What is the best next step for a patient at 34 weeks gestation with ruptured membranes (premature rupture of membranes), no contractions, and meconium-stained liquor, with a fundal height of 30 weeks and no signs of infection or fetal distress?

Management of PPROM at 34 Weeks with Meconium-Stained Liquor

Administer prophylactic antibiotics and proceed with induction of labor (Option C). At 34 weeks gestation with ruptured membranes, the balance shifts decisively toward delivery rather than expectant management, and antibiotics are essential to reduce infectious morbidity 1, 2.

Immediate Management Algorithm

Step 1: Antibiotic Administration

• Start broad-spectrum antibiotics immediately using IV ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 additional days 1, 2
• Azithromycin can substitute for erythromycin if unavailable 2
• Avoid amoxicillin-clavulanic acid due to increased necrotizing enterocolitis risk 2

Step 2: Proceed with Induction of Labor

• Induction is recommended at 34 weeks gestation as the optimal timing for delivery in high-risk situations is 34-35 6/7 weeks, when most centers can effectively manage neonatal complications 1
• Waiting until 37 weeks (Option D) is contraindicated because chorioamnionitis occurs in 38% of expectant management cases versus only 13% with immediate intervention 1, 2

Step 3: Antenatal Corticosteroids

• Administer betamethasone 12 mg IM × 2 doses, 24 hours apart, to accelerate fetal lung maturity 1, 3
• This reduces neonatal respiratory morbidity and NICU admissions even at 34 weeks 3

Why Not the Other Options?

Option A (Induction without antibiotics): Inadequate

• Antibiotics are strongly recommended (Grade 1B) for PPROM at <34 weeks and remain critical at 34 weeks to prolong latency and reduce neonatal morbidity 2
• Omitting antibiotics increases infection risk unnecessarily 4

Option B (Immediate cesarean section): Not Indicated

• Meconium-stained liquor alone is not an indication for cesarean section 1
• The patient has no signs of fetal distress, no active labor, and cesarean section should be reserved for standard obstetric indications 1
• Induction at 34 weeks does not increase cesarean section rates compared to later gestational ages 5

Option D (Expectant management until 37 weeks): Dangerous

• Expectant management significantly increases maternal hospital stay (5.2 vs 2.6 days, p=0.006) and chorioamnionitis risk (16% vs 2%, p=0.007) 4
• Infection can progress rapidly without obvious symptoms, and vigilant monitoring alone is insufficient 2
• Recent evidence shows that at 34 weeks, immediate delivery is safer than waiting 4, 6

Critical Considerations for Meconium

• Have trained personnel and equipment for intubation readily available given meconium-stained fluid 1
• Do not perform routine laryngoscopy with tracheal suctioning for meconium, as this provides no benefit and may delay resuscitation 1
• For nonvigorous newborns delivered through meconium-stained amniotic fluid, immediate resuscitation without direct laryngoscopy is recommended 1

Monitoring During Induction

• Watch for signs of chorioamnionitis: fever, maternal tachycardia, uterine tenderness, and foul-smelling vaginal discharge 1
• Monitor fetal heart rate continuously during induction 2
• Notify the neonatal team of impending preterm delivery 3
• Monitor for neonatal hypoglycemia post-delivery, which is more common after late preterm steroid exposure 3

Common Pitfalls to Avoid

• Do not delay delivery waiting for "term" at 37 weeks—the infection risk outweighs any marginal neonatal benefit at this gestational age 1, 4
• Do not assume absence of fever means no infection—intraamniotic infection may present without maternal fever, especially at earlier gestational ages 2
• Do not perform cesarean section solely for meconium—this is not an indication without fetal compromise 1