CONTRACTIONS • MATERNAL AND FETAL HEART RATE • PERIODICALLY MONITORING WHITE BLOOD CELL COUNTS OR OTHER MARKERS FOR INFLAMMATION/INFECTION HAS NOT BEEN PROVEN USEFUL

AMNIOCENTESIS TO OBTAIN AMNIOTIC FLUID FOR GRAM STAIN, CULTURE, LEUKOCYTE ESTERASE, AND GLUCOSE CONCENTRATION IS MORE CONTROVERSIAL. 1. WE DO NOT ROUTINELY PERFORM TO SCREEN FOR INTRAAMNIOTIC INFECTION IN ASYMPTOMATIC WOMEN. 2. IF THE CLINICAL DIAGNOSIS OF CHORIOAMNIONITIS IS UNCERTAIN AND WE NEED MORE INFORMATION TO DECIDE ABOUT EXPECTANT MANAGEMENT, THEN WE PERFORM AMNIOCENTESIS TO RULE OUT INFECTION. HOWEVER IF THERE IS INSUFFICIENT AMNIOTIC FLUID TO SAMPLE, • WHICH OCCURS IN AT LEAST 50 PERCENT OF PATIENTS, • THEN THE DIAGNOSIS OF CHORIOAMNIONITIS WILL HAVE TO BE BASED ON CLINICAL EXAMINATION AND INDIRECT TESTING SUCH AS IDENTIFICATION OF AN ABNORMAL PERIPHERAL WHITE BLOOD CELL COUNT.

FETAL MONITORING

• A DAILY NST • IF THE NST IS NOT REASSURING, WE PERFORM A BPP. • HOWEVER, NONE OF THESE TESTS HAS GOOD SENSITIVITY FOR PREDICTING FETAL INFECTION • THUS A LOW BPP SCORE (≤6) SHOULD BE MANAGED IN STANDARD FASHION EVEN THOUGH THE PREDICTIVE VALUE FOR INFECTION IS LOW

DOPPLER SURVEILLANCE IS NOT USEFUL FOR MONITORING FETAL STATUS IN PPROM

SPECIAL SITUATIONS

• MECONIUM STAINED FLUID — HAVE HIGHER RATES OF BOTH OVERT AND SUBCLINICAL CHORIOAMNIONITIS AND POSITIVE AMNIOTIC FLUID CULTURES • MECONIUM RELEASE PREDISPOSES TO INFECTION BY ENHANCING THE GROWTH OF BACTERIA AND LOWERING PHAGOCYTIC CAPACITY OF NEUTROPHILS

PATIENTS WITH PPROM AND MECONIUM-STAINED AMNIOTIC FLUID SHOULD BE EVALUATED FOR SIGNS OF CHORIOAMNIONITIS.

• IN THE ABSENCE OF THESE SIGNS, MECONIUM ALONE IS NOT AN INDICATION FOR INTERVENTION • TISSUE SEALANTS — A VARIETY OF TISSUE SEALANTS (EG, FIBRIN GLUE, GELATIN SPONGE) HAS SHOWN SOME SUCCESS IN STOPPING LEAKAGE IN CASE REPORTS.

• NEITHER THE SAFETY NOR THE EFFICACY OF THESE SEALANTS HAS BEEN ESTABLISHED. TISSUE SEALANTS ARE DISCUSSED IN MORE DETAIL SEPARATELY • —IN PATIENTS WHO RECEIVED ANTEPARTUM TRANSABDOMINAL AMNIOINFUSION VERSUS THOSE WHO RECEIVED USUAL CARE FOR MANAGEMENT OF PPROM IN THE THIRD TRIMESTER • TRANSABDOMINAL AMNIOINFUSION RESULTED IN STATISTICALLY SIGNIFICANT REDUCTIONS IN NEONATAL DEATH, SEPSIS/INFECTION, AND PULMONARY HYPOPLASIA • , BUT DATA FOR EACH OUTCOME WERE LIMITED TO ONE TO TWO VERY SMALL TRIALS OF LOW TO MODERATE QUALITY.

