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


    Antenatal steroids and magnesium sulfate

    Just as for any woman at risk of imminent preterm delivery, a course of antenatal steroids was recommended for women with PPROM 24 0/7 – 34 0/7 weeks’ gestation. That is a change from the 2011 Committee Opinion, which recommended antenatal steroids only for women with PPROM before 32 weeks’ gestation, based on lack of efficacy data between 32 and 34 weeks in PPROM.

    The new guidance, of course, makes the general antenatal steroid recommendation much simpler: Treat all women likely to deliver imminently before 34 weeks with antenatal steroids to improve neonatal outcome. Data are insufficient to make a recommendation as to whether women with PPROM should receive a rescue course.

    The concept that antenatal magnesium sulfate is associated with a reduced risk of cerebral palsy (CP) is also new since the last Practice Bulletin on PROM. The largest randomized trial, reporting a significant reduction in CP in the children of mothers who received antenatal magnesium sulfate, included a large proportion of women with PPROM.7 Therefore, ACOG recommended (Level A) that women with PPROM likely to deliver before 32 0/7 weeks’ gestation, just like women at risk of imminent preterm delivery without ruptured membranes, should be candidates for magnesium sulfate for neuroprotection.

    Like women with prior spontaneous preterm delivery, those with a history of prior PPROM are at increased risk of subsequent preterm delivery. Women with a history of PPROM were included in the randomized trials of progesterone for reduction of subsequent preterm delivery and they are candidates for progesterone treatment beginning at 16 to 24 weeks’ gestation in a subsequent pregnancy.8

    Obstetric principles

    Interesting affirmations of basic obstetric principles also appear in this Practice Bulletin. We are reminded to allow sufficient time (12-18 hours) for latent labor to progress before proceeding with a failed induction in women induced at term with PPROM.

    This is a timely reminder, given our national efforts to decrease the rate of nulliparous term singleton vertex cesarean delivery. We are reminded to avoid digital exams in women with PPROM who are not in labor. And, we are reminded that there is no consensus or reasonable data to direct the frequency of fetal assessment or assessment for infection in women with viable PPROM.

    So, in this time of medicine moving toward value-based care, perhaps we should minimize if not eliminate any routine laboratory evaluation of women with asymptomatic PPROM?

    This Practice Bulletin recommends proceeding with induction because in randomized trials and meta-analysis, induction was associated with reduced time to delivery and reduced chorioamnionitis.9,10 However, the Practice Bulletin states that expectant management may be appropriate if a patient declines induction, and she is informed of the potential increased risks of delayed delivery.

    There continues to be recommendation for delivery at 34 weeks’ gestation in women with PPROM. However, the Practice Bulletin goes on to state that if expectant management is undertaken after 34 weeks, then the risk: benefit balance should be considered and discussed with the patient, and delivery should not be delayed past 37 weeks.


    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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