From the Guidelines
For preterm premature rupture of membranes (PPROM) at 35 weeks, immediate delivery is generally recommended rather than expectant management. At this gestational age, the risks of prolonging pregnancy (such as chorioamnionitis, placental abruption, and cord prolapse) typically outweigh the benefits of further fetal maturation. The most recent guidelines from the Society for Maternal-Fetal Medicine do not specifically address PPROM at 35 weeks, but they do emphasize the importance of individualized counseling about the maternal and fetal risks and benefits of both abortion care and expectant management for previable and periviable preterm prelabor rupture of membranes 1.
Key Considerations
- The risks of intrauterine infection and other complications increase with prolonged rupture of membranes, making immediate delivery a safer option for both the mother and the fetus.
- Antibiotic prophylaxis may be considered in certain cases, but the specific recommendations for PPROM at 35 weeks are not clearly outlined in the provided evidence.
- Corticosteroids are not typically recommended at 35 weeks as fetal lung maturity is generally adequate, but this decision should be made on a case-by-case basis.
- Tocolytics are contraindicated in the setting of PPROM, as they can increase the risk of infection and other complications.
Management
- Immediate delivery is the recommended course of action for PPROM at 35 weeks, taking into account the individual circumstances of the patient and the fetus.
- The decision for immediate delivery at 35 weeks is supported by evidence showing minimal neonatal morbidity at this gestational age, while the risk of intrauterine infection increases with prolonged rupture of membranes 1.
- Group B Streptococcus (GBS) prophylaxis should be administered if GBS status is positive or unknown, following standard guidelines.
From the Research
Definition and Diagnosis of PPROM
- Preterm premature rupture of membranes (PPROM) is defined as the rupture of membranes before 37 weeks' gestation and before the onset of labor 2, 3, 4.
- PPROM is diagnosed through sterile speculum examination and patient's history, with additional tests in equivocal cases 5.
Management of PPROM at 35 Weeks of Gestation
- The current management of PPROM at 35 weeks of gestation involves either delivery or expectant management, with the goal of weighing the potential neonatal benefits against the maternal risks 2.
- A study found no difference in composite neonatal morbidity between expectant management until 35 weeks and immediate delivery at 34 weeks 6.
- However, expectant management is associated with a decreased length of NICU admission but increased short-term infectious morbidity 6.
Recommendations for Management
- The American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynaecologists, and the Society of Obstetricians and Gynaecologists of Canada recommend expectant management from viability until the late preterm period, with immediate induction of labor if severe complications are identified 5.
- There are discrepancies on the optimal timing of delivery, with some guidelines recommending immediate delivery at 34 weeks of gestation or later due to the higher risk of maternal complications 2.
- Magnesium sulfate should be administered in case of imminent preterm delivery, but there is no consensus on the upper gestational age limit 5.
Outcomes and Risks
- PPROM is a significant contributor to maternal and neonatal morbidity, with risks including respiratory distress syndrome, neonatal sepsis, umbilical cord prolapse, placental abruption, and fetal death 4.
- Expectant management is associated with an increased risk of maternal complications, such as hemorrhage and infection, and neonatal risks, such as sepsis or composite neonatal morbidity 2, 6.