OBSTETRICS
Pretnature rupture of the membranes: A conservative approach KENNETH A. KAPPY, M.D.
CETRULO, M.D
CURTIS L
ROBERT A. KNUPPEL, M.D. CHARLES
INGARDIA, M.D.
J.
ANTHONY
J.
SBARRA, PH.D
JOSE C. SCERBO, M.D. GEORGE W. MITCHELL, M.D.
Boston, M'assachusetts A conservative approach was followed in 188 patients with premature rupture of the membranes (PR0tv1) ovei a 2 yea; peiiod. Theie weie no neonatal deaths from sepsis, and only one infant showed a positive central bacteriologic culture. Fifty-seven percent of all patients less than 37 weeks' ge.station had a latent period of 24 hours and 19% went beyond 7 days before labor began. Patients IE•SS than 34 weeks' gestation who received antepartum steroids for lung maturation showed no increased infectious morbidity or mortality. A conservative approach to patients with PROM se~~ms reasonable when either prematurity and/or a cervix unfavorable for induction further complicate·s the pregnancy. (AM. J. 0BSTET. GYNECOL. 134:655, 1979.)
PREMATURE rupture of the membranes (PROM) is a major obstetric complication. It is associated with a high perinatal mortality rate, which is attributed primarily to delivery of premature, low-birth weight infants. 1- 6 The clinical management of patients \vith PROI',1 is
From the D.?partments of Obstetrics and Gynecology and Medical Research Laboratories, Tufts University School of Medicine Affiliated Hospitals, and St. Margaret's Hospital for Women. Receivedforpublicatwnjune 12, 1978. Revised August 30, 1978. Accepted
Sej~tember
18, 1978.
Reprint requests: Dr. Kenneth A. Kapp_v. Tufts Universitr ScJ.dlol of A1edicine Affiliated liospitals, St. 1'.-Jargarets Hospital for Women, 90 Cushing Ave., Boston, Massachusetts 02125. 0002-9378/79/140655+07$00.70/0 © 1979 The C. V. Mosby Co.
controversial. Infection and prematurity are two major complications. Two main management approaches are being used: (I) aggressive and (2) expectant or conservative. The aggressive approach consists of delivery within 24 to 48 hours of ruptured membranes. 2 · 7 - 9 The expectant or conservative approach consists of a '"\vatchful v;aiting" period \vith close attention to either spontaneous labor or signs of infection. 4 · 6 • 10 · 11 Gunn and associates 2 demonstrated an increased perinatal mortality rate after 48 hours of PROM and advocated early delivery. Because of maternal deaths from infection occurring after PROM, Russell and Anderson12 advocated an aggressive approach. Recently, Meade and Clapps administered steroids to mothers with PROM in an attempt to accelerate fetal lung maturation 13 in pre term pregnancies. In this study. 27 patients received antepartum steroids and
655
656 Kappy et al.
Am.
TOTAL PATIENTS 188 A
z. 37
B
wks
t..37 wks
119
78 (41. 5%)
U4 :fks -89 (47.3%)
(58. 5%)
35-36 wks
21 ( 11.1%)
I No
Steroids 42 (23.9%)
Steroids 44 (23.4%)
Fig. 1. Distribution of patients with PROM by weeks of gestation at delivery.
were delivered in 24 to 28 hours with a lower rate of respiratory distress syndrome (RDS) and a decreased neonatal mortality rate. They also showed that a conservative approach was not significantly beneficial in prolonging intrauterine development. On the other hand, Taylor and associates 4 contended that the perinatal mortality rate from PROM is mainly due to prematurity and rarely to infection. He showed a corrected perinatal mortality rate of only 3.5% due to infection in PROM patients. From this he advocated a conservative approach. in this study we report our results over a two-year period using a conservative approach.
Materials and methods All patients admitted to St. Margaret's Hospital for Women between July, 1975, and June, 1977, with a diagnosis of PROM and an intrauterine pregnancy greater than 24 weeks were included. St. Margaret's Hospital for Women is a regioro..al perinatal care center in the Greater Boston area receiving high-risk transfers from outlying hospitals. The participants in this study consisted of high-risk referral, clinic, and private patients. Upon arrival at the hospital, a thorough history was taken. Leakage of fluid was documented by a sterile speculum examination. No attempt was made to do a digital examination of the cervix except in cases where patients were thought to be in labor. If no fluid was seen on the speculum examination, fundal pressure was exerted and the patient was asked to perform a Valsalva maneuver to demonstrate any leakage of fluid. Vaginal fluid was tested with Nitrazine paper for pH and swabbed on a slide for ferning or aborization. Vaginal pooling confirmed ruptured membranes, but both a positive Nitrazine test and positive ferning were needed to confirm rupture of the membranes in the absence of pooling. In cases ·where the history was suggestive of PROM but no confirmation was possible by speculum examination, amniocentesis with i!'.sti!lation of indigo carmine into the amniotic sac was considered.
