What is the best course of action for a patient at 34 weeks gestation with ruptured membranes for 6 hours, meconium-stained liquor, and no uterine contractions?

Management of PPROM at 34 Weeks with Meconium-Stained Liquor

The correct answer is C: Induction of labor with prophylactic antibiotics. At 34 weeks gestation with ruptured membranes for 6 hours and meconium-stained liquor, immediate induction with concurrent antibiotic prophylaxis is the standard of care to minimize infection risk while avoiding unnecessary cesarean delivery.

Rationale for Induction of Labor

• At 34 weeks gestation, neonatal outcomes are favorable with modern intensive care, making delivery the appropriate management rather than expectant observation 1
• The presence of meconium-stained fluid in the setting of PPROM signals potential fetal compromise and is a contraindication to expectant management 1
• Prolonged expectant management at this gestational age exposes the mother to unacceptable infection risk, with clinical symptoms potentially being less overt at earlier gestational ages 2, 1
• Induction minimizes the interval from membrane rupture to delivery, reducing maternal and neonatal infectious morbidity 1

Antibiotic Prophylaxis Protocol

Antibiotics are strongly recommended (GRADE 1B) for PPROM ≥24 weeks gestation to prolong latency, reduce maternal infection and chorioamnionitis, and decrease neonatal morbidity 1, 3, 4

Standard Regimen:

• IV ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 days (total 7-day course) 1, 5, 6, 3
• Azithromycin can replace erythromycin if unavailable 6
• GBS prophylaxis is mandatory for preterm delivery (<37 weeks) with ruptured membranes, regardless of GBS colonization status 1
• IV penicillin or ampicillin should be initiated immediately (or cefazolin if penicillin-allergic) 1

Why Not the Other Options

Option A (Induction alone without antibiotics):

• Fails to provide necessary antimicrobial coverage when membrane rupture exceeds 6 hours in a preterm patient 1
• Antibiotics are indicated after 18 hours of membrane rupture regardless of other risk factors, but at 34 weeks with PPROM, they should be started immediately 5

Option B (Cesarean section):

• Cesarean delivery should not be performed reflexively based on meconium alone without clear obstetric indication 1
• Neither meconium presence nor GBS concerns justify cesarean section in the absence of fetal compromise or other obstetric indications 1
• The patient is stable with no contractions and no documented fetal distress

Option D (Antibiotics with expectant management):

• Expectant management is contraindicated once meconium is identified in PPROM at viable gestational age 1
• At 34 weeks, the risks of expectant management outweigh any minimal benefits of continued pregnancy 1
• Waiting for spontaneous delivery exposes both mother and fetus to unnecessary infection risk 1

Induction Protocol

• Begin IV oxytocin immediately after initiating antibiotic prophylaxis 1
• Continuous fetal heart rate monitoring is essential given meconium presence 1
• Monitor for signs of chorioamnionitis: maternal fever, uterine tenderness, fetal tachycardia, purulent/malodorous discharge 1, 6
• Obtain vaginal-rectal GBS culture if not already done, though treatment should not be delayed pending results 1

Critical Pitfalls to Avoid

• Never use amoxicillin-clavulanic acid (Augmentin), which increases necrotizing enterocolitis risk in neonates 1, 5, 6
• Do not delay antibiotic administration beyond what is necessary to establish IV access 1
• Do not wait for maternal fever to diagnose infection, as clinical symptoms may be subtle at preterm gestational ages 2, 1
• Do not perform cesarean section without clear obstetric indication based solely on meconium or preterm status 1