Lee C. Yang, DO; Donald R. Taylor, DO; Howard H. Kaufman, DO; Roderick Hume, MD; Byron Calhoun, MD
The authors retrospectively evaluated maternal and fetal reterm premature rupture of membranes (PROM) at
outcomes of 73 consecutive singleton pregnancies com- P 16 through 26 weeks of gestation complicates approxi-
mately 1% of pregnancies in the United States and is associ-
plicated by preterm premature rupture of amniotic mem-
branes. When preterm labor occurred and fetuses were at ated with significant risk of neonatal morbidity and mor-
tality.l,2
a viable gestational age, pregnant patients were managed
Perinatal mortality is high if PROM occurs when fetuses
aggressively with tocolytic therapy, antenatal corticos- are of previable gestational age. Moretti. and Sibai 3 reported
teroid injections, and antenatal fetal testing. The mean an overall survival rate of 50% to 70% after delivery at 24 to
gestational age at the onset of membrane rupture and 26 weeks of gestation.
delivery was 22.1 weeks and 23.8 weeks, respectively. The Although neonatal morbidity remains significant,
latency from membrane rupture to delivery ranged despite improvements in neonatal care for extremely pre-
from 0 to 83 days with a mean of 8.6 days. Among the mature newborns, neonatal survival has improved over
73 pregnant patients, there were 22 (30.1%) stillbirths and recent years. Fortunato et al2 reported a prolonged latent
phase, low infectious morbidity, and good neonatal out-
13 (17.8%) neonatal deaths, resulting in a perinatal death
comes when physicians manage these cases aggressively
rate of 47.9%. The perinatal survival rate based on gesta-
with active expectant management using tocolysis and pro-
tional age at the onset of fetal membrane rupture was 12.1% phylactic antibiotics.
at less than 23 weeks of gestation, 60% at 23 weeks, and In previous studies,H investigators generally excluded
100% at 24 to 26 weeks. Maternal morbidity was minimal newborns with chorioamnionitis or pregnant patients whose
with puerperal endomyometritis in 5 (6.8%) cases, one of deliveries occurred shortly after PROM or on hospital admis-
which became septic; however, there was no long-term sion. By excluding these patients from study protocols, out-
sequela. Eight (15.7%) liveborn infants had pulmonary comes-especial1y in the latency period-might appear better
than expected. Therefore, this retrospective study aims to
hypoplasia,5 (62.5%) of which resulted in neonatal death.
evaluate the outcome of every consecutive singleton preg-
In 33 (45.2%) patients, amniotic membranes ruptured
nancy complicated by PROM that occurred when fetuses
before 23 weeks of gestation. At previable gestational age, were at 16 to 26 weeks of gestation. Patients were treated at
the risk of neonatal pulmonary hypoplasia appears to be Rockford Memorial Hospital in Illinois, a regional perinatal
primarily dependent on gestational age at the onset of center, from January 1995 to December 2001.
premature rupture of membrane rather than gestational age
at delivery. Pregnancy outcomes remain dismal when the Methods
fetal membrane ruptures before 23 weeks of gestation. From January 1995 to December 2001, 73 pregnant patients
who had preterm PROM at 16 to 26 weeks of gestation received
medical care at Rockford Memorial Hospital. These patients
were identified through the perinatal computer database and
neonatal delivery logbooks. Institutional approval for a chart
review was obtained from the Rockford Memorial Hospital
Investigation Review Board.
Midtrimester PROM is defined as rupture of amniotic
From Saint Alexius Medical Center in Hoffman Estates, III (Yang) and Rock- membranes occurring between 16 and 26 weeks of gestation.5
ford Memorial Hospital, also in III (Taylor, Kaufman, Hume, and Calhoun).
Address correspondence to: Lee C. Yang; DO, Perinatology Clinic, Saint
When fetuses were at viable gestational age (ie, 24 weeks of ges-
Alexius Medical Center, 1555 Barrington Rd, Hoffman Estates, IL 60194-1018. tation), pregnant patients who had PROM were given tocolytic
E-mail: dadphiev90@aol.com therapy if they went into spontaneous preterm labor, as well
538· JAOA . Vol 104 • No 12 · December 2004 Yang et al • Orig inal Contribution
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ORIGINAL CONTRIBUTION
Table 2
Rupture of Membranes: Perinatal Outcome by Gestational Age (N=73)
* Percentages reported were rounded for each group by gestational age. Therefore, the sum ofthese percentages may not equal 100%.
