Skip to main content Accessibility help
×
Home
  • Print publication year: 2005
  • Online publication date: August 2009

7 - Management of preterm premature ruptured membranes

Summary

Introduction

It would be reasonable to question the need for a separate chapter dealing with the management of preterm, premature rupture of the fetal membranes (pPROM). After all, pPROM is present in up to 40% of cases of premature labour, almost always results in birth of a premature infant and has a common infectious aetiology with preterm labour. However, important data, such as those from the ORACLE 1 randomised trial which showed therapeutic benefit from maternal antibiotic treatment after pPROM but not preterm labour with intact membranes, suggest that in some respects these two clinical scenarios should be considered as separate, but related entities.

The increasing realisation that the fetal inflammatory response to materno-fetal infection can lead to bronchopulmonary dysplasia and long-term neurological disability is now a key factor in the management of pPROM. The high frequency of proven intra-amniotic infection (approximately 30%) with pPROM, potentially long delays between presentation and spontaneous onset of labour, and evidence that the rate of microbial invasion increases over time (up to 75% by the onset of labour), give rise to management issues unique to this pregnancy complication. These issues include: how is materno-fetal infection and its inflammatory consequences best detected, are there therapeutic interventions which can ameliorate the fetal inflammatory response and so reduce perinatal and long-term morbidity, and when is the optimal time to deliver the fetus? As will become clear, the data are not yet available to answer many of these questions.

