1

Is conservative management of premature rupture of membranes remote from term justified?

Fathia H. Hassanain1 PhD Marryam O. Fallatah2 MB, ChB Othman S. Sindi3 FRCSC Hassan Abduljabbar1 FRCSC Abdulrahim A. R u!i1 FRCSC

Fr m th" D"#artm"nts $ Obst"tri%s and &yn"% l 'y at (in' Abdula!i! )ni*"rsity H s#ital1, +"ddah, th" Mat"rnity and Childr"n,s H s#ital2, Ma--ah, and (in' Faisal S#"%ialist H s#ital3, +"ddah, Saudi Arabia

C rr"s# ndan%" and r"#rint r".u"sts t Abdulrahim A. R u!i (in' Abdula!i! )ni*"rsity H s#ital PO B / 01212 +"ddah 21203, Saudi Arabia 4"l"#h n" 5 6 37727882128 Fa/ 5 6 37722382212

9:mail addr"ss6 aar u!i;h tmail.% m

2 Abstract Objective: 4 d"t"rmin" th" ut% m" $ a r utin" # li%y $ % ns"r*ati*" mana'"m"nt $ < m"n <ith #r"matur" ru#tur" $ m"mbran"s =PROM> r"m t" $r m t"rm in a l %al h s#ital in Ma--ah, Saudi Arabia. Materials and Methods: 4h" h s#ital r"% rds $ th" Mat"rnity and Childr"n,s H s#ital, Ma--ah, Saudi Arabia $r m +anuary 1333 t O%t b"r 2111 <"r" r"tr s#"%ti*"ly r"*i"<"d t id"nti$y < m"n <h <"r" admitt"d t th" h s#ital <ith PROM at 17:27 <""-s $ '"stati n. 4h" r"l"*ant data r"latin' t th" mat"rnal and $"tal ut% m"s <"r" "*aluat"d. Results: Durin' th" study #"ri d, th"r" <"r" 3180? d"li*"ri"s and 7? < m"n <"r" admitt"d t th" h s#ital <ith PROM at 17:27 <""-s $ '"stati n. 4hr"" < m"n <"r" "/%lud"d b"%aus" $ %h ri amni nitis = n" < man> and #r la#s"d $"tal #arts utsid" th" *a'ina =t< < m"n> n admissi n. 9l"*"n =10@> PROM %%urr"d in < m"n at 17:13 <""-s '"stati n, ?1 =78.2@> PROM %%urr"d in < m"n at 13:2? <""-s '"stati n, and 3 =1?.0@> PROM %%urr"d in < m"n at 2?:27 <""-s '"stati n. Only 3 =?.3@> in$ants sur*i*"d and <"r" dis%har'"d h m" in ' d '"n"ral % nditi n. 4h" r"st 20 =32.1@> di"d

imm"diat"ly a$t"r birth r $"< days lat"r. 4h"r" <as n mat"rnal m rtality in this 'r u# $ < m"n. H <"*"r, th" mat"rnal m rbidity in%lud"d s"#ti%"mia and # st:#artum hyst"r"%t my $ r su##urati*" "nd m"tritis unr"s# ndin' t antibi ti%s in n" < man, %h ri amni nitis in "i'ht < m"n, # st:#artum "nd m"tritis in th"r t< < m"n, d""# *"in thr mb sis in n" < man, # st:#artum h"m rrha'" and hyst"r"%t my $ r #la%"nta a%%r"ta in n" < man, and admissi n t th" int"nsi*" %ar" unit in t< < m"n. Conclusions: An ur %ir%umstan%"s, b"%aus" $ th" la%- $ ad*an%"d n" natal %ar" and th" #r"s"n%" $ mat"rnal li$":thr"at"nin' % m#li%ati ns, th" % ns"r*ati*" mana'"m"nt $

3 < m"n <ith PROM r"m t" $r m t"rm may n t b" justi$i"d. Furth"r studi"s ar" r".uir"d t % n$irm ur $indin's.