26.9 weeks (mean 22.1 weeks; median 23 weeks). The mean ges- treated with broad-spectrum antibiotics, recovering without
tational age at delivery was 23.8 weeks and the mean latency any sequela.
period from PROM to delivery was 8.6 days. Twenty- Nine (40.9%) of the 22 patients who delivered stillbirth had
seven (37%) patients presented with clinical chorioamnionitis; curettage to remove the retained placenta; one of these patients
however, placental examination demonstrated histologic received a blood transfusion because of significant blood loss.
chorioamnionitis in 49 (67.1%) cases. There were no reported cases of maternal mortality or long-
Of the 22 (30.1%) stillbirths recorded in this group, the term morbidity.
gestational age at the onset of PROM ranged from 16 to
23.1 weeks (mean 20.3 weeks, median 20.4 weeks). The mean Perinatal Outcome
gestational age at delivery was 20.7 weeks with a mean The perinatal survival rate based on gestational age at the
latency period from PROM to delivery of 3 days. Eleven (50%) onset of PROM was 12.1 % at fewer than 23 weeks of gestation,
of these patients presented with vaginal bleeding, whereas 60% at 23 weeks, and 100% in the 24 to 26 weeks' gestational
10 (45%) patients initially had a clinical diagnosis of abruptio age group (Table 2).
placentae. Fifteen (68.2%) patients went into labor sponta- Among the 73 fetuses that were delivered, 22 (30.1%)
neously. Four (18.2%) patients presented with clinical were stillborn, and 13 (17.8%) died within 24 hours of delivery,
chorioamnionitis. The rate of histologic chorioamnionitis resulting in an immediate perinatal death rate of 47.9%.
was 63.6%, or 14 cases. Among the stillbirths, fetal membranes were ruptured at or
There were 13 (17.8%) neonatal deaths and the gesta- before 23 weeks of gestation and all were delivered before
tional age at the onset of PROM in these cases ranged from 16 to 24 weeks of gestation. Of the 13 neonatal deaths, 5 (38.5%)
23.4 weeks (mean 20.5 weeks, median 20.7 weeks). Two (15.4%) resulted from pulmonary hypoplasia and 2 (15.4%) were the
of the patients had abruptio placentae. All of these neonates result of neonatal sepsis (Table 3). Detailed data on neonatal
died within 24 hours of birth because of extreme prematu- deaths for liveborn infants were available for only 7 of the 13
rity, respiratory insufficiency, and/ or sepsis. infants in this group, however. Eight (15.7%) liveborn infants
had pulmonary hypoplasia, 5 (62.5%) of which, as noted,
Mode of Delivery resulted in neonatal death. Three (37.5%) liveborn infants
Twenty-eight (38.4%) fetuses were in cephalic position and with pulmonary hypoplasia survived. The mean gestational
45 (61.6%) fetuses were in breech presentation. age at the onset of PROM and delivery was 21.1 weeks and
Twenty-three (31.5%) neonates were delivered by cesarean 26.4 weeks, respectively. In 7 of these 8 patients with pul-
section. Indications for abdominal delivery were as follows: fetal monary hypoplasia, amniotic membranes ruptured before
distress and/or umbilical cord prolapsed (7 [30.4%]), fetal 22 weeks of gestation.
malpresentation (15 [65.2%]), or failed induction of a stillbirth Thirty-eight (74.5%) liveborn infants survived and were
(1 [4.3%]). There were 8 (11%) reported cases of prolapsed discharged from the hospital. Of these, 21 (55.3%) were boys
umbilical cord, but, as noted, not all of these fetuses were and 17 (44.7%) were girls. For 11 (28.9%) of these patients,
delivered abdominally. fetal membranes had ruptured before 24 weeks of gestation.
There was one case each of PROM at 16 and 19 weeks of ges-
Maternal Morbidity tation. All 38 surviving infants were diagnosed with respira-
Five (6.8%) of the 73 patients had puerperal endomy- tory distress syndrome. Twenty-six (68.4%) surviving neonates
ometritis. As noted, one of these became septic and was had long-term sequela with bronchopulmonary dysplasia.
Table 3
Rupture of Membranes: Neonatal Deaths in Newborns Delivered After 24 Weeks (n=13)*
* Detai led data on neonatal deaths for liveborn infants after rupture of membrane who were delivered after 24 weeks
of gestational age were available for only 7 ofthe 13 infants in this group.
t Th e Apgar scores (Activity, Pulse, Grimace, Appearance, Respiration) reported here were provided by the attending
physician at 1 and 5 minutes after birth . The lowest score possible is 0 (for stil lbirths); the highest for live births is 10.
