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

Management of 35-Week Gestation with PPROM and Meconium-Stained Liquor

The correct answer is C: Induction of labor with prophylactic antibiotics. At 35 weeks gestation with ruptured membranes for 6 hours and meconium-stained liquor, immediate induction with IV antibiotics is the standard of care to minimize maternal-neonatal infectious complications while avoiding unnecessary cesarean delivery. 1, 2

Rationale for Immediate Induction with Antibiotics

At 35 weeks, the benefits of delivery clearly outweigh any risks of expectant management, and aggressive management by induction is both safe for the infant and prevents maternal-neonatal infectious complications. 1, 2

Why Antibiotics Are Mandatory

• GBS prophylaxis is required for all preterm deliveries (<37 weeks) with ruptured membranes, regardless of known GBS colonization status, according to CDC guidelines. 1, 2
• Latency antibiotics are strongly recommended (GRADE 1B) for PPROM ≥24 weeks to reduce maternal infection, chorioamnionitis, and neonatal morbidity. 1, 2
• Intrapartum antibiotic prophylaxis provides 86-89% effectiveness in preventing early-onset neonatal sepsis among infants born to women who received prophylaxis. 1

Why Immediate Induction Is Required

• The risk of chorioamnionitis increases progressively with time from membrane rupture, and at 6 hours post-rupture, immediate induction minimizes this risk. 3
• Meconium-stained liquor in the setting of PPROM signals potential fetal compromise requiring delivery rather than expectant management. 1
• Infection can progress rapidly without obvious symptoms—the absence of fever or contractions should not provide false reassurance, as clinical signs may be less overt at preterm gestational ages. 1, 2

Specific Management Algorithm

Immediate Actions (Within Minutes of Presentation)

• Initiate GBS prophylaxis immediately with IV penicillin G or ampicillin (or cefazolin if penicillin-allergic without anaphylaxis risk). 1, 2
• Obtain vaginal-rectal GBS culture if not already done within the preceding 5 weeks, though treatment should not be delayed pending results. 1, 2
• Begin induction of labor with IV oxytocin to minimize the interval from membrane rupture to delivery, with a goal of delivery within 24 hours. 1, 2

Continuous Monitoring Requirements

• Continuous fetal heart rate monitoring is mandatory given meconium presence to detect signs of fetal compromise. 1, 2
• Monitor maternal vital signs every 2-4 hours for signs of chorioamnionitis: fever (≥38°C), maternal tachycardia, uterine tenderness, fetal tachycardia, or purulent cervical discharge. 1, 2

Delivery Planning

• Vaginal delivery should be attempted unless clear obstetric indications for cesarean section exist—meconium presence alone does not mandate cesarean delivery. 1, 2
• The standard antibiotic regimen is IV ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 days (total 7-day course). 1

Why Other Options Are Incorrect

Option A (Induction Alone) Is Inadequate

• Failing to administer antibiotics promptly when membrane rupture exceeds 6 hours in a preterm patient violates CDC and ACOG guidelines and exposes both mother and neonate to preventable infectious morbidity. 1, 2

Option B (Cesarean Section) Is Inappropriate

• Cesarean section should not be performed reflexively based on meconium alone without obstetric indication, as this increases maternal morbidity without improving neonatal outcomes. 1, 2
• Meconium presence and GBS concerns are not indications for cesarean delivery. 1

Option D (Observation) Is Dangerous

• Expectant management at 35 weeks with ruptured membranes exposes the mother to unacceptable infection risk with no meaningful fetal benefit from continued pregnancy. 1, 2
• The risk of chorioamnionitis is significantly higher with expectant management (38%) compared to immediate intervention (13%). 1

Critical Pitfalls to Avoid

• Never use amoxicillin-clavulanic acid (Augmentin) for PPROM management, as it increases the risk of neonatal necrotizing enterocolitis. 1, 2
• Do not wait for maternal fever to diagnose infection—intraamniotic infection may present without fever, especially at preterm gestational ages. 1, 2
• Do not delay antibiotic administration beyond what is necessary to establish IV access and begin infusion. 1, 2
• Do not perform digital cervical examinations in patients with PROM who are not in labor and in whom immediate induction is planned, as this increases infection risk. 4