Related content

Powered by UNSILO
REFERENCES
Ayres, Ar W. (2002) Home management of preterm premature rupture of membranes. Int. J. Obstet. Gynecol. 78, 153–5.
Badawi, N., Kurinczuk, J. J., Keogh, J. M.et al. (1998) Intrapartum risk factors for newborn encephalopathy: the Western Australian case-control study. BMJ 317, 1554–8.
Baud, O., Ville, Y., Zupan, V.et al. (1998) Are neonatal brain lesions due to intrauterine infection related to mode of delivery?BJOG 105, 121–4.
Baud, O., Foix-L'Helias, L., Kaminski, M.et al. (1999) Antenatal glucocorticoid treatment and cystic periventricular leukomalacia in very preterm infants. N. Engl. J. Med. 341, 1190–6,
Bearfield, C., Davenport, E. S., Sivapathasundaram, V. and Allaker, R. P. (2002) Possible association between amniotic fluid micro-organism infection and microflora in the mouthBJOG 109, 527–33.
Bottoms, S. F., Paul, R. H., Iams, J. D.et al. (1997) Obstetric determinants of neonatal survival: influence of willingness to perform Caesarean delivery on survival of extremely low-birth-weight infants. Am. J. Obstet. Gynecol. 176, 960–6.
Carlan, S. J., O'Brien, W. F., Parsons, M. T. and Lense, J. J. (1993) Preterm premature rupture of membranes: a randomized study of home versus hospital management. Obstet. Gynecol. 81, 61–4.
Carlan, S. J., Richmond, L. B and O'Brien, W. F. (1997) Randomized trial of endovaginal ultrasound in preterm premature rupture of membranes. Obstet. Gynecol. 89, 458–61.
Carroll, S. G., Papaioannou, S., Davies, E. T. and Nicolaides, K. H. (1995a) Maternal assessment in the prediction of intrauterine infection in preterm prelabor amniorrhexis. Fetal Diagn. Ther. 10, 290–6.
Carroll, S. G., Papaioannou, S. and Nicolaides, K. H. (1995b) Doppler studies of the placental and fetal circulation in pregnancies with preterm prelabor amniorrhexis. Ultrasound Obstet. Gynecol. 5, 184–8.
Carroll, S. G., Papaioannou, S., Ntumazah, I. L., Philpott-Howard, J. and Nicolaides, K. H. (1996) Lower genital tract swabs in the prediction of intrauterine infection in preterm prelabour rupture of the membranes. BJOG 103, 54–9.
Confidential Enquiries, 1997–1999. Why Mothers Die 1997–1999; Confidential Enquiries into maternal deaths in the United Kingdom. RCOG Press 2001.
Costeloe, K., Hennessy, E., Gibson, A. T., Marlow, N. and Wilkinson, A. R. (2000) The EPICure study: outcomes to discharge from hospital for infants born at the threshold of viability. Pediatrics 106, 659–71.
Cox, S. M. and Leveno, K. J. (1995) Intentional delivery versus expectant management with preterm premature ruptured membranes at 30–34 weeks' gestation. Obstet. Gynecol. 86, 875–9.
Crowley, P. (2002) Prophylactic corticosteroids for preterm birth (Cochrane review). In The Cochrane Library, Issue 2, Oxford: Update Software.
Dalitz, P., Harding, R., Rees, S. M. and Cock, M. L. (2003) Prolonged reductions in placental blood flow and cerebral oxygen delivery in preterm fetal sheep exposed to endotoxin: possible factors in white matter injury after acute infection. J. Soc. Gynecol. Investig. 10: 283–90.
Dewan, H. and Morris, J. M. (2001) A systematic review of pregnancy outcome following preterm premature rupture of membranes at a periviable gestation. Aust. N. Z. J. Obstet. Gynaecol. 41, 389–94.
Eklind, S., Mallard, C., Leverin, A-L.et al. (2001) Bacterial endotoxin sensitizes the immature brain to hypoxic-ischemic injury. Eur. J. Neurosci. 13, 1101–6.
Farooqi, A., Holmgren, P. A., Engberg, S. and Serenius, F. (1998) Survival and 2 year outcome with expectant mangement of second trimester rupture of membranes. Obstet. Gynecol. 92, 895–901.
Fortunato, S. J., Welt, S. I., Eggleston, M.et al. (1990) Prolongation of the latency period in preterm premature rupture of membranes using prophylactic antibiotics and tocolysis. J. Perinatol. 10, 252–6.
Friedman, M. L. and McElin, T. W. (1969) Diagnosis of ruptured fetal membranes: clinical study and review of the literature. Am. J. Obstet. Gynecol. 104, 544–50.
Gomez, R., Romero, R., Ghezzi, F.et al. (1998) The fetal inflammatory response syndrome. Am. J. Obstet. Gynecol. 179, 194–202.
Goncalves, L. F., Chaiworapongsa, T. and Romero, R. (2002) Intrauterine infection and prematurity. Met. Retard. Dev. Disabil. Res. Rev. 8, 3–13.
Grau, A. J., Buggle, F., Becher, H.et al. (1998) Recent bacterial and viral infection is a risk factor for cerebrovascular ischaemia: clinical and biochemical studies. Neurology 50, 196–203.
Gyetvai, K., Hannah, M. E., Hodnett, E. D. and Ohlsson, A. (1999) Tocolytics for preterm labor: a systematic review. Obstet. Gynecol. 94, 869–77.
Hadi, H. A., Hodson, C. A. and Strickland, D. (1994) Premature rupture of the membranes between 20 and 25 weeks gestation: role of amniotic fluid volume in perinatal outcome. Am. J. Obstet. Gynecol. 170, 1139–44.
Hillier, S. L., Witkin, S. S., Krohn, M. A.et al. (1993) The relationship of amniotic fluid cytokines and preterm delivery, amniotic fluid infection, histological chorioamnionitis and chorioamnion infection. Obstet. Gynecol. 81, 941–8.