Sixteen (42.1 %) newborns had neonatal sepsis. Severe intra- consistent use of broad-spectrum antibiotics among the study
ventricular hemorrhage (grade ill or M occurred in 3 (7.9%) group once infection was recognized by the attending physi-
liveborn infants. Other significant premature complications cian, a decision that also allowed physicians to expedite
are listed in (Table 4). delivery.8,12
Among the 73 patients, there were 22 stillbirths and 13 live
Discussion births resulting in neonatal death. Therefore, the perinatal sur-
Midtrimester PROM occurs in about 1 % of pregnancies and vival rate was 52.1 %, a figure that is comparable to most pre-
continues to pose significant levels of morbidity among live- vious studies.3A The perinatal survival rate based on gesta-
born infants. The mean latency period from PROM to delivery tional age at the onset of PROM was poor when the fetal
was 8.6 days among all 73 patients analyzed, which is a shorter membrane was ruptured before 23 weeks of gestation, how-
period of time than has been reported in previous studies ever. The 100% survival rate a t viable gestational age
(eg, 18.6 days).1,3,7,8 (ie, 24 weeks), however, is most likely a result of the use of ante-
This shorter latency period can be explained in part by the natal antibiotics, corticosteroids, and improved neonatal care.
large number of stillbirths recorded in our study (30.1 %), No previous studies have reported such a high survival rate
whereas previous studies excluded from analysis those patients among this age group (ie, 24-26 weeks of gestation).3-5
who delivered within 24 hours of PROM. In the current study, once fetuses had reached viable ges-
The incidence of clinical cl10rioanmionitis (37%) and his- tational age, pregnant patients were managed aggressively
tologic chorioamnionitis (67.1 %) noted here is comparable with tocolytic therapy in the presence of spontaneous uterine
with previous findingS.1,4,~ll Among patients with stillbirth, the contraction, immediately receiving antenatal corticosteroids and
incidence of clinical chorioamnionitis (18%) was low, but in line prophylactic antibiotics. Amon et al13 demonstrated that pro-
with figures reported by Beydoun and Yasin.4 Of the 27 (37%) phylactic antibiotics prolonged the latency phase and reduced
patients who had clinical cl10riOamniOnitis, 50% did so within the incidence of neonatal infection.
the first 48 hours and 61.5% within 1 week following PROM. In 1988, Moretti and Sibai3 evaluated maternal and
The risk of infection is significant following preterm neonatal outcomes for 118 rnidtrimester cases of PROM that
PROM. Five (6.8%) patients had endomyometritis, one incident were managed expectantly and occurred between 16 and
of whicl1 resulted in maternal sepsis. There was no long-term 26 weeks of gestation. The mean gestational age at the onset of
maternal sequ ela. PROM was 23.1 weeks with a mean latency period of 13 days.
The level of maternal morbidity reported in our current Sixty-seven percent of patients delivered within 1 week fol-
study is low compared to previous studies.5,1l,12 We theorize lowing PROM. Perinatal mortality was .r ecorded at 67.7%.
that this positive maternal outcome may be due in part to the The perinatal survival rate, based on gestational age at the
Yang et al • Original Contribution JAOA' Vol 104 • No 12. December 2004' 541
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ORIGINAL CONTRIBUTION
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preterm premature rupture of the membranes and subsequent perinatal efits of maternal corticosteroid therapy in infants weighing 0;;; 1000 grams at
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26 weeks' gestation [review]. Obstet Gynecol Gin North Am. 1992;19:339--351 . 15. Elimian A. Verma U, Beneck 0, Cipriano R, Visintainer P, Tejani N. Histologic
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10. Dexter SC, Pinar H, Malee MP, Hogan J, Carpenter MW, Vohr BR. Outcome 2000;96:333-336.
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Obstet Gynecol. 2000;96: 172-177. 16. Vintzileos AM, Campbell WA, Rodis JF, Nochimson OJ, Pinette MG,
Petrikovsky BM. Comparison of six different ultrasonographic methods for pre-
11. Yoon BH, Kim YA, Romero R, Kim JC, Park KH, Kim MH, et al. Associa- dicting lethal fetal pulmonary hypoplasia. Am J Obstet Gynecol .
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