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    Premature Rupture of Membranes: What Have We Learned Since 2007?

    Premature Rupture of Membranes

    Preterm delivery occurs in approximately 12% of all births in the United States and is a major factor that contributes to perinatal morbidity and mortality (1,2). Preterm premature rupture of membranes (PROM) complicates approximately 3% of all pregnancies in the United States (3). The optimal approach to clinical assessment and treatment of women with term and preterm PROM remains controversial. Management hinges on knowledge of gestational age and evaluation of the relative risks of delivery versus the risks of expectant management (eg, infection, abruptio placentae, and umbilical cord accident). The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.

    Used with permission. Copyright the American College of Obstetricians and Gynecologists.

    ACOG Practice Bulletin No. 139: Premature Rupture of Membranes, October 2013 Obstet Gynecol 2013;122;918-30. Full text of ACOG Practice Bulletin available to ACOG members at http://www.acog.org/Resources_And_Publications/Practice_Bulletins/Commit...

    References

    1. Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Wilson EC, Mathews TJ. Births: final data for 2010. Natl Vital Stat Rep 2012;61(1):1-71. (Level II-3)

    2. Mathews TJ, MacDorman MF. Infant mortality statistics from the 2006 period linked birth/infant death data set. Nat Vital Stat Rep 2010;58:1-31. (Level II-3)

    3. Waters TP, Mercer B. Preterm P:ROM: prediction, prevention, principles. Clin Obstet Gynecol 2011;54:307-12. (Level III)

    Commentary

    PROM: What have we learned since 2007?

    Dr. Kilpatrick is the Helping Hand Endowed Chair, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, and a member of the Contemporary OB/GYN Editorial Board.

     

    Practice Bulletin Number 139 replaced a 2007 Practice Bulletin and a 2011 Committee Opinion.1 Not much has changed regarding the incidence or diagnosis of PROM, so what prompted this new document?

    Six new questions or recommendations were addressed:

    1. Should expectant management of preterm premature rupture of membranes (PPROM) continue after 34 weeks’ gestation?

    2. Should a cerclage be removed after PPROM?

    3. Should women with PPROM receive antenatal steroids between 32 and 34 weeks’ gestation just like those with other risks for imminently delivering preterm?

    4. Should women with PPROM receive a rescue course of antenatal steroids?

    5. Should antenatal magnesium sulfate for neuroprotection be recommended for women with PPROM?

    6. What should be offered to women with a history of PPROM in their subsequent pregnancy?

     

    The standard recommendation—that women with PPROM and no other indications for delivery should be delivered at 34 weeks—stemmed from retrospective studies suggesting that risk of infection to mother and neonate outweighed the prematurity risks by 34 weeks. Recent studies have questioned this principle and suggest that expectant management between 34 and 37 weeks’ gestation was not associated with a significant increase in neonatal infection.2,3 However, the same studies reported a significant increase in chorioamnionitis in the expectant group.

    Based on these results, the American College of Obstetricians and Gynecologists (ACOG) reaffirmed its position to recommend induction at 34 weeks’ gestation in women with PPROM. 

    Cerclage after PPROM

    How to manage a cerclage after PPROM is a difficult issue because data are insufficient to recommend either retention or removal, which is exactly what the current Practice Bulletin concludes. That conclusion is similar to the 2007 Practice Bulletin. However, the results of a randomized trial published this year provide little additional guidance because it was stopped before it reached its intended power.4 No significant difference in latency to delivery was found between women with cerclage retention and those with cerclage removal (mean 9 vs 13 days, respectively). Chorioamnionitis occurred in 42% of the women with retained cerclage versus 25% of those in whom a cerclage was removed. Although that difference was not significant, there is always the possibility of a type 2 error (ie, accepting a null hypothesis that is false).

    Likewise, there was no difference in neonatal composite morbidity with incidences of 56% and 50%, respectively, in neonates born to women with retained cerclages versus removed cerclages. I have always removed cerclages in women with PPROM based on the earlier data regarding a possible association with increase in neonatal death and infection,5,6 and this new randomized trial supports this approach.4-6

     

    Sarah J. Kilpatrick, MD, PhD
    Dr. Kilpatrick is the Helping Hand Endowed Chair in the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los ...

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