Summary Fetal age Management Term > 37 weeks * Induction of labor * Antibiotics if needed to prevent group B streptococcus (GBS) transmission Late pre-term 34–36 weeks * Same as for term Preterm 24–33 weeks * * Watchful waiting (expectant management) * Tocolytics to prevent the beginning of labor * Magnesium sulfate infusion for 24–48 hours to allow maximum efficacy of corticosteroids for fetal lungs and also confer benefit to fetal brain and gut before delivery * One time dose of corticosteroids (two separate administrations, 12–24 hours apart) before 34 weeks * Antibiotics if needed to prevent GBS transmission Pre-viable < 24 weeks * Discussion of watchful waiting or induction of labor * No antibiotics, corticosteroids, tocolysis, or magnesium sulfate The management of PROM remains controversial, and depends largely on the gestational age of the fetus and other complicating factors. The risks of quick delivery (induction of labor) vs. watchful waiting in each case is carefully considered before deciding on a course of action. As of 2012, the Royal College of Obstetricians and Gynaecologists advised, based on expert opinion and not clinical evidence, that attempted delivery during maternal instability increases the rates of both fetal death and maternal death, unless the source of instability is an intrauterine<unk>  In all women with PROM, the age of the fetus, its position in the uterus, and its well being should be evaluated. This can be done with ultrasound, Doppler fetal heart rate monitoring, and uterine activity monitoring. This will also show whether or not uterine contractions are happening which may be a sign that labor is starting. Signs and symptoms of<unk> should be closely monitored, and, if not already done, a group B streptococcus (GBS) culture should be collected. At any age, if the fetal well-being appears to be compromised, or if intrauterine<unk> is suspected, the baby should be delivered quickly by induction of labour. Term Both expectant management (watchful waiting) and an induction of labor (artificially stimulating labor) are considered in this case. 90% of women start labor on their own within 24 hours, and therefore it is reasonable to wait for 12–24 hours as long as there is no risk of<unk>  However, if labor does not begin soon after the PROM, an induction of labor is recommended because it reduces rates of<unk> , decreases the chances that the baby will require a stay in the neonatal intensive care unit (NICU), and does not increase the rate of caesarean sections. If a woman strongly does not want to be induced, watchful waiting is an acceptable option as long as there is no sign of<unk>  the fetus is not in distress, and she is aware and accepts the risks of PPROM. There is not enough data to show that the use of prophylactic antibiotics (to prevent<unk>  is beneficial for mothers or babies at or near term because of the potential side effects and development of antibiotic resistance. 34 to 37 weeks When the fetus is 34 to 37 weeks gestation, the risk of being born prematurely must be weighed against the risk of PROM. Previously it was recommended that delivery be carried out as if the baby was term. A 2017 Cochrane review however found waiting resulted in better outcomes when pregnancy is before 37 weeks. 24 to 34 weeks Before 34 weeks, the fetus is at a much higher risk of the complications of prematurity. Therefore, as long as the fetus is doing well, and there are no signs of<unk> or placental abruption, watchful waiting (expectant management) is recommended. The younger the fetus, the longer it takes for labor to start on its own, but most women will deliver within a week. Waiting usually requires a woman to stay in the hospital so that health care providers can watch her carefully for<unk>  placental abruption, umbilical cord compression, or any other fetal emergency that would require quick delivery by induction of labor. In 2017, a review of watchful waiting vs the early birth strategy was conducted to ascertain which was associated with a lower overall risk. Focusing on the 24–37-week range, the review analysed twelve randomised controlled trials from the "Cochrane Pregnancy and Childbirth's Trials Register", concluding that "In women with PPROM before 37 weeks' gestation with no contraindications to continuing the pregnancy, a policy of expectant management with careful monitoring was associated with better outcomes for the mother and baby." There is believed to be a correlation between volume of amniotic fluid retained and neonatal outcomes before 26 weeks' gestation. Amniotic fluid levels are an important consideration when debating expectant management vs clinical intervention, as low levels, or oligohydramnios, can result in lung and limb