What is the management for a 20-year-old female with no prenatal care, who delivered a 27-week gestation, 785-gram baby via vaginal delivery after 3 days of premature rupture of membranes (PROM), with the baby having initial low Apgar scores improving after bag-mask ventilation?

Management of 27-Week Preterm Infant After Prolonged PROM

This infant requires immediate admission to a Level III-IV NICU with comprehensive neonatal resuscitation support, antibiotic therapy for both mother and infant given the 3-day PROM, and close monitoring for complications of extreme prematurity including respiratory distress, infection, and intraventricular hemorrhage. The mother requires postpartum antibiotics and monitoring for chorioamnionitis and hemorrhage.

Immediate Neonatal Management

Resuscitation and Stabilization

• The infant should be delivered at or immediately transferred to a center with Level III-IV NICU capabilities, as periviable infants do not survive without life-sustaining interventions immediately after delivery 1
• Continue respiratory support as needed following the initial bag-mask ventilation that improved Apgar scores from 5 to 9 1
• Establish continuous cardiorespiratory monitoring, temperature regulation, and vascular access 1
• The improved Apgar score at 5 minutes (9) suggests adequate initial response to resuscitation, though Apgar scores have limitations in predicting long-term outcomes 2

Infection Risk Management - CRITICAL PRIORITY

• Initiate broad-spectrum antibiotics immediately for the neonate given the 3-day duration of membrane rupture, which dramatically increases infection risk 1, 3
• The prolonged PROM (3 days) places this infant at extremely high risk for early-onset sepsis 1
• Obtain blood cultures, complete blood count, and C-reactive protein before starting antibiotics 3
• Standard empiric coverage typically includes ampicillin and gentamicin for early-onset sepsis 3

Respiratory Management

• Assess need for surfactant administration and mechanical ventilation versus CPAP based on respiratory status 4
• At 27 weeks gestation, early CPAP may be considered if respiratory effort is adequate, though many infants at this gestational age require intubation 4
• Monitor for respiratory distress syndrome, which is nearly universal at this gestational age without antenatal corticosteroids 5

Maternal Management - EQUALLY CRITICAL

Infection Assessment and Treatment

• Administer broad-spectrum antibiotics to the mother immediately postpartum - the 3-day PROM duration creates a 38% risk of intraamniotic infection 1, 3
• Evaluate for clinical chorioamnionitis: maternal fever ≥38°C, maternal tachycardia, uterine tenderness, purulent or foul-smelling discharge 6, 3
• Critical pitfall: Infection may be present without fever, especially in the peripartum period - do not delay antibiotics waiting for fever 3
• Monitor for signs of endometritis and sepsis in the immediate postpartum period 1

Hemorrhage Monitoring

• Monitor closely for postpartum hemorrhage, which occurs in 23.1% of cases with prolonged PROM 1, 6
• Assess for placental abruption, which has increased incidence with prolonged PROM 6
• Check hemoglobin/hematocrit and have blood products available 6

Maternal Vital Signs

• Monitor temperature, heart rate, and blood pressure every 4 hours initially 6
• Watch for signs of sepsis: fever, tachycardia, hypotension, altered mental status 1, 3

Anticipated Neonatal Complications

Short-Term Morbidities

• Respiratory distress syndrome and potential bronchopulmonary dysplasia - expect 50-57% of survivors to require respiratory medications long-term 3
• Intraventricular hemorrhage risk - perform cranial ultrasound within 72 hours and at 7-10 days 3
• Necrotizing enterocolitis risk increases with infection and prematurity 3
• Retinopathy of prematurity screening required 3
• Sepsis from prolonged PROM exposure 3

Pulmonary Hypoplasia Risk

• At 27 weeks with 3-day PROM, assess for pulmonary hypoplasia, though risk is lower than with earlier PROM 3
• Monitor oxygen requirements and ventilation parameters closely 3

Prognosis and Counseling

Survival Expectations

• At 27 weeks gestation, neonatal survival rates are significantly higher than at earlier periviable gestations, though exact outcomes depend on birth weight, presence of infection, and availability of intensive care 1
• The 3-day PROM significantly increases morbidity risk even if survival is achieved 1

Long-Term Outcomes

• Parents should be counseled about high rates of chronic pulmonary disease, neurodevelopmental impairment, and other long-term morbidities associated with extreme prematurity 1
• Approximately 50-57% of surviving children require ongoing respiratory medications 3

Critical Pitfalls to Avoid

• Do not delay neonatal antibiotics - the 3-day PROM makes infection highly likely 1, 3
• Do not assume absence of maternal fever means no infection - chorioamnionitis can present without fever 3
• Do not discharge mother without ensuring adequate postpartum infection surveillance - maternal sepsis risk is 6.8% with periviable PROM 3
• Ensure both maternal and neonatal teams are coordinating care, as both are at high risk for serious complications 1

Future Pregnancy Counseling

• In subsequent pregnancies, this mother has nearly 50% risk of recurrent preterm birth 1, 3
• Follow guidelines for management of previous spontaneous preterm birth, typically including progesterone supplementation and increased surveillance 1, 7
• History-indicated cerclage should be reserved for classic features of cervical insufficiency 1