Key ords Ru#tur", M"mbran"s, R"m t", 4"rm

? Introduction Pr"matur" ru#tur" $ m"mbran"s =PROM> b"$ r" th" ns"t $ lab r %%urs in

a##r /imat"ly 2:8@ $ all #r"'nan%i"s and #r"%"d"s 31:?1@ $ #r"t"rm d"li*"ri"s. 1 At is ass %iat"d <ith an in%r"as"d ris$ a%.uirin' #"rinatal in$"%ti ns in%ludin'

%h ri amni nitis, "nd m"tritis and n" natal s"#sis. 4h" "ti l 'y $ PROM is un%l"ar, alth u'h it is "stimat"d that u# t 21@ $ %as"s ar" du" t in$"%ti n. An$"%ti n <ith ba%t"ria and %hlamydia, ha*" b""n im#li%at"d. 2 4h" mana'"m"nt $ PROM is

% ntr *"rsial. M st %lini%ians < uld mana'" < m"n <ith PROM #ri r t 3? <""-s $ '"stati n % ns"r*ati*"ly unl"ss %h ri amni nitis r $"tal distr"ss "/ist. 4his is b"%aus" th" % m#li%ati ns $ #r"maturity ut<"i'h th" ris-s $ mat"rnal and n" natal in$"%ti ns and m rbidity. Pr"matur" ru#tur" $ m"mbran"s r"m t" $r m t"rm r"#r"s"nts an bst"tri% %hall"n'" "s#"%ially <h"n li' hydramni s is #r"s"nt. 4his situati n has b""n ass %iat"d <ith sh rt"r lat"n%y #"ri d and an in%r"as"d ris- $ %h ri amni nitis, #la%"ntal abru#ti n, #r"t"rm d"li*"ry and n" natal d"ath.3,? H <"*"r, r"%"nt "*id"n%" su''"sts that % ns"r*ati*" mana'"m"nt $ < m"n <ith PROM r"m t" $r m t"rm is <arrant"d b"%aus" $ th" im#r *"m"nt in #"rinatal sur*i*al rat"s $ "/tr"m"ly #r"matur" babi"s. 2 4h"

bj"%ti*" $ this study <as t d"t"rmin" th" ut% m" $ a r utin" # li%y $ % ns"r*ati*" mana'"m"nt $ < m"n <ith PROM r"m t" $r m t"rm in a l %al h s#ital in Ma--ah, Saudi Arabia.

Material and Methods All < m"n <ith sin'l"t n #r"'nan%i"s % m#li%at"d by PROM b"t<""n 17:27 <""-s $ '"stati n <h <"r" admitt"d t th" Mat"rnity and Childr"n,s H s#ital in Ma--ah, Saudi

2 Arabia, b"t<""n +anuary 1333 t O%t b"r 2111, <"r" id"nti$i"d and th" %harts <"r" r"tr s#"%ti*"ly studi"d. 4h" dia'n sis $ PROM <as mad" by *isuali!ati n $ amni ti% $luid by st"ril" s#"%ulum "/aminati n at <hi%h tim" *a'inal %ultur" <as als ta-"n. Di'ital "/aminati ns <"r" n t #"r$ rm"d unl"ss th" < man <as in a%ti*" lab r. &"stati nal a'" <as "stablish"d by m"nstrual hist ry and in s m" < m"n this <as % n$irm"d by r utin" ultras n 'ra#hi% "/aminati n b"$ r" 21 <""-s. C m#l"t" bl d % unt <ith di$$"r"ntial and C:r"a%ti*" #r t"in <"r" d n" t<i%" <""-ly. All < m"n had an ultras und "/aminati n n admissi n. Am#i%illin 211 m' "*"ry 7 h urs rally $ r n" <""- <as 'i*"n t all < m"n. 4ar'"t"d antibi ti% th"ra#y <as 'i*"n i$ *a'inal %ultur" <as # siti*" $ r #ath '"ni% ba%t"ria. A$ th" '"stati nal a'" <as 22 <""-s r m r"

d"/am"thas n" 12 m' intramus%ularly <as 'i*"n n admissi n and <as r"#"at"d a$t"r 2? h urs. 4 % lyti%s <"r" n t us"d. F"tal sur*"illan%" in% r# rat"d daily n n:str"ss t"st startin' at 27 <""-s. Andi%ati ns $ r d"li*"ry in%lud"d lab r, th" dia'n sis $ %h ri amni nitis, $"tal d"ath, *a'inal bl""din' r n n:r"assurin' $"tal h"art tra%in'. Ch ri amni nitis <as r m r" $ th" $ ll <in'6 mat"rnal $"*"r $ 38.0 d"'r""s

dia'n s"d in th" #r"s"n%" $ t<

C"lsius r m r", ut"rin" t"nd"rn"ss, mat"rnal ta%hy%ardia, l"u- %yt sis, $"tal ta%hy%ardia <ith diminish"d *ariability r $ ul sm"llin' *a'inal dis%har'". P st:#artum "l"*ati n $ ral t"m#"ratur" t 38.0B r m r" in t< %%asi ns ? h urs a#art, ut"rin" t"nd"rn"ss, and

