In a 35‑week pregnant woman with preterm premature rupture of membranes (PPROM) for 6 hours, stable vital signs, no uterine contractions, fundal height 30 cm, and meconium‑stained amniotic fluid, what is the most appropriate management?

Management of PPROM at 35 Weeks with Meconium-Stained Liquor

The correct answer is C: Induction of labor with prophylactic antibiotics. At 35 weeks gestation with PPROM and meconium-stained amniotic fluid, immediate induction with concurrent antibiotic prophylaxis is mandatory to minimize infection risk while avoiding unnecessary cesarean delivery 1.

Rationale for Immediate Induction with Antibiotics

At 35 weeks, the risks of expectant management far outweigh any minimal benefits of prolonging pregnancy, and delivery should proceed promptly 1. The presence of meconium-stained fluid in the setting of PPROM signals potential fetal compromise and makes expectant management contraindicated 1.

Why Antibiotics Are Essential

• GBS prophylaxis is mandatory for all preterm deliveries (<37 weeks) with ruptured membranes, regardless of known colonization status, per CDC guidelines 1.
• Antibiotics are strongly recommended (GRADE 1B) for PPROM ≥24 weeks to prolong latency, reduce maternal infection and chorioamnionitis, and decrease neonatal morbidity 1, 2.
• The standard regimen is IV ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 days (total 7-day course) 1, 2.
• With 6 hours of membrane rupture, infection risk is already elevated and will continue to rise rapidly—infection can progress to maternal sepsis with a median time to death of only 18 hours once clinical signs appear 3.

Why Induction Rather Than Expectant Management

• Prolonged expectant management carries unacceptable maternal morbidity, with intraamniotic infection rates of 38% versus 13% with immediate intervention 2.
• At 35 weeks, neonatal outcomes are favorable with modern intensive care, making delivery the appropriate choice rather than risking maternal infection 1.
• Meconium presence specifically contraindicates expectant management in PPROM, as it indicates potential fetal compromise requiring delivery 1.

Why Not Cesarean Section

• Cesarean delivery should not be performed reflexively based solely on meconium presence or GBS concerns without clear obstetric indication 1.
• The meconium and PPROM status alone do not constitute indications for cesarean delivery—proceed with vaginal delivery unless standard obstetric indications arise 1.

Specific Management Algorithm

Immediate Actions (Within Minutes)

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

Continuous Monitoring Requirements

• Continuous fetal heart rate monitoring is essential given meconium presence to detect signs of fetal compromise 1.
• Monitor for maternal fever (≥38°C), uterine tenderness, fetal tachycardia, and purulent/malodorous discharge as signs of chorioamnionitis 1, 2.
• Do not wait for maternal fever to diagnose infection—intraamniotic infection may present without fever, especially at preterm gestational ages 1, 2.

Critical Pitfalls to Avoid

• Never delay antibiotic administration when membrane rupture exceeds 6 hours in a preterm patient—start immediately upon diagnosis 1.
• Never use amoxicillin-clavulanic acid (Augmentin), which increases necrotizing enterocolitis risk in neonates 1, 2.
• Never perform digital cervical examinations in patients with PROM who are not in active labor, as this decreases latency period and increases infection risk 4.
• Never assume absence of fever means absence of infection—clinical symptoms may be less overt at earlier gestational ages, and infection can progress rapidly without obvious symptoms 1, 2.

Why Other Options Are Incorrect

• Option A (Induction alone): Fails to provide essential GBS prophylaxis and latency antibiotics, exposing both mother and neonate to preventable infection risk 1.
• Option B (Cesarean section): Unnecessary surgical intervention without obstetric indication, exposing the patient to surgical risks when vaginal delivery is appropriate 1.
• Option D (Antibiotics with expectant management): Unacceptably high maternal infection risk (38% chorioamnionitis rate) and contraindicated by meconium presence 1, 2.