Hitti, J., Riley, D. E., Krohn, M. A.et al. (1997) Broad-spectrum bacterial rDNA polymerase chain reaction assay for detecting amniotic fluid infection among women in premature labor. Clin. Infect. Dis. 24, 1228–32.
Jobe, A. H., Newham, J. P., Willett, K. E.et al. (2000) Effects of antenatal endotoxin and glucocorticoids on the lungs of preterm lambs. Am. J. Obstet. Gynecol. 182, 401–8.
Kenyon, S. L., Taylor, D. J. and Tarnow-Mordi, W; ORACLE Collaborative Group. (2001a) Broad-spectrum antibiotics for preterm, prelabour rupture of fetal membranes: the ORACLE I randomised trial. Lancet 357, 979–88.
Kenyon, S. L., Taylor, D. J. and Tarnow-Mordi, W.; ORACLE Collaborative Group. (2001b) Broad-spectrum antibiotics for spontaneous preterm labour: the ORACLE II randomised trial. Lancet 357, 989–94.
Kenyon, S. L., Boulvain, M. and Neilson, J. (2002) Antibiotics for preterm premature rupture of membranes (Cochrane review). In The Cochrane Library, Issue 2, Oxford: Update software
Kilbride, H. W. and Thibeault, D. W. (2001) Neonatal complications of preterm premature rupture of membranes. Pathophysiology and management. Clin. Perinatol. 28, 761–5.
Kishida, T., Yamada, H., Negishi, H.et al. (1996) Diagnosis of premature rupture of the membranes in preterm patients, using an improved AFP kit: comparison with ROM-check and/or nitrazine test. Eur. J. Obstet. Gynecol. Reprod. Biol. 69, 77–82.
Kurkinen-Raty, M., Koivisto, M. and Jouppila, P. (1998) Perinatal and neonatal outcome and late pulmonary sequelae in infants born after preterm premature rupture of membranes. Obstet. Gynecol. 92, 408–15.
Laudy, J. A., Tibboel, D., Robben, S. G.et al. (2002) Prenatal prediction of pulmonary hypoplasia: clinical, biometric, and Doppler velocity correlates. Pediatrics 109, 250–8.
Leviton, A., Paneth, N., Reuss, M. L.et al. (1999) Maternal infection, fetal inflammatory response, and brain damage in very low birthweight infants. Developmental Epidemiology Network Investigators. Pediatr. Res. 46, 566–75.
Lewis, D. F., Major, C. A., Towers, C. V.et al. (1992) Effects of digital examinations on latency period in preterm premature rupture of membranes. Obstet. Gynecol. 80, 630–4.
Locatelli, A., Vergani, P., Di Pirro, G.et al. (2000) Role of amnioinfusion in the mangement of premature rupture of the membranes at < 26 weeks' gestation. Am. J. Obstet. Gynecol. 183, 878–82.
Ludmir, J., Bader, T., Chen, L., Lindenbaum, E. S. and Wong, G. (1994) Poor perinatal outcome associated with retained cerclage in patients with premature rupture of membranes. Obstet. Gynecol. 84, 823–6.
Major, C. A. and Kitzmiller, J. L. (1990) Perinatal survival with expectant management of midtrimester rupture of membranes. Am. J. Obstet. Gynecol. 163, 838–44.
Major, C. A., Veciana, M., Lewis, D. F. and Morgan, M. A. (1995) Preterm premature rupture of membranes and abruptio placentae: is there an association between these pregnancy complications?Am. J. Obstet. Gynecol. 172, 672–6.
Matsuda, T., Nakajima, T., Hattori, S.et al. (1997) Necrotising funisitis: clinical significance and association with chronic lung disease in premature infants. Am. J. Obstet. Gynecol. 177, 1402–7.
Matsuda, Y., Ikenoue, T. and Hokanishi, H. (1993) Premature rupture of the membranes-aggressive versus conservative approach: effect of tocolytic and antibiotic therapy. Gynecol. Obstet. Invest. 36, 102–7.
McElrath, T. F., Norwitz, E. R., Lieberman, E. S. and Heffner, L. J. (2000) Management of cervical cerclage and preterm premature rupture of the membranes: should the stitch be removed? Am. J. Obstet. Gynecol. 183, 840–6.
Mercer, B. M. (2003) Preterm premature rupture of the membranes. Obstet. Gynecol. 101, 178–93.
Mercer, B. M., Crocker, L. G., Boe, N. M. and Sibai, B. M. (1993) Induction versus expectant management in premature rupture of the membranes with mature amniotic fluid at 32 to 36 weeks: a randomized trial. Am. J. Obstet. Gynecol. 169, 775–82.
Morales, W. J. and Talley, T. (1993) Premature rupture of membranes at < 25 weeks: a management dilemma. Am. J. Obstet. Gynecol. 168, 503–7.
Moretti, M. and Sibai, B. (1988) Maternal and perinatal outcome of expectant management of premature rupture of the membranes in the midtrimester. Am. J. Obstet. Gynecol. 159, 390–6.
Naef, R. W., Allbert, J. R., Ross, E. L.et al. (1998) Premature rupture of membranes at 34 weeks to 37 weeks' gestation: aggressive versus conservative management. Am. J. Obstet. Gynecol. 178, 126–30.
Neerhof, M. G., Cravello, C., Haney, E. I. and Silver, R. K. (1999) Timing of labor induction between 32 and 36 weeks' gestation. Am. J. Obstet. Gynecol. 180, 349–52.
Nelson, K. B. and Grether, J. K. (1998) Potentially asphyxiating conditions and spastic cerebral palsy in infants of normal birthweight. Am. J. Obstet. Gynecol. 179, 507–13.
