Fetal growth after premature rupture of membranes R. C:. ALBRECHT,
LIEUTENANT
R.
C.
CEFALO.
P.
E.
LEWIS,
LIEUTENANT
J.
P.
SMITH,
CAPTAIN
BPthecda.
CAPTAIN
JUNIOR
(MC)
(MC)
(MC)
USN
USN
Mar$and
Four patier& with preterm rupture of thP membranes uvre treated the p~rioti UJ obwrziation (jz~ to nine uwks), cachfr~us displayed gmzvth as mr’asured by serial biparictal diameter dctrrminations. GYNECOI..
consenmtively. a rc.ormul rate
(AM. J.
During oj
OBSTET.
127: 869, 1977.)
THE MANAGEMENT OF a preterm pregnancy after premature rupture of the membranes (PROM) has been a long-standing controversy in the practice of obstetrics. The advocates of aggressive termination of pregnancy have placed major emphasis on the threat of potentially severe maternal and/or fetal infection. In addition, others favoring aggressive treatment have questioned whether fetuses are capable of a normal rate of growth following PROM. Charles’ has stated that I’. . . few infants in this predicament (PROM) gain weight in utero even if a conservative, cautious attitude is adopted.” We advocate the conservative approach to the management of preterm pregnancy after PROM in the absence of labor or clinical signs of maternal or fetal infection. In our opinion, the mortality rate for premature infants is still high, and this outweighs the potential risk of sepsis after PROM. This approach allows the fetus to mature and, therefore, avoids the complications of prematurity. The purpose of this communication is to report four cases in which there is definitive evidence of a normal rate of fetal growth following PROM. From the Department of Obstetrics National .Nazd Medxal Center.
The prenatal course in each of the cases that follow was uncomplicated until the time of PROM. The diagnoses were confirmed by the findings in amniotic fluid pooled in the vaginal vault which demonstrated “ferning” microscopically and which had a pH of 7 or greater by Nitrazine paper. The patients were hospitalized and placed at modified bed rest for the duration of their pregnancies. Determinations of biparietal diameter (BPD) were performed with a Picker Echoview IX and XI grayscale ultrasound system with a 2.25 MHz transducer. The diameters were obtained with the use of the method of the leading edge, that is. measurements were made from the initial recorded echo on either side of the fetal skull. All were obtained from B-scan gray-scale images. The change in BPD (ABPD) was calculated with the equation: ABPD =
for publication
Decembw
BPD2 - BPDl + aa N N
The error involved with B-scans has been reported to lie between 1.2 1 and 2.74 sq. mm. In calculating the change in BPD (ABPD), we used the maximum 3 mm. error.
and Gynecology,
Case reports
The opinions and assertions contained herein are those qf the authors and are not to be construed as official or a~ replesentzng those of the Bureau of Medic& and Surge9 qf the Department of tha Nay or of the Nazxzl Serzke nt InrgP. Recrixvd
USNR
USN
COMMANDER
(MC)
GRADE
Case 1. B. C., a 32-year-old white woman, gravida 1, para 0, presented with premature rupture of the membranes in Week 30 of pregnancy. Ultrasound determination of the BPD at that time was 73 mm., consistent with gestational age. Subsequent BPD determinations performed two and seven weeks later were 78 and 87 mm., respectively. The BPD was calculated to be 2.0 * 0.4 mm., consistent with the normal rate of fetal growth. At Week 39
15, I976
Artr,pted
Dwrmbrr
Reprint National 2001-J.
requests: R. C. Cefalo, Captain (MC) USN, Naval Medical Center, Bethesda, Mar$and
21, 1976
669
870
Albrecht
et al.
