EXPECTANT MANAGEMENT OF PRETERM PREMATURE RUPTURE OF THE MEMBRANES

OBJECTIVES: Our purpose was to (1) evaluate expectant management of pr eterm premature rupture of the membranes between 20 and < 36 weeks' ge station and (2) compare outcomes in service and private populations. S TUDY DESIGN: The study included only singleton pregnancies prospective ly managed between 20 and < 36 weeks' gestation with proved preterm pr emature rupture of the membranes. None of the patients received prophy lactic antibiotics, tocolytics, or steroids, and none of the neonates received surfactant or had lethal anomalies. Patients (n = 511) were d ivided into private (n = 194) and staff (n = 317) categories, but all were managed identically. RESULTS: Approximately 50% of patients were delivered within 48 hours. Infection is more likely with preterm prema ture rupture of membranes before 28 weeks' gestation (p = 0.001), as i s fetal death associated with infection (p < 0.001). Other findings in this study were (1) no significant differences in evaluated outcomes between private and staff patients, except that significantly more vag inal deliveries occurred in staff patients, (2) a prolongation of preg nancy greater than or equal to 7 days in 12.9% of patients, (3) a sign ificant increase in the rate-of maternal infection if preterm prematur e rupture of membranes occurred before 28 weeks' gestation, (4) a sign ificant increase in fetal and neonatal deaths if preterm premature rup ture of membranes occurred before 28 weeks, and (5) an increased proba bility of survival whose rate of increase is dependent on the gestatio nal age at which preterm premature rupture of membranes occurred. For babies weighing <1500 gm at birth compared with controls, babies deliv ered of mothers not having preterm premature rupture of membranes, 1-y ear follow-up revealed (1) a significantly lower incidence of pulmonar y interstitial emphysema and cerebral palsy in the study group deliver ed before 28 weeks' gestation, (2) a significantly lower incidence in bronchopulmonary dysplasia in the study group delivered after 28 weeks ' gestation, and (3) no significant differences in the incidence of in traventricular hemorrhage, pneumothorax, or Bayley Mental Developmenta l Index < 68 between those delivered before or after 28 weeks' gestati on. CONCLUSION: Over 47.8% of the patients continued their pregnancy b eyond 48 hours, and in 12.9% of cases expectant management of preterm premature rupture of membranes prolonged the pregnancy by greater than or equal to 7 days. The maternal infection rate is greater before 28 weeks' gestation and is associated with higher fetal-neonatal mortalit y. Status has little impact on outcome. Expectant management is not de trimental to quality of survival. Survival probability increases at a more rapid rate with preterm premature rupture of membranes after 22 w eeks of gestation.