Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group

Premature rupture of the membranes in term patients

Premature rupture of the membranes (PROM) occurs in 5-10% of pregnancies. Approximately 60% of cases are in term patients. Infection of the lower genital tract and/or amniotic cavity is one of the most important etiologies of PROM. The diagnosis is usually established by direct observation of pooling of amniotic fluid in the vaginal vault. In problematic cases, the nitrazine and fern tests can be used to confirm the diagnosis. Term patients with PROM and favorable cervices should undergo induction of labor with oxytocin. Patients with unfavorable cervices probably are best managed by induction of labor with prostaglandin compounds, although, in highly selected cases, expectant management may be considered. During induction of labor, long latent phases should be anticipated, and vaginal examinations should be minimized. Patients should receive prophylactic antibiotics, if indicated, for prevention of group B streptococcal infection and should be observed carefully for early signs of chorioamnionitis.

Selected issues in premature rupture of the membranes: herpes, cerclage, twins, tocolysis, and hospitalization

A number of issues related to premature rupture of the membranes (PROM) are less common or have not been thoroughly evaluated. Genital herpes simplex colonization carries the potential for significant perinatal morbidity, particularly with primary infection and membrane rupture. Cervical cerclage is both a risk factor for preterm PROM (pPROM) and confounds the management of women with PROM. Twin gestations carry an increased risk of pPROM and earlier membrane rupture. Membrane rupture can involve the presenting or nonpresenting sac. In each case, the fetus with intact membranes is at risk due to brief latency or intrauterine infection after membrane rupture of its sibling. Prophylactic and therapeutic tocolysis remains controversial because of the high risk of intrauterine infection after PROM, and the lack of data demonstrating long-term efficacy. With increased attention to health care costs, home management of pPROM has recently been suggested as an alternative to hospitalization after pPROM. This article reviews the clinical course and management options regarding these issues. Also discussed are those issues for which there is controversy but little available data. Each of these issues offers fruitful ground for discussion and further study.