abnormalities. Additionally, labor and<unk> are less likely to occur when there are sufficient levels of amniotic fluid remaining in the uterus. Serial amnioinfusion in pregnancies with PPROM-related oligohydramnios at less than 26 weeks gestation, successfully alleviates oligohydramnios, with perinatal outcomes that are significantly better than the outcome in those with the persistent condition and is comparable with gestations with PPROM in which oligohydramnios never develops. Recommended * Monitoring for<unk>  signs of<unk> include a fever in the mother, fetal tachycardia (fast heart rate of the fetus, more than160 beats per minute), or tachycardia in the mother (more than 100 beats per minute). White blood cell (WBC) counts are not helpful in this case because WBC's are normally high in late pregnancy. * Steroids before birth: corticosteroids (betamethasone) given to the mother of a baby at risk of being born prematurely can speed up fetal lung development and reduce the risk of death of the infant, respiratory distress syndrome, brain bleeds, and bowel necrosis. It is recommended that mothers receive one course of corticosteroids between 24 and 34 weeks when there is a risk of preterm delivery. In cases of PPROM these medications do not increase the risk of<unk> even though steroids are known to suppress the immune system. More than two courses is not recommended because three or more can lead to small birth weight and small head circumference. In pregnancies between 32 and 34 weeks (right around the time that fetal lungs mature) vaginal fluid can be tested to determine fetal lung maturity using chemical markers which can help to decide if corticosteroids should be given. * Magnesium sulfate: Intravenous magnesium sulfate is given to the mother in cases when there is a risk of preterm birth before 32 weeks. This has been shown to protect the fetal brain and reduce the risk of cerebral palsy. * Latency antibiotics: The time from PROM to labor is termed the latency period, and there is an inverse relationship between gestational age and the length of latency, meaning that the earlier the rupture, the longer it will take for labor to begin naturally. As expected, antibiotics given to mothers that experience PPROM serve to protect against<unk>  during this lengthened latency period. Additionally, antibiotics increase the time that babies stay in the womb. Antibiotics don't seem to prevent death or make a difference in the long-term (years after the baby is born). But, because of the short-term benefits, routine use of antibiotics in PPROM is still recommended. The American Congress of Obstetricians and Gynecologists (ACOG) recommends a seven-day course of intravenous ampicillin and erythromycin followed by oral amoxicillin and erythromycin if watchful waiting is attempted before 34 weeks. Amoxicillin/clavulanic acid increases the risk of fetal bowel death (necrotizing enterocolitis) and should be avoided in pregnancy. * Prophylactic antibiotics: If a woman is colonized with GBS, than the typical use of antibiotics during labor is recommended to prevent transmission of this bacteria to the fetus, regardless of earlier treatments. Controversial or not recommended * Preventative tocolysis (medications to prevent contractions): the use of tocolytic medications to prevent labor contractions is controversial. On the one hand, this can delay delivery and allow the fetus more time to develop and benefit from antenatal corticosteroid medication, on the other hand it increases the risk of<unk> or chorioamnionitis. The use of tocolysis has not shown to benefit mom or baby and currently there is not enough data to recommend or discourage its use in the case of preterm PROM. * Therapeutic tocolysis (medications to stop contractions): Once labor has started, using tocolysis to stop labor has not been shown to help, and is not recommended. * Amnioinfusion: This treatment attempts to replace the lost amniotic fluid from the uterus by infusing normal saline fluid into the uterine cavity. This can be done through the vagina and cervix (transcervical amnioinfusion) or by passing a needle through the abdominal wall (transabdominal amnioinfusion). Current data suggests that this treatment prevents<unk>  lung problems, and fetal death. However, there have not been enough trials to recommend its routine use in all cases of PPROM. * Home care: Typically women with PPROM are managed in the hospital, but, occasionally they opt to go home if watchful waiting is attempted. Since labor usually starts soon after PPROM, and
risks of Postpartum infections
risks of Obstructed labour
risks of Vaginal yeast infection
risks of Necrotizing enterocolitis
risks of Pelvic inflammatory disease
risks of Peritonitis
risks of Appendix cancer
Miscarriage risks