Journal of Obstetrics and Gynaecology, 2015; Early Online: 1–6

© 2015 Informa UK, Ltd.

ISSN 0144-3615 print/ISSN 1364-6893 online
DOI: 10.3109/01443615.2014.990432

ORIGINAL ARTICLE

Conservative management of preterm premature rupture of membranes

beyond 32 weeks’ gestation: Is it worthwhile?
Z. Tsafrir1, G. Margolis1, Y. Cohen1, A. Cohen1, I. Laskov1, I. Levin1, D. Mandel2 & A. Many1
1The Department of Gynecology and 2Neonatal Intensive Care Unit, Lis Maternity Hospital, Tel-Aviv Sourasky Medical Center, Sackler Faculty

of Medicine, Tel-Aviv University, Tel Aviv, Israel

necrotising enterocolitis (NEC) and neonatal sepsis (Egarter et al.

We aimed to investigate whether conservative management
1996; Lewis et al. 1996; Pattinson et al. 1999; Kenyon et al. 2003).
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of preterm premature rupture of membranes (PPROM) at

In addition, prophylactic antibiotic treatment assists in reducing
32–34 weeks’ gestation improves outcome. In this retrospective
the likelihood of chorioamnionitis and delays delivery, thereby
analysis of singleton pregnancies, the study group included
allowing sufficient time for the administration of prophylactic
patients with PPROM at 28–34 weeks’ gestation and the control
prenatal corticosteroids (Mercer et al. 1997; Kenyon et al. 2001;
group included patients presented with spontaneous preterm
RCOG 2006). However, an extended latency period may increase
delivery at 28–34 weeks’ gestation. Both groups were subdivided
the risk of chorioamnionitis, thereby exposing the foetus to an
according to gestational age – early (28–31 weeks’ gestation)
unfavourable intrauterine environment, which is associated with
versus late (32–34 weeks’ gestation). Adverse neonatal outcome
adverse neonatal outcomes, including cerebral palsy, lung injury,
included neonatal death, intraventricular haemorrhage grade
NEC and early neonatal sepsis. Other complications associated
3/4, respiratory distress syndrome, periventricular leucomalacia
with conservative management include cord compression due to
and neonatal sepsis. The study and control groups included
oligohydramnios and umbilical cord prolapse, especially in cases
For personal use only.

94 and 86 women, respectively. The study group had a lower

incidence of adverse neonatal outcome at the earlier weeks
(28–31), compared with the control group at the same
gestational age. In contrast, at 32–34 weeks’ gestation no
difference in the risk for adverse neonatal outcome was
noticed. Additionally, within the study group, chorioamnionitis
rate was significantly higher among those who delivered at
32–34 weeks’ gestation (p ⬍ 0.01). No advantage for
conservative management of PPROM was demonstrated
beyond 31 weeks’ gestation. Moreover, conservative
management of PPROM at 32–34 weeks’ gestation may
expose both mother and neonate to infectious morbidity.
Keywords: Conservative management, chorioamnionitis, outcome,
preterm premature rupture of membranes
Introduction
Preterm premature rupture of membranes (PPROM) accounts
for nearly 3% of all pregnancies and is a leading cause of
maternal and perinatal morbidity and mortality (Mercer 2003;
ACOG 2007). There is an inverse correlation between the fre-
quency and severity of neonatal complications after PROM and
the gestational age at membrane rupture and at delivery (Locatelli
et al. 2005). The appropriate management in the event of PPROM
is controversial (Ramsey et al. 2004). Expectant management
is justified in order to decrease gestational age-related morbid-
ity associated with prematurity. Accumulated experience in the
last decade established the benefit of administering prophylactic
glucocorticoids and antibiotics before 32 weeks’ gestation in pre-
venting neonatal morbidity and mortality, especially respiratory
distress syndrome (RDS), intraventricular haemorrhage (IVH),
of malpresentation.
There is a consensus on the need for expeditious delivery in the
following scenarios, regardless of gestational age: (1) overt chorio-
amnionitis, (2) abruptio placenta, (3) foetal distress and (4) advanced
labour. In the event of foetal malpresentation and significant cervical
dilatation, it may be justified to operate without delay. Furthermore,
induction of labour is the accepted policy when PPROM occurs at
or beyond 34 weeks’ gestation, or in the cases of PPROM which had
been managed expectantly and reached 34 weeks’ gestation (ACOG
2007). The American Congress of Obstetricians and Gynecologists
(ACOG) recommends conservative management with the admin-
istration of glucocorticoids and antibiotics up to 33 weeks’ gestation
(ACOG 2007). However, the Royal College of Obstetricians and
Gynecologists (RCOG) states that delivery should be considered at
34 weeks’ gestation (RCOG 2006).
There is also wide agreement that in the absence of any of the
indications mentioned above, women who present with PPROM
remote from term (i.e. ⬍ 32 weeks’ gestation) should be treated
expectantly. In cases of PPROM at 32–34 weeks’ gestation, how-
ever, the optimal management is controversial. We performed this
retrospective analysis in order to determine whether expectant
management in PPROM at 32–34 weeks’ gestation is beneficial.
Materials and methods
This retrospective cohort analysis was conducted on all
singleton pregnancies that were delivered at 280/7–346/7 weeks’
gestation between 2004 and 2011 in a single tertiary centre.
The study group was comprised of women who presented with
PPROM. The control group included randomly selected women
who presented with spontaneous preterm labour (SPTL) and

