EXPECTANT MANAGEMENT OF PRETERM PREMATURE RUPTURE OF THE MEMBRANES

OBJECTIVES: Our purpose was to (1) evaluate expectant management of preterm premature rupture of the membranes between 20 and < 36 weeks' gestation and (2) compare outcomes in service and private populations. STUDY DESIGN: The study included only singleton pregnancies prospectively managed between 20 and < 36 weeks' gestation with proved preterm premature rupture of the membranes. None of the patients received prophylactic antibiotics, tocolytics, or steroids, and none of the neonates received surfactant or had lethal anomalies. Patients (n = 511) were divided into private (n = 194) and staff (n = 317) categories, but all were managed identically. RESULTS: Approximately 50% of patients were delivered within 48 hours. Infection is more likely with preterm premature rupture of membranes before 28 weeks' gestation (p = 0.001), as is fetal death associated with infection (p < 0.001). Other findings in this study were (1) no significant differences in evaluated outcomes between private and staff patients, except that significantly more vaginal deliveries occurred in staff patients, (2) a prolongation of pregnancy greater than or equal to 7 days in 12.9% of patients, (3) a significant increase in the rate-of maternal infection if preterm premature rupture of membranes occurred before 28 weeks' gestation, (4) a significant increase in fetal and neonatal deaths if preterm premature rupture of membranes occurred before 28 weeks, and (5) an increased probability of survival whose rate of increase is dependent on the gestational age at which preterm premature rupture of membranes occurred. For babies weighing <1500 gm at birth compared with controls, babies delivered of mothers not having preterm premature rupture of membranes, 1-year follow-up revealed (1) a significantly lower incidence of pulmonary interstitial emphysema and cerebral palsy in the study group delivered before 28 weeks' gestation, (2) a significantly lower incidence in bronchopulmonary dysplasia in the study group delivered after 28 weeks' gestation, and (3) no significant differences in the incidence of intraventricular hemorrhage, pneumothorax, or Bayley Mental Developmental Index < 68 between those delivered before or after 28 weeks' gestation. CONCLUSION: Over 47.8% of the patients continued their pregnancy beyond 48 hours, and in 12.9% of cases expectant management of preterm premature rupture of membranes prolonged the pregnancy by greater than or equal to 7 days. The maternal infection rate is greater before 28 weeks' gestation and is associated with higher fetal-neonatal mortality. Status has little impact on outcome. Expectant management is not detrimental to quality of survival. Survival probability increases at a more rapid rate with preterm premature rupture of membranes after 22 weeks of gestation.