gynecology and obstetrics
Prelabor Rupture of Membranes (PROM)
Treatment
Delivery if there is fetal compromise, infection, or gestational age ≥ 34 weeks Otherwise, pelvic rest, close monitoring, antibiotics, and sometimes corticosteroids Guidelines for managing PROM in specific situations are available from theAmerican College of Obstetricians and Gynecologists (ACOG). PROM management requires balancing risk of infection when delivery is delayed with risks due to fetal immaturity when delivery is immediate. No one strategy is correct, but generally, signs of fetal compromise or infection (eg, persistently nonreassuring fetal testing results, uterine tenderness plus fever) should prompt delivery. Otherwise, delivery can be delayed for a variable period if fetal lungs are still immature or if labor could start spontaneously (ie, later in the pregnancy). Induction of labor is recommended when gestational age is ≥ 34 weeks. When appropriate management is unclear, amniotic fluid tests can be done to assess fetal lung maturity and thus guide management; the sample may be obtained from the vagina or by amniocentesis. When expectant management is used, the woman’s activity is limited to modified bed rest and complete pelvic rest. Blood pressure, heart rate, and temperature must be measured≥3 times a day. Antibiotics (usually 48 hours of IVampicillinanderythromycin, followed by 5 days of oralamoxicillinanderythromycin) are given; they lengthen the latency period and reduce risk of neonatal morbidity. Instead oferythromycin, a single dose ofazithromycin1 g can be given orally. 34 weeks, clinicians should give the woman Corticosteroids to accelerate fetal lung maturity. Another course of corticosteroids can be considered if all of the following are present: The pregnancy is < 34 weeks. Women are at risk of delivering within 7 days. The last course was given ≥ 14 days prior. Corticosteroids should also be considered in the following circumstances: At gestational age 34 weeks 0 days to 36 weeks 6 days if women are at risk of delivering within 7 days and no prior corticosteroids have been given ( Treatment reference ) Starting at gestational age 23 weeks 0 days if there is a risk of preterm delivery within 7 days ( Treatment reference ) Corticosteroids are contraindicated if there are signs of chorioamnionitis. IV magnesium sulfate should be considered in pregnancies < 32 weeks; in utero exposure to this drug appears to reduce the risk of severe neurologic dysfunction (eg, due to intraventricular hemorrhage), including cerebral palsy, in neonates. Use of tocolytics (drugs that stop uterine contractions) to manage preterm PROM is controversial; their use must be determined case by case. 1.American College of Obstetricians and Gynecologists: Committee Opinion No. 713 Summary: Antenatal corticosteroid therapy for fetal maturation.Obstet Gynecol130 (2):493–494, 2017. doi: 10.1097/AOG.0000000000002231 