Correspondence: Ziv Tsafrir, MD, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel. Tel: ⫹ 972-3-6925604.
Fax: ⫹ 972-3-6925687 and Current address: 7632 Goshen Dr. West Bloomfield, Michigan 48322, USA. Tel: ⫹ 1-248-859-5255, 1-248826-3782, 1-313-673-
4757. Fax: ⫹ 1-248-325-0094. E-mail: zivtsafrir@gmail.com
 2 Z. Tsafrir et al.
intact membranes, during the same study period. Both groups
were divided according to gestational age at delivery: early
(280/7–316/7) and late (320/7–336/7). Patients who presented
with PPROM or SPTL and gave birth before the completion of
34 weeks’ gestation (i.e. ⬍ 35 weeks’ gestation) were included in
the ‘late’ group as well. We excluded all pregnancies with known
foetal malformations, multiple foetuses, stillbirths, placenta pre-
via, women who presented with abruptio placenta and cases in
which a decision to deliver was made due to other maternal or
foetal indications. Women who delivered within 24 h of PPROM
were also excluded from the study group. This study was approved
by the Institutional Review Board.
PPROM was defined as spontaneous rupture of membranes
(ROM) occurring before the onset of active labour and at
⬍ 340/7 weeks’ gestation. ROM was diagnosed by the observation
of persistent vaginal pooling on sterile speculum examination.
Gestational age was determined by the last menstrual period,
and confirmed by first-trimester ultrasound. The latency period
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was defined as ‘the time interval between ROM and time of
delivery’. Clinical chorioamnionitis was defined as ‘the pres-
ence of uterine tenderness and/or foul-smelling amniotic fluid,
maternal fever (⬎ 38.0°C), leucocytosis or foetal tachycardia’.
All women who presented with PPROM at ⬍ 340/7 weeks’ ges-
tation were managed by a standardised protocol as follows: (1)
inpatient management after excluding cases of active labour, cho-
rioamnionitis, placental abruption or foetal compromise; (2) intra-
muscular administration of betamethasone (12 mg, 2 doses 12 h
apart) and prophylactic antibiotics (ampicillin and azithromycin)
based on the ACOG and RCOG guidelines (ACOG, 2007; RCOG,
For personal use only.
2006); (3) urine culture upon admission; and (4) monitoring of mater-
nal and foetal status for signs of chorioamnionitis, labour and/or
foetal compromise. The routine follow-up included daily mea-
surement of vital signs, examination for uterine tenderness, non-
stress test three times daily, complete blood count every other day,
biophysical profile twice a week and estimation of foetal weight
every 2 weeks. Vaginal examination was avoided unless the patient
was symptomatic or complained of contractions.
Indications for rejecting expectant management were cho-
rioamnionitis, abruption placenta, foetal compromise and active
labour. Tocolysis was avoided for women who presented with
PPROM. Women who presented with SPTL were given betame-
thasone at the time of admission to the emergency room. All the
women in active labour were treated using prophylactic antibi-
otics intrapartum (intravenous penicillin 5 million U, followed
by 2.5 million U every 4 h) to prevent vertical transmission of
group B streptococci, regardless of earlier treatments. Induction
of labour, when indicated, was performed by oxytocin.
Data for this study were retrieved from our computerised
obstetrics database as well as from neonatal intensive care unit
(NICU) records. Maternal information included demographics,
age, height, weight and calculated body mass index, smoking,
alcohol use and medical and obstetrical history. Obstetrical infor-
mation included current pregnancy follow-up, latency period,
mode of delivery and complications. Clinical chorioamnionitis
was confirmed by histopathological examination when available.
Primary adverse neonatal outcomes included IVH, sepsis, RDS,
NEC, retinopathy of prematurity, periventricular leucomalacia
(PVL) and neonatal death. The composite adverse neonatal out-