$ ully sm"llin' *a'inal dis%har'" % nstitut"d th" d"$initi n $ "nd m"tritis. 4h" d"li*"ry <as att"nd"d by a n" nat l 'ist <h <as r"s# nsibl" $ r r"sus%itati n and assi'nin' A#'ar s% r"s. Mat"rnal data su%h as a'", #arity, ra%", m"di%al % m#li%ati ns durin' #r"'nan%y, r ut" $ d"li*"ry, indi%ati n $ r indu%ti n $ lab r, l"n'th $ lat"n%y #"ri d,

7 and ut% m" <"r" "/tra%t"d and statisti%ally analy!"d usin' SPSS:PC $ r Cind <s. A # *alu" l"ss than r ".ual t 1.12 <as % nsid"r"d statisti%ally si'ni$i%ant.

Results Durin' th" study #"ri d, th"r" <"r" 3180? d"li*"ri"s and 7? < m"n <"r" admitt"d t th" h s#ital <ith PROM at 17:27 <""-s $ '"stati n. 4hr"" < m"n <"r" "/%lud"d $r m th" analysis b"%aus" $ %h ri amni nitis = n" < man> and #r la#s"d $"tal #arts utsid" th" *a'ina =t< < m"n> n admissi n. 9l"*"n =10@> PROM %%urr"d in < m"n at 17:13 <""-s '"stati n, ?1 =78.2@> PROM %%urr"d in < m"n at 13:2? <""-s '"stati n, and 3 =1?.0@> PROM %%urr"d in < m"n at 2?:27 <""-s '"stati n. 4h" mat"rnal -"d =did n t

%hara%t"risti%s ar" sh <n in 4abl" 1. 4h" maj rity $ th" < m"n <"r" un:b

% m" t th" h s#ital $ r #r"natal %ar" in th" %urr"nt #r"'nan%y> and Saudi. 4h" mat"rnal and $"tal ut% m"s ar" #r"s"nt"d in 4abl" 2. 5in" babi"s <"r" admitt"d t th" n" natal int"nsi*" %ar" unit =5AC)> $ r *aryin' numb"r $ days. Only 3 =?.3@> in$ants sur*i*"d and <"r" dis%har'"d h m" in ' d '"n"ral % nditi n. 4h"y <"r" in th" 5AC) $ r 2?, 20,

and 37 days. 4h" r"st 20 =32.1@> di"d imm"diat"ly a$t"r birth r $"< days lat"r. 4h"r" <as n mat"rnal m rtality in this 'r u# $ < m"n. H <"*"r, th" mat"rnal m rbidity in%lud"d s"#ti%"mia and # st:#artum hyst"r"%t my $ r su##urati*" "nd m"tritis unr"s# ndin' t antibi ti%s in n" < man, %h ri amni nitis in "i'ht =13.1@> < m"n, # st:#artum "nd m"tritis in th"r t< < m"n, d""# *"in thr mb sis in n" < man, # st: #artum h"m rrha'" and hyst"r"%t my $ r #la%"nta a%%r"ta in n" < man, and admissi n t th" int"nsi*" %ar" unit in t< < m"n

8 !iscussion 4h" %lini%al % urs" $ PROM in th" midtrim"st"r is us"d t b" %hara%t"ri!"d by in%r"as"d mat"rnal and $"tal m rbidity. An mana'in' < m"n <ith PROM at r b"l < th" a'" $ *iability % ns"r*ati*"ly, % nsid"rati n must b" 'i*"n t th" # t"ntial mat"rnal and

