What is the best course of action for a stable 35-week gestation woman with ruptured membranes (Ruptured Membranes) for 6 hours, meconium-stained liquor, and no uterine contractions, with a fundal height of 30 cm?

Management of 35-Week Gestation with PPROM, Meconium-Stained Liquor, and No Contractions

The best course of action is induction of labor with prophylactic antibiotics (Option C). At 35 weeks gestation with ruptured membranes for 6 hours and meconium-stained liquor, the risks of expectant management outweigh any minimal benefits of continued pregnancy, and both induction and antibiotics are mandated by current guidelines. 1

Rationale for Induction of Labor

• At 35 weeks, delivery is indicated rather than expectant management because neonatal outcomes are favorable at this gestational age, and prolonging pregnancy exposes the mother to unacceptable infection risk. 1
• Meconium-stained liquor in the setting of PPROM signals potential fetal compromise and is a contraindication to expectant management, requiring prompt delivery. 1
• The goal is to minimize the interval from membrane rupture to delivery to reduce maternal and neonatal infectious morbidity. 1
• Induction with IV oxytocin should be initiated immediately to expedite delivery. 1

Rationale for Prophylactic Antibiotics

• CDC guidelines mandate GBS prophylaxis for all preterm deliveries (<37 weeks) with ruptured membranes, regardless of known GBS colonization status. 1, 2
• 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
• The risk of infection increases significantly after 6 hours of membrane rupture, making prompt antibiotic administration critical. 2
• Intrapartum antibiotic prophylaxis provides 86-89% effectiveness in preventing early-onset neonatal sepsis. 1

Specific Management Algorithm

Immediate Actions:

• Initiate GBS prophylaxis immediately with IV penicillin or ampicillin (or cefazolin if penicillin-allergic without anaphylaxis risk). 1, 2
• Begin induction of labor with IV oxytocin without delay. 1
• Obtain vaginal-rectal GBS culture if not already done, though treatment should not be delayed pending results. 1

Antibiotic Regimen:

• Standard regimen: IV ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 days (total 7-day course). 1, 2, 3
• Azithromycin can replace erythromycin if unavailable. 3

Monitoring During Labor:

• Continuous fetal heart rate monitoring is essential given the presence of meconium. 1
• Monitor for signs of chorioamnionitis: maternal fever (≥38°C), maternal tachycardia, uterine tenderness, fetal tachycardia, and purulent/malodorous discharge. 1, 2
• Do not delay diagnosis of intraamniotic infection due to absence of maternal fever—clinical symptoms may be less overt at preterm gestational ages. 1, 3

Why Other Options Are Incorrect

Option A (Induction alone without antibiotics):

• Fails to provide mandatory GBS prophylaxis for preterm delivery with ruptured membranes. 1
• Omits antibiotics that reduce maternal infection, chorioamnionitis, and neonatal sepsis by 86-89%. 1

Option B (Cesarean section):

• Cesarean section should not be performed reflexively based on meconium alone without clear obstetric indication. 1
• No data support cesarean section for meconium-stained liquor in the absence of fetal compromise or other obstetric indications. 1
• Vaginal delivery with continuous monitoring is appropriate when labor progresses normally. 1

Option D (Antibiotics and observation for spontaneous delivery):

• Expectant management is contraindicated once meconium is identified in PPROM at 35 weeks. 1
• Waiting for spontaneous labor unnecessarily prolongs the interval from membrane rupture to delivery, increasing infection risk. 1
• Active induction is superior to expectancy at this gestational age. 1

Critical Pitfalls to Avoid

• Never use amoxicillin-clavulanic acid (Augmentin), which increases necrotizing enterocolitis risk in neonates. 1, 2, 3
• Do not delay antibiotic administration beyond what is necessary to establish IV access. 1
• Avoid performing cesarean section without clear obstetric indication based solely on meconium or GBS concerns. 1
• Do not wait for maternal fever to diagnose infection—clinical symptoms may be subtle at preterm gestational ages. 1, 3
• Failing to administer antibiotics promptly when membrane rupture exceeds 6 hours in a preterm patient is a critical error. 1, 2