Management of preterm premature rupture of membranes

In conclusion, the suggested management for PROM follows two general principles. The first principle, which is accepted by most, consists of searching for a positive history of PROM, confirming PROM (by speculum examination, pooling, positive Nitrazine testing, and ferning), and obtaining cervical and vaginal cultures (for group B streptococcus/gonococcus and chlamydia). If free-flowing fluid from the cervix is seen, or if pooling is present, a sample should be sent for L-S and PG analysis. The cervix is assessed (for position, dilatation, and abnormalities), monitoring of maternal vital signs and fetal heart rate is done, white blood cell and differentials are obtained, and finally, immediate ultrasonogrpahy should be performed to document fetal position and viability, the number of fetuses, the amount of amniotic fluid, fetal anatomy, gestational age, and estimated weight. The other principle is a controversial one. It involves the use of amniocentesis for determination of fetal lung maturity and the presence of bacteria (if technically feasible); the use of a short course of tocolysis (terbutaline, 0.250 mg subcutaneously, or a similar medication for patient evaluation) if patient has contractions and all information is not yet available; the administration of steroids to accelerate fetal lung maturity; and finally, the administration of prophylactic antibiotics. In any event, delivery is indicated if there is clinical evidence of chorioamnionitis, as evidenced by maternal fever and tachycardia, tender uterus, fetal tachycardia, elevated white blood cell count with bands or left shift, and a positive Gram stain on examination of amniotic fluid. Antibiotic prophylaxis or treatment is only used if group B streptococcus or N. gonorrhea, or both, are present. Cesarean sections are reserved for obstetrical indications only. Furthermore, delivery is also indicated if there is evidence of lung maturity, fetal distress, active labor or advanced cervical dilatation (greater than or equal to 4 cm), PROM before the 20th to 22nd week of gestation, advanced gestational age of more than 36 weeks, or hemorrhage. In all circumstances, monitoring of the fetus with PROM is essential, with a nonstress test performed every other day to assess variable decelerations or a daily biophysical profile performed, as previously recommended. Even though no absolute recommendation exists as to the frequency of intrapartum testing, evaluation of the fetus with PROM should be done frequently, even on a daily basis.(ABSTRACT TRUNCATED AT 400 WORDS)