n" natal m rbidity and m rtality. A''r"ssi*" att"m#ts t d"lay d"li*"ry may "/# s" th" m th"r t s"*"r" m rbidity. B"%aus" $ th" "n rm us ad*an%"s in n" natal sur*i*al at *"ry "arly '"stati ns, th"r" is a 'r <in' int"r"st in th" % ns"r*ati*" mana'"m"nt $ PROM r"m t" $r m t"rm. Many studi"s ha*" d %um"nt"d th" mat"rnal and #"rinatal ut% m" $ #r"'nan%i"s % m#li%at"d by PROM b"$ r" *iability. 4h" studi"s #ublish"d b"t<""n 130? and 1331 r"# rt"d #"rinatal sur*i*al $ 22@ t 73@ in < m"n <ith PROM b"$ r" 27 <""-s, '"stati n.7:11 M r" *"r, a r"%"nt study r"# rt"d a #"rinatal sur*i*al $ 87@.2 H <"*"r, %auti n must b" % nsid"r"d in int"r#r"tin' r"sults $r m t"rtiary r"$"rral %"nt"rs. P t"ntial bias du" t #r"admissi n s"l"%ti n $ < m"n <ith PROM %an n t b" rul"d: ut. On th" th"r hand, ur study in%lud"d alm st all < m"n <ith PROM r"m t" $r m t"rm. 4h" in%id"n%" $ %h ri amni nitis in th" studi"s <as b"t<""n 22@ and ?7@. Our rat" $ %h ri amni nitis <as 13.1@. 4his may b" du" t ur r utin" us" $ antibi ti%s.

Ant"natal %ar" in ur h s#ital is $r"". H <"*"r, th" maj rity $ th" < m"n <"r" un: b -"d and Saudi. 4his is a # t"ntial ris- $a%t r. Our study in%lud"d < m"n <ith PROM r. 4his <as a%% m#ani"d

b"t<""n 17:27 <""-s '"stati n. 4h" sur*i*al rat" <as *"ry #

by si'ni$i%ant mat"rnal m rbidity. S m" < m"n d"*"l #"d # t"ntially li$":thr"at"nin' % m#li%ati ns. 4h" n ti n that antibi ti%s %an "radi%at" %h ri amni nitis <ith ut s"ri us % m#li%ati ns is #r *"d t b" <r n' as in ur study s m" < m"n d"*"l #"d s"#ti%"mia

0 and su##urati*" "nd m"tritis n"%"ssitatin' t tal abd minal hyst"r"%t my. S m" < m"n als <"r" admitt"d t th" int"nsi*" %ar" units b"%aus" $ th" s"ri usn"ss $ th"ir

% nditi n. All th"s" # t"ntial % m#li%ati ns n""d t b" "/#lain"d t th" % u#l" as #art $ th" n n:dir"%ti*" % uns"lin' t "nabl" th"m ma-" an in$ rm"d d"%isi n. 4h" "*id"n%" in th" r"%"nt lit"ratur" su''"sts that % ns"r*ati*" mana'"m"nt $ < m"n <ith PROM

r"m t" $r m t"rm is justi$iabl". 4his is du" t th" ad*an%"d n" natal %ar" $a%ility and th" subs".u"nt "/%"ll"nt sur*i*al rat" $ "/tr"m"ly #r"matur" babi"s.11 H <"*"r, th"

situati n is di$$"r"nt <h"n th" a##r #riat" n" natal %ar" is n t su$$i%i"nt as in ur %as". D %al studi"s li-" this ar" r".uir"d t su## rt s%i"nti$i%ally <hat <" sh uld d in < m"n <ith PROM r"m t" $r m t"rm. An ar'um"nt is usually mad" that % ns"r*ati*" mana'"m"nt $ < m"n <ith

PROM r"m t" $r m t"rm is mandat ry b"%aus" t"rminati n $ #r"'nan%y in ur r"li'i n is n t #"rmitt"d unl"ss % ntinuati n $ #r"'nan%y thr"at"ns th" li$" $ th" m th"r. 4his issu" <ill n t b" dis%uss"d h"r". H <"*"r, in li'ht $ ur $indin's $ # sur*i*al and #r"s"n%" r n" natal

$ s"ri us li$":thr"at"nin' mat"rnal m rbidity, th" r"li'i us

ar'um"nt n""ds $urth"r % nsid"rati n. An % n%lusi n, in ur %ir%umstan%"s b"%aus" $ th" la%- $ ad*an%"d n" natal %ar" and th" #r"s"n%" $ mat"rnal li$":thr"at"nin' % m#li%ati ns, th" % ns"r*ati*"

mana'"m"nt $ < m"n <ith PROM r"m t" $r m t"rm may n t b" justi$i"d. Furth"r studi"s ar" r".uir"d t % n$irm ur $indin's.