come was defined as ‘the presence of at least one of the followings:
RDS, IVH stage ¾, PVL, sepsis and neonatal death’. Secondary
neonatal outcomes included number of days in the NICU, birth
weight, Apgar score, intubation/mechanical ventilation in the
delivery room, hypotension, inotropic or crystalloids support,
administration of indomethacin for patent ductus arteriosus
(PDA), bilirubin and haematocrit levels, phototherapy treat-
ment, erythropoietin treatment, documented hypoglycaemia or
hyponatremia, and administration of surfactants.
Statistical analysis
According to our calculation with the implementation of Z-test,
a sample size of 90 patients in each studied group could reveal
a decrease of at least 25% in the incidence of composite adverse
neonatal outcome in the study group compared with that in the
control group, with a power of 80% at the 0.05 significance level.
This assumption was based upon accepted differences in the
literature regarding the rate of RDS, IVH stage 3/4, PVL, sepsis,
and neonatal death between newborns before 32 weeks’ gestation
and those at 32–34 weeks’ gestation (Mercer, 2003; Hartling et al.
2006; RCOG, 2006). Data were analysed with the Student’s t-test,
the χ2 test and the Fisher’s exact test as appropriate. A multivari-
able logistic regression with backward elimination was performed
to examine the effect of possible confounding variables that were
considered risk factors for the composite neonatal outcome. Odds
ratio (OR) and their 95% confidence intervals (CIs) were com-
puted. Probability values of ⬍ 0.05 for all two-tailed tests were
considered significant.
Results
During 2004–2011, we had 80,384 deliveries in our medical cen-
tre. There were 1262 preterm births at 28–34 weeks’ gestation.
After applying the above-mentioned exclusion criteria, we had
238 cases of PPROM, of which 94 singleton pregnancies were
eligible for study entry, that is the women presented with PPROM
and gave birth after more than 24 h from ROM. In addition, we
had 337 cases of SPTL. The control group of 86 women was ran-
domly selected within the same time period. After stratification
by gestational age at delivery, there were 43 women in the study
group who delivered between 280 and 316/7 weeks’ gestation (the
early PPROM subgroup), and 51 women who delivered between
32 and 34 weeks’ gestation (the late PPROM subgroup). The con-
trol group consisted of 37 and 49 women in the early and late
SPTL subgroups, respectively. Demographic and obstetric details
of all four subgroups are summarised in Table I.
The late PPROM subgroup had more events of urinary tract
infection (UTI) compared with the late PTL subgroup (9 vs. 1;
p ⬍ 0.01). Cerclage in the current pregnancy or a history of cervi-
cal procedures was present in 7/43 of early PPROM cases com-
pared with 0/37 early SPTL cases (p ⬍ 0.01).
Neonatal outcome
The rate of composite adverse neonatal outcome was significantly
lower in the early PPROM subgroup than that of the early SPTL
subgroup but not between the late PPROM and SPTL subgroups
(Table II). In order to examine whether the better neonatal
outcome in PPROM events at 28–31 weeks’ gestation could be
attributed to expectant management, we used linear regression
and included potential confounders that might affect neonatal
outcome, i.e. maternal age, parity, caesarean section/operative
delivery, chorioamnionitis and birth weight. The expectant man-
agement of PPROM at 28–31 weeks’ gestation was associated with
less neonatal morbidity than preterm deliveries at 28–31 weeks’
gestation, even after adjusting for the variables mentioned above
(OR: 0.34; 95% CI: 0.13–0.89).
Analysis of secondary adverse neonatal outcome (Table III)
revealed that more cases of PDA occurred in the early SPTL
subgroup compared with those in the early PPROM subgroup
(13 vs. 5; p ⫽ 0.013). In addition, fewer premature newborns in
 Conservative management of PPROM 3
Table I. Demographic and obstetric characteristics of pregnancies with PPROM and SPTL.