J
July 15, 197
Pretnature rupture of the membranes: A conservative approach KENNETH A. KAPPY, M.D.
CETRULO, M.D
CURTIS L
ROBERT A. KNUPPEL, M.D. CHARLES
INGARDIA, M.D.
J.
ANTHONY
J.
SBARRA, PH.D
JOSE C. SCERBO, M.D. GEORGE W. MITCHELL, M.D.
Boston, M'assachusetts A conservative approach was followed in 188 patients with premature rupture of the membranes (PR0tv1) ovei a 2 yea; peiiod. Theie weie no neonatal deaths from sepsis, and only one infant showed a positive central bacteriologic culture. Fifty-seven percent of all patients less than 37 weeks' ge.station had a latent period of 24 hours and 19% went beyond 7 days before labor began. Patients IE•SS than 34 weeks' gestation who received antepartum steroids for lung maturation showed no increased infectious morbidity or mortality. A conservative approach to patients with PROM se~~ms reasonable when either prematurity and/or a cervix unfavorable for induction further complicate·s the pregnancy. (AM. J. 0BSTET. GYNECOL. 134:655, 1979.)
PREMATURE rupture of the membranes (PROM) is a major obstetric complication. It is associated with a high perinatal mortality rate, which is attributed primarily to delivery of premature, low-birth weight infants. 1- 6 The clinical management of patients \vith PROI',1 is
From the D.?partments of Obstetrics and Gynecology and Medical Research Laboratories, Tufts University School of Medicine Affiliated Hospitals, and St. Margaret's Hospital for Women. Receivedforpublicatwnjune 12, 1978. Revised August 30, 1978. Accepted
Sej~tember
18, 1978.
Reprint requests: Dr. Kenneth A. Kapp_v. Tufts Universitr ScJ.dlol of A1edicine Affiliated liospitals, St. 1'.-Jargarets Hospital for Women, 90 Cushing Ave., Boston, Massachusetts 02125. 0002-9378/79/140655+07$00.70/0 © 1979 The C. V. Mosby Co.
controversial. Infection and prematurity are two major complications. Two main management approaches are being used: (I) aggressive and (2) expectant or conservative. The aggressive approach consists of delivery within 24 to 48 hours of ruptured membranes. 2 · 7 - 9 The expectant or conservative approach consists of a '"\vatchful v;aiting" period \vith close attention to either spontaneous labor or signs of infection. 4 · 6 • 10 · 11 Gunn and associates 2 demonstrated an increased perinatal mortality rate after 48 hours of PROM and advocated early delivery. Because of maternal deaths from infection occurring after PROM, Russell and Anderson12 advocated an aggressive approach. Recently, Meade and Clapps administered steroids to mothers with PROM in an attempt to accelerate fetal lung maturation 13 in pre term pregnancies. In this study. 27 patients received antepartum steroids and
655
656 Kappy et al.
Am.
TOTAL PATIENTS 188 A
z. 37
B
wks
t..37 wks
119
78 (41. 5%)
U4 :fks -89 (47.3%)
(58. 5%)
35-36 wks
21 ( 11.1%)
I No
Steroids 42 (23.9%)
Steroids 44 (23.4%)
Fig. 1. Distribution of patients with PROM by weeks of gestation at delivery.
were delivered in 24 to 28 hours with a lower rate of respiratory distress syndrome (RDS) and a decreased neonatal mortality rate. They also showed that a conservative approach was not significantly beneficial in prolonging intrauterine development. On the other hand, Taylor and associates 4 contended that the perinatal mortality rate from PROM is mainly due to prematurity and rarely to infection. He showed a corrected perinatal mortality rate of only 3.5% due to infection in PROM patients. From this he advocated a conservative approach. in this study we report our results over a two-year period using a conservative approach.
Materials and methods All patients admitted to St. Margaret's Hospital for Women between July, 1975, and June, 1977, with a diagnosis of PROM and an intrauterine pregnancy greater than 24 weeks were included. St. Margaret's Hospital for Women is a regioro..al perinatal care center in the Greater Boston area receiving high-risk transfers from outlying hospitals. The participants in this study consisted of high-risk referral, clinic, and private patients. Upon arrival at the hospital, a thorough history was taken. Leakage of fluid was documented by a sterile speculum examination. No attempt was made to do a digital examination of the cervix except in cases where patients were thought to be in labor. If no fluid was seen on the speculum examination, fundal pressure was exerted and the patient was asked to perform a Valsalva maneuver to demonstrate any leakage of fluid. Vaginal fluid was tested with Nitrazine paper for pH and swabbed on a slide for ferning or aborization. Vaginal pooling confirmed ruptured membranes, but both a positive Nitrazine test and positive ferning were needed to confirm rupture of the membranes in the absence of pooling. In cases ·where the history was suggestive of PROM but no confirmation was possible by speculum examination, amniocentesis with i!'.sti!lation of indigo carmine into the amniotic sac was considered.
J
July 15, 197