3 References =1> Eia FH, Andr" P, Da%a!":Masm nt"il 4, Audib"rt F, Fu#an G, D"han M. Out% m" $ #r"matur" in$ants d"li*"r"d a$t"r #r l n'"d #r"matur" ru#tur" $ m"mbran"s b"$ r" 22 <""-s $ '"stati n. 9ur + Obst"t &yn" l R"# rd Bi l 2111H 31678:81. =2> ("lly 4. th" #ath #hysi l 'y $ #r"matur" ru#tur" $ m"mbran"s in

#r"'nan%y. Curr O#in Obst"t &yn"% l 1332H 861?1:1?2. =3> Da 44, Ch"un' GI. 9/#"%tant mana'"m"nt $ #r"t"rm #r":lab r ru#tur" $ th" m"mbran"s, th" si'ni$i%an%" $ li' hydramin s at #r"s"ntati n. 9ur + Obst"t &yn" l R"# rd Bi l 13333H ?0608:31. =?> Hadi AH, H ds n CA, Stri%-land D. #r"matur" ru#tur" $ m"mbran"s

b"t<""n 21 and 22 <""-s6 r l" $ amni ti% $luid * lum" in #"rinatal ut% m". Am + Obst"t &yn"% l 133?H 18161133:11??. =2> Far .i A, H lm'r"n P, 9n'b"r' S, S"r"nius F. Sur*i*al and 2:y"ar ut% m"

<ith "/#"%tant mana'"m"nt $ s"% nd:trim"st"r ru#tur" $ m"mbran"s. Obst"t &yn"% l 1330H 326032:311. =7> 4ayl r +, &arit" 4+. Pr"matur" ru#tur" $ m"mbran"s b"$ r" $"tal *iability. Obst"t &yn"% l 130?H 7?6712:21. =8> B"yd un S5, Iasin SI. Pr"matur" ru#tur" *iability. Obst"t &yn"% l 130?H 7?6712:21. =0> M r"tti M, Sibai, BM. Mat"rnal and #"rinatal ut% m" $ "/#"%tant $ m"mbran"s b"$ r" $"tal

mana'"m"nt $ #r"t"rm #r"matur" ru#tur" $ m"mbran"s in th" mid trim"st"r 1300H 1236331:7.

11 =3> B"n'ts n +M, Gan Mart"r D+, Barr GA, &r""n" MF, 4u mala R9, 9#sti"n MF. Pr"'nan%y ut% m" a$t"r #r"matur" ru#tur" $ m"mbran"s at r b"$ r" 27 <""-s $ '"stati n. Obst"t &yn"% l 1303H 836321:8. =11> Maj r CA, (it!mill"r +D. P"rinatal sur*i*al <ith "/#"%tant mana'"m"nt $ midtrim"st"r ru#tur" $ m"mbran"s. Am + bst"t &yn"% l 1331,1736030:??. =11> Chan (, Ohlss n A, Synn"s A, D"" DSC, Ch"in DI, D"" S(. Sur*i*al, m rbidity, and r"s ur%" us" $ in$ants $ 22 <""-s, '"stati nal a'" r l"ss. Am + Obst"t &yn"% l 2111H1026221:7.

"able #: Maternal Characteristics

11

Gariabl" A'" =y"ars> &ra*idity Parity )n:B -"d Saudi

17:13 C""-s 11 C m"n 28.? J ?.3 3.2 J 2.2 1.3 J 2.3 11 =111@> 0 =82.8@>

13:2? C""-s ?1 C m"n 20.2 J 7.0 2.1 J 3.3 2.3 J 2.7 31 =82.7@> 20 =70.3@>

2?:27 C""-s 3 C m"n 23.7 J 8.8 7.2 J 2.1 ?.3 J 2.2 3 =111> 7 =77.8>

!ata are presented as mean $ %! or number and &percentage'(

"able ): Maternal and fetal outcomes Gariabl" &"stati nal a'" at d"li*"ry =<""-s> 17:13 C""-s 11 C m"n 18.3 J .0 13 :2? C""-s ?1 C m"n 21.2 J 1.8 2? K 27 C""-s 3 C m"n 20.? J 2.1

12 Admissi n days =m th"r> 5" natal int"nsi*" %ar" admissi n S# ntan" us t"rminati n Andu%ti n Ga'inal "/#ulsi n C"sar"an s"%ti n 7.2 J ?.? 1 2 =?2.2@> 7 =2?.2@> 11 =111@> 1 8.1 J 8.1 ? =3.0@> 28 =72.0@> 1? =3?.1@> ?1 =111@> 1 13.3 J 18.? 2 =22.2@> 8 =88.0@> 2 =22.2@> 2 =22.7@> ? =??.?@>

!ata are presented as mean $ %! or number and &percentage'