Early gestational age at labour Late gestational age at labour

(28–31 weeks) (32–34 weeks)

Early PPROM Early SPTL Late PPROM Late SPTL

Characteristics (n ⫽ 43) (n ⫽ 37) p value (n ⫽ 51) (n ⫽ 49) p

Maternal age (years) 32.7 ⫾ 6.1 31.6 ⫾ 9.0 0.14 31.6 ⫾ 5.8 31.1 ⫾ 5.1 0.65
Body mass index (kg/m2) 20.5 ⫾ 3.5 20.4 ⫾ 3.5 0.96 21.0 ⫾ 4.6 21.1 ⫾ 3.8 0.89
Smoking rate 2 (4.6) 2 (5.4) 0.87 7 (13.7) 6 (12.2) 0.41
Pre-gestational diabetes 0 0 N/A 0 1 (2) N/A
History of abdominal surgery 4 (9.3) 1 (2.7) 0.21 5 (8.7) 4 (8.1) 0.39
History of caesarean section 3 (6.9) 3 (8.1) 0.92 5 (9.8) 5 (10.2) 0.97
Nulliparous 15 (34.8) 21 (56.7) 0.04 21 (41.1) 16 (32.6) 0.6
Recurrent pregnancy loss (⬎ 2 miscarriages) 10 (23.2) 3 (8.1) 0.07 14 (27.4) 10 (20.4) 0.48
Previous SPTL 2 (4.6) 4 (10.8) 0.31 8 (15.6) 11 (22.4) 0.2
Assisted reproductive technique 7 (16.3) 1 (2.7) 0.06 5 (9.8) 5 (10.2) 0.97
Gestational diabetes 2 (4.6) 2 (5.4) 0.87 3 (5.8) 7 (14.3) 0.08
UTI 3 (6.9) 2 (4.6) 0.77 9 (17.6) 1 (2) ⬍ 0.01
Cerclage in current pregnancy/history of cervical procedure 7 (16.2) 0 (0) ⬍ 0.01 3 (5.8) 5 (10.2) 0.21
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Antepartum vaginal bleeding 5 (11.3) 3 (8.1) 0.6 5 (9.8) 3 (6.1) 0.25

Data presented as number (%) or mean ⫾ standard deviation (SD).

N/A, not applicable.

the early PPROM subgroup needed fluids or inotropic support
and their mean haematocrit level was higher compared with the
newborns in the early SPTL subgroup, although these differences
did not reach a level of significance.
Maternal outcome
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neonates of both groups of women. These results were repeated
even after applying multivariate analysis, which included latency
period, maternal age, birth weight, UTI during pregnancy, cur-
rent cerclage or history of cervical procedures, and chorioamni-
onitis. We next evaluated the effect of the duration of the latency
period on the rate of chorioamnionitis in the PPROM group