• WHETHER AMNIOINFUSION IS BENEFICIAL IN PPROM • WE DO NOT RECOMMEND PERFORMING ANTEPARTUM AMNIOINFUSION ON PATIENTS WITH PPROM.

• TWIN PREGNANCY — WE MANAGE TWIN PPROM IN THE SAME WAY AS SINGLETON PPROM BASED ON CLINICAL EXPERIENCE AND GENERALLY ACCEPTED PRACTICE PATTERNS.

• DIAGNOSIS AND TREATMENT OF OVERT INFECTION — 1. MATERNAL FEVERH 2. LEUKOCYTOSIS 3. FETAL TACHYCARDIA 4. PURULENT-APPEARING FLUID COMING FROM THE CERVICAL OS.

• DIAGNOSIS OF SUBCLINICAL CHORIOAMNIONITIS REQUIRES AMNIOCENTESIS TO IDENTIFY MICROORGANISMS IN THE AMNIOTIC FLUID 1. GRAM STAIN 2. AND CULTURE 3. LOW AMNIOTIC FLUID GLUCOSE • A RAPID TEST FOR INTERLEUKIN-6 (IL-6), WHICH IS PERHAPS THE MOST SENSITIVE MARKER FOR MICROBIAL INVASION OF THE AMNIOTIC CAVITY, IS AVAILABLE IN SOME COUNTRIES

WOMEN WHO DEVELOP OVERT INFECTION REQUIRE THERAPEUTIC, RATHER THAN PROPHYLACTIC, ANTIBIOTICS.

• ASSESS FETAL LUNG MATURITY BY FIRST TRYING TO ASPIRATE AMNIOTIC FLUID FROM THE VAGINAL VAULT, • BUT WILL PERFORM AMNIOCENTESIS IF REQUIRED TO OBTAIN FLUID (IF AMNIOCENTESIS IS PERFORMED WE ALSO PERFORM CULTURES TO CHECK FOR INFECTION).

• WE USE THE LAMELLAR BODY COUNT AS OUR INITIAL SCREEN FOR FETAL LUNG MATURITY • IF THIS TEST IS IMMATURE, WE PERFORM A LECITHIN/SPHINGOMYELIN (L/S) RATIO. • THE BALANCE BETWEEN MORBIDITY RELATED TO PREMATURITY AND MORBIDITY RELATED TO COMPLICATIONS OF PPROM (INFECTION, PLACENTAL ABRUPTION, CORD PROLAPSE/COMPRESSION).

• THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS (ACOG) SUGGESTS DELIVERY FOR ALL SUCH PATIENTS ≥34 WEEKS OF GESTATION

• IF THE PREGNANCY IS SUBOPTIMALLY DATED, OR WE CANNOT OBTAIN AMNIOTIC FLUID, OR TESTING SUGGESTS A HIGH RISK OF NEONATAL RESPIRATORY PROBLEMS, WE CONTINUE TO MANAGE THE PREGNANCY EXPECTANTLY UNTIL 37 WEEKS OF GESTATION • EARLIER DELIVERY WOULD BE INDICATED IF THE PATIENT DEVELOPED CLINICAL EVIDENCE OF INFECTION OR ABRUPTION, PRETERM LABOR, OR NONREASSURING TESTS OF FETAL WELL-BEING.

