Pregnancy Outcome Following Preterm Premature Rupture of the Membranes at Less Than 26 Weeks' Gestation

EDITORIAL COMMENT : This careful analysis of 71 cases of premature rupture of the membranes (PROM) in singleton pregnancies without cervical suture reports important findings that will assist those who manage these difficult and important pregnancies. They are often especially important because the patient has had a bad past history of pregnancy wastage and is anxious to receive conservative therapy regardless of the risks (to her and her fetus) and cost (to the community). In Melbourne it has until recently been the rule to advise hospitalization until delivery in women with PROM ‐ now that bed costs are high as in the USA, we have begun to do what has been done for years in the USA ‐ manage these women at home after an initial week or so in hospital if the drainage of liquor ceases and there is no evidence of infection. In this study 69 of the 71 women remained in hospital but in future a large proportion are likely to be managed (definitely without coitus) at home. In this series 6 of the 71 women had PROM before 20 weeks and there was only 1 fetal survivor in this group. It should be noted that the series excluded cases in which PROM resulted in delivery before 20 weeks. Therefore this study does not support the editor's opinion that conservative management is reasonable when PROM occurs before 20 weeks' gestation, and the fetus is alive and ultrasonographically normal, even when there is oligohydramnios, if the patient agrees with or requests this regimen. Many obstetricians would consider that it is perfectly proper practice to put up an oxytocin drip and deliver the woman with PROM if she is unwilling to face the clinical and social prospects ahead and the period of gestation is less than 20 weeks; a 5 in 40 take‐home‐baby rate when PROM occurs before 24 weeks indicates that conservative therapy has some winners in such cases. A final comment is what constitutes maturity in these cases ‐ when is the battle won?; in this series 2 of the 71 women were induced for ‘maturity’ and figure 1 shows that this was 33 and 34 weeks respectively. In the editor's opinion it is wise to allow these pregnancies to go to 37 weeks' gestation; despite the excellence of modern neonatal care tragic losses still occur in infants born between 34–37 weeks' gestation. Perhaps we could allow pregnancy to continue longer and reduce costs (mother in hospital, baby in special care nursery) if we managed more of these patients at home. We need careful studies to see if such a regimen is safe enough for the mother and her fetus. Summary: The outcome of 71 singleton pregnancies where premature rupture of the membranes (PROM) occurred at gestations of less than 26 weeks was assessed retrospectively. The incidence of chorioamnionitis was 39.4% and the overall maternal morbidity rate was 53% but there were no long‐term maternal sequelae. The latent period from PROM until delivery ranged from <12 hours to 77 days, with 41% of women delivering within 1 week. There was no increased risk of infection with increasing latent period. The perinatal mortality was 66.2% (26.7% stillbirths and 39.4% neonatal deaths). There was a 65 % chance of a live baby if PROM occurred between 24–26 weeks but only 5 of 40 fetuses (12.5%) survived if PROM occurred before 24 weeks. The use of antibiotics, tocolytics and steroids in an uncontrolled manner is reported. Overall there is little serious risk to the mother if a conservative approach is adopted but only about one‐third of such women will take home a live baby.