Women who presented with PPROM at 32–34 weeks’ gesta-
tion suffered from a higher rate of clinical and histological
chorioamnionitis, underwent more operative deliveries/cae-
sarean sections and had prolonged length of stay in hospital
compared with the control women. These differences also
applied to the earlier PPROM subgroup (Table IV). There were
more cases of chorioamnionitis in the PPROM group at 28–31
weeks’ gestation compared with 32–34 weeks’ gestation (15 vs.
9; p ⬍ 0.05).
Effect of a latency period
In order to examine the influence of a latency period on adverse
neonatal outcome of the PPROM women, we divided these
patients into cases with a prolonged latency period (i.e. ⬎ 7
days) and cases with a short latency period (i.e. ⱕ 7 days). There
was no significant difference in adverse outcome between the
and found no significant difference between the women with
short or long latency periods at any gestational age. The rate of
neonatal sepsis among neonates who were born at 32–34 weeks’
gestation after a prolonged latency period, however, was higher
compared with that of neonates who were born after a short
latency period (15.3% vs. 0%; p ⫽ 0.05). This difference was not
observed in PPROM cases at 28–31 weeks’ gestation.
Finally, we performed a multivariate regression analysis
in order to determine which risk factors for PPROM were
independently or directly associated with the composite
adverse neonatal outcome. The results showed that gestational
age at the time of membrane rupture correlated to adverse
neonatal outcome, even after adjustment for confounding fac-
tors, such as maternal age, history of vaginal bleeding, cho-
rioamnionitis, prolonged latency period, nulliparity and the
newborn’s gender.

Table II. Primary adverse neonatal outcome in PPROM and SPTL Groups.

Early gestational age at labour Late gestational age at labour

(28–31 weeks) (32–34 weeks)

Early PPROM Early PTL Late PPROM Late SPTL

Outcome (n ⫽ 43) (n ⫽ 37) p (n ⫽ 51) (n ⫽ 49) p

Composite neonatal outcome¶ 17 (39.5) 24 (64.9) 0.02 9 (17.6) 11 (22.4) 0.28

Neonatal death 1 (2.3) 1 (2.7) 0.91 0 0 N\A
IVH (grade 3–4) 1 (2.3) 2(5.4) 0.48 0 0 N\A
Neonatal sepsis 6 (13.9) 5 (13.5) 0.95 2 (3.9) 0 0.48
RDS 16 (37.2) 21 (56.7) 0.11 8 (15.6) 11 (22.4) 0.19
NEC 4 (9.2) 2 (5.4) 0.5 2 (3.9) 1 (2.0) 0.29
PVL 0 3 (8.1) 0.09 0 0 N/A
ROP 6 (13.9) 2 (5.4) 0.19 0 0 N/A

Data presented as number (%).

RDS, respiratory distress syndrome; IVH, intraventricular haemorrhage; NEC, necrotising enterocolitis; PVL, periventricular
leucomalacia; ROP, retinopathy of prematurity; N/A, not applicable.
¶Defined in the ‘Materials and methods’ section
 4 Z. Tsafrir et al.
Table III. Secondary adverse neonatal outcome in PPROM and SPTL groups.

Early gestational age at labour Late gestational age at labour

(28–31 weeks) (32–34 weeks)

Early PPROM Early PTL Late PPROM Late SPTL

Outcome (n ⫽ 43) (n ⫽ 37) p (n ⫽ 51) (n ⫽ 49) p

Days at the NICU 40.9 ⫾ 12.5 44.9 ⫾ 15 0.84 18.9 ⫾ 8.3 17.2 ⫾ 7.5 0.88
Birth weight(g) 1477 ⫾ 285 1503 ⫾ 266 0.68 2018 ⫾ 234 2148 ⫾ 305 0.73
Apgar score ⬍ 7 at 1 min 9 (20.9) 7 (18.9) 1 6 (11.7) 6 (12.2) 1
Apgar score ⬍ 7 at 5 min 2 (4.6) 1 (2.7) 1 1 (1.9) 3 (6.1) 0.35
Hypotension at admission to NICU 3 (6.9) 6 (16.2) 0.2 2 (3.9) 3 (6.1) 0.3
Fluids/inotropic agents treatment 4 (9.3) 9 (24.3) 0.08 3 (5.8) 3 (6.1) 0.48
PDA 5 (11.6) 13 (35.1) 0.014 1 (1.9) 2 (4.0) 0.27
Indomethacin treatment 4 (9.3) 9 (24.3) 0.08 0 0 N/A
Jaundice requiring phototherapy 32 (74.4) 24 (64.8) 0.36 21 (41.2) 17 (34.6) 0.25
Haematocrit upon discharge 34.4 ⫾ 4.6 32.4 ⫾ 5.3 0.07 44.1 ⫾ 7.6 42.6 ⫾ 10.6 0.45
Erythropoietin treatment 13 (30) 11(29) 0.96 0 0 N/A
Hypoglycaemia 3 (6.9) 2 (5.4) 0.77 6 (11.8) 4 (8.1) 0.27
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Hyponatremia 4 (9.3) 3 (8.1) 0.85 0 0 N/A

Data presented as number (%) or mean ⫾ SD.