of gestation. rhe patient went into spontaneous labor. A 3,380 gram infant (seventieth percentile on the Colorado intrauterine growth chart) was delivered vaginally. Case 2. B. M.. a 28-year-old white woman, gravida 2, para 1, with a history of previous cesarean section, presented with premature rupture of the membranes in Week 31 of’ pregnancy. Determination of BPD at that rime was 77 mm.. consistent with gestationaf age. Repeat BPD determination five weeks later leas 90 mm. Calculated ABPD was 2.6 * 0.6 mm.. consistent with the expected rate of fetal growth. Amniocentesis revealed a lecithinisphingomyelin (L/S) ratio of 2.511. A repeat cesarean-section was performed at Week 37. A 2,835 gram infant (fiftieth percentile) was delivered. Case 3. P. N.. a 2%year-old white woman, gravida 1, para 0, presented with premature rupture of the membranes in Week 29 of pregnancy. Determination of’ BPD at that time was 76 mm. Subsequent BPD determinations performed two and five weeks later were 81 and 90 mm.. respectively. Calculated ABPD was 2.X t 0.6 mm., consistent with expected fetal growth. Labor \\as induced at 36 lveeks’ gestation after amniocentesis revealed an L/S ratio of 2.511. A 2~550 gram (fiftieth percentile) infant was delivered vaginally. Case 4. B. W., a 1%year-old white woman. gravida 2, para 1, presented bvith PROM in Week 31 of pregnancy. B-scans lvere obtained one and two weeks later
and were’ 84 and 88 mm.. respecti\,efy. ABPD I\~L~ 4.0 + 3 mm. Onset of labor was spontaneous in 1Ycck 33 by dates and Week 36 b) W-scan. A 2,367 gram (thirtieth percentile for 36 weeks) infant was deli\erec! by cesarean-section brcausr of compound pre~t’ntation.
Comment Ultrasound
determination
be an accurate
method
growth.
Growth
weeks
of gestation
an expected results
pattern
subsequenl
the
of
with
these
of fetal
growth
in
shown
rate
mm. findings
thirtieth
pattern per
with
week.
and
to
of fetal
to
in a linear
2.6 _t 0.05
IO PROM
the
eighteenth
is normally
ABPD
has been
following
during
are consistent
a normal
of BPD for
Our
show
that
can be demonstrated
an otherwise
uncomplicated
pregnancy. It is our in this
opinion
that
predicament
if’ a conservative, inaccurate part
in
the
the statement
(PROM)
gain
cautious
attitude
“.
few
weight
infants
in utero
even
is adopted”’
is an
statement
and,
therefore.
should
argument
for
aggressive
management
play
no 01’
PROM. Therefore, hospitalization gro\+
it appears and
at an appropriate
conservatilc
that
modified
management
rate.
under bed This
the rest further
of’ pregnancy
conditions the
supports after
01
fetus
LIEUTENANT
R.
C.
CEFALO.
P.
E.
LEWIS,
LIEUTENANT
J.
P.
SMITH,
CAPTAIN
BPthecda.
CAPTAIN
JUNIOR
(MC)
(MC)
(MC)
USN
USN
Mar$and
Four patier& with preterm rupture of thP membranes uvre treated the p~rioti UJ obwrziation (jz~ to nine uwks), cachfr~us displayed gmzvth as mr’asured by serial biparictal diameter dctrrminations. GYNECOI..
consenmtively. a rc.ormul rate
(AM. J.
During oj
OBSTET.
127: 869, 1977.)
THE MANAGEMENT OF a preterm pregnancy after premature rupture of the membranes (PROM) has been a long-standing controversy in the practice of obstetrics. The advocates of aggressive termination of pregnancy have placed major emphasis on the threat of potentially severe maternal and/or fetal infection. In addition, others favoring aggressive treatment have questioned whether fetuses are capable of a normal rate of growth following PROM. Charles’ has stated that I’. . . few infants in this predicament (PROM) gain weight in utero even if a conservative, cautious attitude is adopted.” We advocate the conservative approach to the management of preterm pregnancy after PROM in the absence of labor or clinical signs of maternal or fetal infection. In our opinion, the mortality rate for premature infants is still high, and this outweighs the potential risk of sepsis after PROM. This approach allows the fetus to mature and, therefore, avoids the complications of prematurity. The purpose of this communication is to report four cases in which there is definitive evidence of a normal rate of fetal growth following PROM. From the Department of Obstetrics National .Nazd Medxal Center.
