One in a hundred pregnancies is complicated by preterm premature rupture of the membranes (PPROM). Although there is data to guide management of such pregnancies in the third trimester, management at the threshold of viability is difficult and somewhat controversial. Advances in neonatal intensive care and the availability of broad-spectrum antibiotic therapy have generally promoted the expectant management of PPROM, but whether this is appropriate for very early PPROM remains uncertain. This retrospective study examined the outcomes of 66 singleton pregnancies, seen in the years 1997–1999, in which PPROM occurred between 18 and 23 weeks' gestation. Women delivering spontaneously within 12 hours of membrane rupture or who preferred termination, women with poor dating criteria, those with signs of chorioamnionitis (fever, uterine tenderness, purulent discharge, fetal tachycardia), and pregnancies complicated by fetal anomalies or aneupoidy were excluded. All patients were hospitalized for bed rest and intermittent fetal monitoring. Intravenous antibiotic therapy included ampicillin, penicillin (or clindamycin if allergic to penicillin), or a combination of ampicillin/amoxicillin and erythromycin.
Study cases were divided into two gestational age groups for comparison. Pregnancies with PPROM at 18–21 weeks had a mean latency of 48 hours before delivery, while those at 22–23 weeks had an 82 hour latency (P < .022). The two groups had similar rates of chorioamnionitis, abruption, retained placenta, and post partum hemorrhage. Of the 34 pregnancies with PPROM at 18–21 weeks, 32 resulted in intrauterine demise and 2 (10%) resulted in a livebirth, but only one infant was eventually discharged alive. Of the 32 22–23 week pregnancies, 14 resulted in intrauterine demise and 18 (90%) resulted in a livebirth; 11 were discharged alive. The median time in the nursery for infants surviving the perinatal period was nearly 5 months. Of the 12 infants discharged alive, there was follow up information on 11. All surviving infants had major neonatal morbidity—such as respiratory distress syndrome or chronic lung disease, severe gastro esophageal reflux, or seizure disorder, renal atrophy, aortic thrombosis, hydrocephalus, vocal cord paralysis, ileal atresia, hearing loss, hydronephrosis, generalized osteopenia, and congenital brachial plexopathy.
These data indicate that PPROM occurring between 18 and 23 weeks' gestation and managed expectantly results in a very poor outcome.
Department of Obstetrics and Gynecology, University of Miami School of Medicine, Miami, Florida
Eur J Obstet Gynecol Reprod Biol 2006;128:119–124