NICU, neonatal intensive care unit.

Discussion
The results of our analysis demonstrate that expectant manage-
ment of women presenting with PPROM at 28–31 weeks’ gesta-
tion is associated with lower rates of adverse neonatal outcome
compared with cases of SPTL at the same gestational age. How-
ever, we did not detect any benefit for conservative management
For personal use only.
management (Van Der Ham et al. 2012). Mercer et al.’s ran-
domised controlled study demonstrated the importance of anti-
biotic therapy in the event of PPROM occurring up to 32 weeks’
gestation (Mercer et al. 1997). The ACOG recommends conserva-
tive management with the administration of glucocorticoids and
antibiotics up to 33 weeks’ gestation (ACOG 2007). However,

in the event of PPROM occurrence at 32–34 weeks’ gestation. The
most appropriate model to evaluate the benefit of expectant man-
agement of a PPROM event is a prospective clinical trial in which
obstetrical and neonatal outcomes of PPROM cases managed
expectantly are compared with PPROM cases who were actively
delivered. Hartling et al.’s meta-analysis evaluated four randomised
controlled trials that were relevant to this issue. These authors
concluded that while intentional delivery may be more favourable
than expectant management for some maternal outcomes, there
is insufficient evidence to suggest that either strategy is beneficial
or harmful for the baby (Spinnato et al. 1987; Cox and Leveno
1995; Mercer et al. 1996; Naef et al. 1998; Hartling et al. 2006).
Since none of those trials included glucocorticoids or systematic
antibiotic treatment as part of the management, their relevance to
the contemporary clinical context is called into doubt.
Van Der Ham et al. randomised women who presented with
PPROM between 340 and 370 weeks’ gestation to either induc-
tion of labour or expectant management. Patients in both groups
received antibiotics. The authors found that induction of labour
did not improve pregnancy outcomes compared with expectant
the RCOG states that delivery should be considered at 34 weeks’
gestation, and that women should be informed of the increased
risk of chorioamnionitis and the decreased risk of respiratory
problems in the neonate (RCOG 2006).
An alternative model is to compare the obstetrical and neo-
natal outcomes of PPROM versus SPTL. Only a few such studies
were identified in our literature search. Sims et al. retrospectively
compared a PPROM group of 99 neonates and an SPTL group of
267 neonates (at 24–34 weeks’ gestation). Similar to our study
findings, women who presented with PPROM and delivered
within 24 h were excluded, and steroid and antibiotics were
administered to all PPROM patients. Their results showed that
neonates in the PPROM group had a lower incidence of RDS
(Sims et al. 2002). Sciscione et al. analysed the outcome of neo-
nates with very low birth weight (⬍ 1500 g) who were delivered
due to SPTL versus similar infants who were delivered due to
PPROM. Their cohort is comparable to the early subgroups in
our study. These authors concluded that the neonates who were
delivered as a result of PPROM had a higher survival rate than
those who were delivered after SPTL (Sciscione et al. 2008).

Table IV. Maternal outcome in PPROM and SPTL Groups.

Early gestational age at labour Late gestational age at labour

(28–31 weeks) (32–34 weeks)

Early PPROM Early SPTL Late PPROM Late PTL

Outcome (n ⫽ 43) (n ⫽ 37) p (n ⫽ 51) (n ⫽ 49) p

Caesarean/instrumental deliveries 17 (39.5) 7 (18.9) 0.05 18 (35.2) 4 (8.1) ⬍ 0.01

Chorioamnionitis 15 (34.8) 8 (21.6) 0.19 9 (17.6) 1 (2) ⬍ 0.01
White blood count max (mm3) 17.3 ⫾ 5.1 14.3 ⫾ 3.8 ⬍ 0.01 16.2 ⫾ 4.2 13.1 ⫾ 3.3 0.06
Body temperature (Co) 37.3 ⫾ 0.6 37.1 ⫾ 0.5 0.08 37.1 ⫾ 0.3 36.8 ⫾ 0.4 ⬍ 0.01
LOS postpartum (days) 3.1 ⫾ 1.2 2.5 ⫾ 0.9 0.049 2.9 ⫾ 1.4 2.2 ⫾ 0.5 ⬍ 0.01

Data presented as number (%) or mean ⫾ SD.

