A true comment, by Hailemariam SA.

the chances of survival without sequelae are low however in low resource settings, corticosteroids for lung maturation, magnesium infusion for delaying the delivery until corticosteroid effect, and also for brain sparing effect as well as the  antibiotic support in the interim to prevent chorioamnionitis are the usually accepted approaches. None of these ensures a completely intact newborn and a normal development afterwards.  A good counselling for the parents is also a must.

In Egypt one of very low resource countries we should discourage the conservative treatment for such groups of patients as outcome is not guarantee and prognosis is bad . Thanks for all 

Hello, Dear

Premature rupture of membranes (PROM) before the onset of labor occurs in approximately 5-7% of all pregnancies and precedes 30-40% of preterm deliveries. It is associated with an increased risk of acquiring perinatal infections including chorioamnionitis, endometritis and neonatal sepsis. The etiology of PROM is unclear, although it is estimated that up to 50% of cases are due to infection. Infection with bacteria and chlamydia, have been implicated. The management of PROM is controversial. Most clinicians would manage women with PROM prior to 34 weeks of gestation conservatively unless chorioamnionitis or fetal distress exist. This is because the complications of prematurity outweigh the risks of maternal and neonatal infections and morbidity. Premature rupture of membranes remote from term represents an obstetric challenge especially when oligohydramnios is present. This situation has been associated with shorter latency period and an increased risk of chorioamnionitis, placental abruption, preterm delivery and neonatal death. However, recent evidence suggests that conservative management of women with PROM remote from term is warranted because of the improvement in perinatal survival rates of extremely premature babies.

The clinical course of PROM in the midtrimester is used to be characterized by increased maternal and fetal morbidity. In managing women with PROM at or below the age of viability conservatively, consideration must be given to the potential maternal and neonatal morbidity and mortality. Aggressive attempts to delay delivery may expose the mother to severe morbidity. Because of the enormous advances in neonatal survival at very early gestations, there is a growing interest in the conservative management of PROM remote from term. Many studies have documented the maternal and perinatal outcome of pregnancies complicated by PROM before viability. The studies published between 1984 and 1990 reported perinatal survival of 22% to 63% in women with PROM before 26 weeks’ gestation. Moreover, a recent study reported a perinatal survival of 76%.5 However, caution must be considered in interpreting results from tertiary referral centers. Potential bias due to preadmission selection of women with PROM can not be ruled-out. On the other hand, our study included almost all women with PROM remote from term.

The incidence of chorioamnionitis in the studies was between 25% and 46%. Our rate of chorioamnionitis was 13.1%. This may be due to our routine use of antibiotics. Antenatal care in our hospital is free. However, the majority of the women were un-booked and Saudi. This is a potential risk factor. Our study included women with PROM between 16-26 weeks gestation. The survival rate was very poor. This was accompanied by significant maternal morbidity. Some women developed potentially life-threatening complications. The notion that antibiotics can eradicate chorioamnionitis without serious complications is proved to be wrong as in our study some women developed septicemia and suppurative endometritis necessitating total abdominal hysterectomy. Some women also were admitted to the intensive care units because of the seriousness of their condition. All these potential complications need to be explained to the couple as part of the non-directive counseling to enable them make an informed decision. The evidence in the recent literature suggests that conservative management of women with PROM remote from term is justifiable. This is due to the advanced neonatal care facility and the subsequent excellent survival rate of extremely premature babies. However, the situation is different when the appropriate neonatal care is not sufficient as in our case. Local studies like this are required to support scientifically what we should do in women with PROM remote from term.

An argument is usually made that conservative management of women with PROM remote from term is mandatory because termination of pregnancy in our religion is not permitted unless continuation of pregnancy threatens the life of the mother. This issue will not be discussed here. However, in light of our findings of poor neonatal survival and presence of serious life-threatening maternal morbidity, the religious argument needs further consideration.

In conclusion, in our circumstances because of the lack of advanced neonatal care and the presence of maternal life-threatening complications, the conservative management of women with PROM remote from term may not be justified. Further studies are required to confirm our findings.

Thanks so much dear professor

i agree that the availability of postnatal care facilities might be a relevant factor, but about 50% of patients counseled < 26 wks have not given birth before 26 weeks. 

conservative management, so wait and see is a reasonable option as long that the maternal risks are considered 

Thanks professor Karel For your declaration but in low resources countries I thinks termination is preferred for both fetal and maternal outcomes

In the US, women who experience PPROM should be transferred to a Level 3 medical center that has the highest level nursery care available. The woman should be given a betamethasone steroid injection to promote fetal lung maturity. Magnesium sulfate is administered for neuroprotection and should be administered to reduce the incidence of long-term neurological injuries. Antibiotics should be administered to reduce the risk of infection. Maternal vital signs and electronic fetal monitoring should be ongoing. If the maternal temperature begins to increase, chorioamniocitis should be suspected and immediate  cesarean is indicated. The use of tocolytics is no longer recommended for long-term use but may be considered for up to 48 hours when PTL does not stop to give the corticosteroids time to improve fetal lung maturity.

Thanks dear for your answer

First of all, make sure it is not false ROM

Article False vs True rupture of membranes

Thanks so much