In a 31‑week pregnant woman with confirmed preterm premature rupture of membranes, clear amniotic fluid, positive nitrazine test, and reassuring cardiotocography, what is the most appropriate preventive management?

Management of PPROM at 31 Weeks: Antibiotic Prophylaxis and Corticosteroids

The correct answer is C: Give antibiotic prophylaxis and corticosteroid. At 31 weeks gestation with confirmed PPROM, the most appropriate preventive measure combines both antibiotic prophylaxis (to reduce maternal infection and prolong latency) and antenatal corticosteroids (to accelerate fetal lung maturity and reduce neonatal morbidity), which together optimize both maternal safety and neonatal outcomes. 1

Rationale for Combined Antibiotic and Corticosteroid Therapy

Antibiotics are strongly recommended (GRADE 1B) for all pregnant individuals with PPROM at ≥24 weeks gestation to prolong latency, reduce maternal infection including chorioamnionitis, and decrease neonatal morbidity and mortality. 2, 1 The evidence demonstrates that:

• Antibiotic therapy significantly prolongs the latency period (median 89.8 vs 24.3 hours without antibiotics, P<0.001) 3
• Neonatal infectious morbidity is significantly reduced (21% vs 35.3%, P=0.04) 3
• Maternal infectious morbidity remains comparable between treated and untreated groups 3

Antenatal corticosteroids should be administered between 24+0 and 34+0 weeks gestation to accelerate fetal lung maturity and reduce respiratory distress syndrome, intraventricular hemorrhage, and other neonatal complications. 4, 5 At 31 weeks, this patient falls squarely within the gestational age window where corticosteroids provide maximum benefit.

Recommended Antibiotic Regimen

The standard 7-day antibiotic course consists of: 1, 4, 6

• IV ampicillin 2g every 6 hours AND erythromycin 250mg IV every 6 hours for 48 hours
• Followed by oral amoxicillin 250mg every 8 hours AND erythromycin 333mg every 8 hours for 5 additional days

Alternative regimen if IV therapy is not feasible: 6

• Erythromycin 250mg orally every 6 hours for 10 days
• Azithromycin can replace erythromycin if unavailable 1, 4

Why Not the Other Options?

Option A (Tocolytics alone) is incorrect because:

• Tocolytics may delay delivery by 48-72 hours but do not address the fundamental risks of infection or neonatal immaturity 4
• Without antibiotics and corticosteroids, you miss the opportunity to reduce both maternal infection risk and neonatal respiratory complications
• Tocolytics are adjunctive at best, allowing time for corticosteroids to work, but are not the primary preventive measure

Option B (Immediate induction) is incorrect because:

• At 31 weeks, expectant management with antibiotics and corticosteroids is preferred over immediate delivery 1, 7
• The risks of prematurity at 31 weeks outweigh the infection risks when appropriate monitoring and prophylaxis are provided
• Delivery is typically considered after 34 weeks when the benefits clearly outweigh the risks 7
• This patient has reassuring CTG and clear fluid, indicating no immediate maternal or fetal compromise requiring delivery

Critical Monitoring During Expectant Management

After initiating antibiotics and corticosteroids, the patient requires: 1, 4

• Initial hospital observation to ensure stability without preterm labor, abruption, or infection
• Daily patient self-monitoring for temperature, vaginal bleeding, discolored or malodorous discharge, contractions, and abdominal pain
• Weekly outpatient visits for maternal vital signs, fetal heart rate, physical examination, and laboratory evaluation for leukocytosis
• Immediate readmission criteria: maternal fever ≥38°C, maternal or fetal tachycardia, uterine tenderness, purulent cervical discharge, hemorrhage, or abnormal fetal surveillance

Common Pitfalls to Avoid

Do not delay diagnosis of intraamniotic infection due to absence of maternal fever—infection may present without fever, especially at preterm gestational ages, and can progress rapidly without obvious symptoms. 1, 8 Look for subtle signs including maternal tachycardia, fetal tachycardia, uterine tenderness, and purulent discharge. 1

Avoid amoxicillin-clavulanic acid (Augmentin), which increases the risk of necrotizing enterocolitis in neonates. 1, 4, 6 Use amoxicillin without clavulanic acid instead.

Do not use prolonged or repeated antibiotic courses beyond the standard 7-day regimen to optimize antibiotic stewardship. 2, 1

Do not perform digital cervical examinations as they are associated with decreased latency period and potential adverse sequelae; speculum examination is preferred. 5