)

●FOR THE MOTHER, IMMEDIATE DELIVERY REDUCED THE RISK OF ANTEPARTUM HEMORRHAGE (1.7 VERSUS 3.0 PERCENT; AND CHORIOAMNIONITIS (1.3 VERSUS 6.4 PERCENTBUT MODESTLY INCREASED THE RISK OF CESAREAN DELIVERY (22 VERSUS 18 PERCENT)

• MAGNESIUM SULFATE FOR NEUROPROTECTION • MAGNESIUM SULFATE IS ADMINISTERED PRIOR TO DELIVERY ACCORDING TO STANDARD CLINICAL PROTOCOLS FOR FETAL NEUROPROTECTION (EG, PREGNANCIES AT LEAST 24 BUT <32 WEEKS OF GESTATION AT RISK OF IMMINENT DELIVERY

• METHOD OF DELIVERY — IN THE ABSENCE OF CONTRAINDICATIONS TO LABOR AND VAGINAL BIRTH, MOST PATIENTS WILL DELIVER BY SPONTANEOUS OR INDUCED VAGINAL

• IF THE CERVIX IS FAVORABLE, OXYTOCIN IS ADMINISTERED FOR ONCE CERVICAL RIPENING HAS OCCURRED,

• WE PREFER TO USE OXYTOCIN OVER PROSTAGLANDINS BECAUSE OXYTOCIN IS MORE EASILY TITRATED • UNFAVORABLE CERVIX — WE ADMINISTER A PROSTAGLANDIN (MISOPROSTOL) FOR CERVICAL RIPENING WHEN THE CERVIX IS UNFAVORABLE

• WHETHER MISOPROSTOL WAS ADVANTAGEOUS IN THE SUBGROUP OF WOMEN WITH AN UNFAVORABLE CERVIX IS UNKNOWN SINCE THIS WAS NOT EVALUATED.

• THE OPTIMUM DOSE AND ROUTE OF MISOPROSTOL ADMINISTRATION HAVE ALSO NOT BEEN DETERMINED. • PROSTAGLANDIN E2 IS A REASONABLE ALTERNATIVE • THERE IS MINIMAL INFORMATION ON THE SAFETY OF MECHANICAL METHODS OF CERVICAL RIPENING IN PROM

A HISTORY OF PPROM IS A STRONG RISK FACTOR FOR RECURRENCE • WE SUGGEST PROPHYLACTIC 17-HYRDOXYPROGESTERONE CAPROATE SUPPLEMENTATION FOR THESE WOMEN IN FUTURE PREGNANCIES. • PPROM MAY BE RELATED TO CERVICAL INSUFFICIENCY IN SOME CASES. IN FUTURE PREGNANCIES,

• SONOGRAPHIC MEASUREMENT OF CERVICAL LENGTH AND PLACEMENT OF A CERCLAGE IF CERVICAL LENGTH IS <25 MM BEFORE 24 WEEKS OF GESTATION CAN REDUCE THE RISK OF RECURRENT PRETERM BIRTH. •

●THE MANAGEMENT OF WOMEN WITH PPROM, INCLUDING GESTATIONAL AGE, THE AVAILABILITY OF NEONATAL INTENSIVE CARE • THE PRESENCE OR ABSENCE OF MATERNAL/FETAL INFECTION, • THE PRESENCE OR ABSENCE OF LABOR OR ABRUPTIO PLACENTAE, • THE STABILITY OF THE FETAL PRESENTATION • FETAL HEART RATE TRACING PATTERN, • THE PROBABILITY OF FETAL LUNG MATURITY, • AND CERVICAL STATUS. WE HOSPITALIZE WOMEN DURING THE ENTIRE PERIOD OF EXPECTANT MANAGEMENT (DIAGNOSIS OF PPROM TO DELIVERY). (SEE 'HOSPITALIZATION VERSUS HOME CARE' ABOVE.)

FOR PATIENTS WITH OPTIMALLY DATED PREGNANCIES AT ≥34 WEEKS AND CONFIRMATION OF FETAL LUNG MATURITY, WE SUGGEST DELIVERY RATHER THAN EXPECTANT MANAGEMENT (GRADE 2C). IF AMNIOTIC FLUID CANNOT BE OBTAINED OR THE TEST RESULTS DEMONSTRATES LUNG IMMATURITY, WE SUGGEST EXPECTANT MANAGEMENT WITH DELIVERY AT 37 WEEKS, ASSUMING THE MOTHER AND ARE STABLE