The prenatal course in each of the cases that follow was uncomplicated until the time of PROM. The diagnoses were confirmed by the findings in amniotic fluid pooled in the vaginal vault which demonstrated “ferning” microscopically and which had a pH of 7 or greater by Nitrazine paper. The patients were hospitalized and placed at modified bed rest for the duration of their pregnancies. Determinations of biparietal diameter (BPD) were performed with a Picker Echoview IX and XI grayscale ultrasound system with a 2.25 MHz transducer. The diameters were obtained with the use of the method of the leading edge, that is. measurements were made from the initial recorded echo on either side of the fetal skull. All were obtained from B-scan gray-scale images. The change in BPD (ABPD) was calculated with the equation: ABPD =
for publication
Decembw
BPD2 - BPDl + aa N N
The error involved with B-scans has been reported to lie between 1.2 1 and 2.74 sq. mm. In calculating the change in BPD (ABPD), we used the maximum 3 mm. error.
and Gynecology,
Case reports
The opinions and assertions contained herein are those qf the authors and are not to be construed as official or a~ replesentzng those of the Bureau of Medic& and Surge9 qf the Department of tha Nay or of the Nazxzl Serzke nt InrgP. Recrixvd
USNR
USN
COMMANDER
(MC)
GRADE
Case 1. B. C., a 32-year-old white woman, gravida 1, para 0, presented with premature rupture of the membranes in Week 30 of pregnancy. Ultrasound determination of the BPD at that time was 73 mm., consistent with gestational age. Subsequent BPD determinations performed two and seven weeks later were 78 and 87 mm., respectively. The BPD was calculated to be 2.0 * 0.4 mm., consistent with the normal rate of fetal growth. At Week 39
15, I976
Artr,pted
Dwrmbrr
Reprint National 2001-J.
requests: R. C. Cefalo, Captain (MC) USN, Naval Medical Center, Bethesda, Mar$and
21, 1976
669
870
Albrecht
et al.
of gestation. rhe patient went into spontaneous labor. A 3,380 gram infant (seventieth percentile on the Colorado intrauterine growth chart) was delivered vaginally. Case 2. B. M.. a 28-year-old white woman, gravida 2, para 1, with a history of previous cesarean section, presented with premature rupture of the membranes in Week 31 of’ pregnancy. Determination of BPD at that rime was 77 mm.. consistent with gestationaf age. Repeat BPD determination five weeks later leas 90 mm. Calculated ABPD was 2.6 * 0.6 mm.. consistent with the expected rate of fetal growth. Amniocentesis revealed a lecithinisphingomyelin (L/S) ratio of 2.511. A repeat cesarean-section was performed at Week 37. A 2,835 gram infant (fiftieth percentile) was delivered. Case 3. P. N.. a 2%year-old white woman, gravida 1, para 0, presented with premature rupture of the membranes in Week 29 of pregnancy. Determination of’ BPD at that time was 76 mm. Subsequent BPD determinations performed two and five weeks later were 81 and 90 mm.. respectively. Calculated ABPD was 2.X t 0.6 mm., consistent with expected fetal growth. Labor \\as induced at 36 lveeks’ gestation after amniocentesis revealed an L/S ratio of 2.511. A 2~550 gram (fiftieth percentile) infant was delivered vaginally. Case 4. B. W., a 1%year-old white woman. gravida 2, para 1, presented bvith PROM in Week 31 of pregnancy. B-scans lvere obtained one and two weeks later
and were’ 84 and 88 mm.. respecti\,efy. ABPD I\~L~ 4.0 + 3 mm. Onset of labor was spontaneous in 1Ycck 33 by dates and Week 36 b) W-scan. A 2,367 gram (thirtieth percentile for 36 weeks) infant was deli\erec! by cesarean-section brcausr of compound pre~t’ntation.
Comment Ultrasound
determination
be an accurate
method
growth.
Growth
weeks
of gestation
an expected results
pattern
subsequenl
the
of
with
these
of fetal
growth
in
shown
rate
mm. findings
thirtieth
pattern per
with
week.
and
to
of fetal
to
in a linear
2.6 _t 0.05
IO PROM
the
eighteenth
is normally
ABPD
has been
following
during
are consistent
a normal
of BPD for
Our
show
that
can be demonstrated
an otherwise
uncomplicated
pregnancy. It is our in this
opinion
that
predicament
if’ a conservative, inaccurate part
in
the
the statement
(PROM)
gain
cautious
attitude
“.
few
weight
infants
in utero
even
is adopted”’
is an
statement
and,
therefore.
should
argument
for
aggressive
management
play
no 01’
PROM. Therefore, hospitalization gro\+
it appears and
at an appropriate
conservatilc
that
modified
management
rate.
under bed This
the rest further
of’ pregnancy
conditions the
supports after
01
fetus