LOS, length of stay; N/A, not applicable.

We observed that the group of women who presented with
PPROM at 32–34 weeks’ gestation (the late subgroup) had a sig-
nificantly higher rate of chorioamnionitis and operative delivery
or caesarean section, as well as prolonged length of post-delivery
stay in hospital compared with the late SPTL subgroup. Tanir
et al. also observed that histological chorioamnionitis was more
common among PPROM cases compared with that among SPTL
cases, but they did not stratify the outcome according to gesta-
tional week (Tanir et al. 2003).
We observed an inverse correlation between gestational age at
PPROM and the probability of chorioamnionitis, in accordance
with other reports (Ramsey et al. 2005; Aziz et al. 2008; Test et al.
2011). We did not find any link between the length of latency
period and the rate of chorioamnionitis in the PPROM group:
this is in agreement with Aziz et al., but not with Test et al. and
Ramsey et al., who demonstrated opposite correlations (Ramsey
et al. 2005; Aziz et al. 2008; Test et al. 2011).
We then scrutinised the effect of a latency period on adverse
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neonatal outcome and found that a prolonged latency period (i.e.
⬎ 7 days) was not associated with improved neonatal outcome.
Moreover, neonates of women in the PPROM group who had an
extended latency period at 32–34 weeks’ gestation suffered from
higher rates of early neonatal sepsis.
Our results demonstrate that the most important factor influ-
encing neonatal outcome is gestational age at the time of ROM.
In a prospective study of PPROM cases at 24–34 weeks’ gestation,
Pasquier et al. did not detect any association between a latency
period and neonatal outcomes. Those authors also concluded that
the risk of adverse neonatal outcome is inversely related to gesta-
For personal use only.
tional age at PPROM (Pasquier et al. 2009). Locatelli et al. found
that gestational age at PPROM was independently predictive of
white matter damage (Locatelli et al. 2005).
The practitioner who advocates expectant management needs
to find a balance between two opposing processes: as the period of
latency is prolonged, the rate of adverse neonatal outcome associ-
ated with prematurity decreases, but the risk of chorioamnionitis
and related neonatal complications increases. We strived to iden-
tify the definitive point at which expectant management might
be counterproductive. According to our observations, expectant
management of a woman with PPROM at 32–34 weeks’ gestation
is not associated with improved neonatal outcome. Furthermore,
we witnessed a higher rate of chorioamnionitis and neonatal sep-
sis in combination with a prolonged latency period among those
women.
We are aware of several possible limitations of this study. It
has been claimed that SPTL and PPROM are associated with dif-
ferent pathophysiological mechanisms, whereupon a comparison
of neonatal outcome between these two clinical entities may be
open to question. Being limited as we were by the nature of a
retrospective design, we thought that a study group comprised
of SPTL cases will best reflect an alternative management, i.e.
expeditious delivery. An additional weakness of this study is the
lack of follow-up, thus precluding knowledge of the long-term
outcome of these premature newborns, especially with regard to
their neurological development.
In summary, our findings demonstrate that expectant man-
agement of PPROM cases at 28–31 weeks’ gestation is associated
with improved neonatal outcome in comparison to the neonatal
outcome of SPTL cases at the same gestational age. This does not
hold true at 32–34 weeks’ gestation. We also found higher rates of
chorioamnionitis and a higher incidence of neonatal sepsis to be
associated with prolonged latency rates at 32–34 weeks’ gestation,
indicating that expectant management might be counterproduc-
tive and call for judicious decision-making.
Conservative management of PPROM 5
Acknowledgments
We thank Esther Eshkol, the institutional medical and scientific
copyeditor.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the paper.
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