Pankuch, G. A., Appelbaum, P. C., Lorenz, R. P. (1984) Placental microbiology and histology and the pathogenesis of chorioamnionitis. Obstet. Gynecol. 64, 802–6.
Peebles, D. M., Miller, S. L., Newman, J. P., Scott, R. and Hanson, M. A. (2003) The effect of systemic administration of lipopolysaccharide on cerebral haemodynamics and oxygenation in the 0.65 gestation ovine fetus in utero. BJOG 110, 735–43
Prins, J. M., Kuiper, E. J., Mevissen, M. L. C. M., Speelman, P. and Deventer, S. J. H. (1995) Release of tumor necrosis factor alpha and interleukin 6 during antibiotic killing of Escherichia coli in whole blood: influence of antibiotic class, antibiotic concentration, and presence of septic serum. Infect. Immun. 63, 2236–42.
Quintero, R. A., Morales, W. J., Kalter, C. S.et al. (1998) Transabdominal intra-amniotic endoscopic assessment of previable premature rupture of membranes. Am. J. Obstet. Gynecol. 179, 71–6.
Rotschild, A., Ling, E. W., Puterman, M. L. and Farquharson, D. (1990) Neonatal outcome after prolonged rupture of the membranes. Am. J. Obstet. Gynecol. 162, 46–52.
Rutter, N. (1995) The extremely preterm infant. BJOG 102, 682–7.
Savitz, D. A., Ananth, C. V., Luther, E. R. and Thorp, J. M. Jr. (1997) Influence of gestational age on the time from spontaneous rupture of the chorioamniotic membranes to the onset of labor. Am. J. Perinatol. 14, 129–33.
Seaward, P. G., Hannah, M. E., Myhr, T. L.et al. (1998) International multicenter PROM study: evaluation of predictors of neonatal infection in infants born to patients with premature rupture of membranes at term. Am. J. Obstet. Gynecol. 179, 635–9
Sims, E. J., Vermilion, S. T. and Soper, D. E. (2002) Preterm premature rupture of the membranes is associated with a reduction in neonatal respiratory distress syndrome. Am. J. Obstet. Gynecol. 187, 268–72.
Spitz, B., Vossen, C., Devlieger, R. and Assche, F. A. (1999) Rupture of membranes before 26 weeks of gestation: outcome of 148 consecutive cases. J. Perinat. Med. 27, 451–7.
Vergani, P., Locatelli, A., Strobelt, N.et al. (1997) Amnioinfusion for prevention of pulmonary hypoplasia in second trimester rupture of membranes. Am. J. Perinatol. 14, 325–9.
Vintizileos, A. M., Campbell, W. A., Nochimson, D. J.et al. (1985) The fetal biophysical profile in patients with premature rupture of the membranes – an early predictor of fetal infection. Am. J. Obstet. Gynecol. 152, 510–6.
Volpe, J. J. (2001) Neurobiology of periventricular leukomalacia in the premature infant. Pediatr. Res. 50, 553–62.
Watterberg, K. L., Demers, L. M., Scott, S. M. and Murphy, S. (1996) Chorioamnionitis and early lung inflammation in infants in whom bronchopulmonary dysplasia develops. Pediatrics 97, 210–5.
Winn, H. N., Chen, M., Amon, E.et al. (2000) Neonatal pulmonary hypoplasia and perinatal mortality in patients with mid trimester rupture of amniotic membranes: a critical analysis. Am. J. Obstet. Gynecol. 182, 1638–44.
Wood, N. S., Marlow, N., Costeloe, K., Gibson, A. T. and Wilkinson, A. R. (2000) Neurologic and developmental disability after extremely preterm birth. EPICure study group. N. Engl. J. Med. 343, 378–84.
Wu, Y. W. and Colford, J. M. Jr. (2000) Chorioamnionitis as a risk factor for cerebral palsy: A meta-analysis. JAMA 284, 1417–24.
Xiao, Z. H., Andre, P., Lacaze-Masmonteil, T.et al. (2000) Outcome of premature infants delivered after prolonged premature rupture of membranes before 25 weeks of gestation. Eur. J. Obstet. Gynecol. Reprod. Biol. 90, 67–71.
Yanowitz, T. D., Jordan, J. A., Gilmour, C. H.et al. (2002) Hemodynamic disturbances in premature infants born after chorioamnionitis: association with cord blood cytokine concentrations. Pediatr. Res. 51, 310–16.
Yeast, J. D. and Garite, T. R. (1988) The role of cerclage in the management of preterm premature rupture of membranes. Am. J. Obstet. Gynecol. 158, 106–10.
Yoon, B. H., Jun, J. K., Park, K. H.et al. (1996a) Serum C-reactive protein, white blood cell count, and amniotic fluid white blood cell count in women with premature rupture of membranes. Obstet. Gynecol. 88, 1034–40.
Yoon, B. H., Romero, R., Yang, S. H.et al. (1996b) Interleukin-6 concentrations in umbilical cord plasma are elevated in neonates with white matter lesions associated with periventricular leukomalacia. Am. J. Obstet. Gynecol. 174, 1433–40.
Yoon, B. H., Jun, J. K., Romero, R.et al. (1997a) Amniotic fluid inflammatory cytokines (interleukin-6, interleukin –1β and tumor necrosis factor-alpha). Neonatal brain white matter lesions, and cerebral palsy. Am. J. Obstet. Gynecol. 177, 19–26.
Yoon, B. H., Kim, C. J., Romero, R.et al. (1997b) Experimentally induced intrauterine infection causes fetal brain white matter lesions in rabbits. Am. J. Obstet. Gynecol. 177, 797–802
Yoon, B. H., Romero, R., Jun, J. K.et al. (1997c) Amniotic fluid cytokines (interleukin-6, tumor necrosis factor-alpha, interleukin-1beta and interleukin-8) and the risk for the development of bronchopulmonary dysplasia. Am. J. Obstet. Gynecol. 177, 825–30.