PRELABOR RUPTURE OF MEMBRANES 00955108/01 $15.00
.

00

MANAGEMENT OF PREMATURE
RUPTURE OF MEMBRANES
Thomas J. Garite, MD

The challenge of management in the setting of premature rupture

of the membranes (PROM), as with any situation in obstetrics, is to
achieve the optimal outcome for mother and baby. Unfortunately, with
this diagnosis there are often conicting priorities between mother and
fetus or newborn. These priorities, as with the management of PROM,
differ at various gestational ages. At term, the challenge is to avoid
maternal and neonatal infection associated with prolonged ruptured
membrane, usually by expeditious delivery, without increasing the need
for operative delivery. In the preterm gestation, the challenge increases
because the priority of avoiding infection needs to be balanced by
avoiding the neonatal complications of prematurity. Evaluation for addi-
tional complications including umbilical cord compression and abruptio
placentae must also be ongoing. In previable gestations the additional
risk of the fetal deformation syndrome must also enter into the equation.
Because these risks vary with each pregnancy based on gestational age,
fetal lung maturity, demographic risk factors, degree of oligohydram-
nios, and other identiable variables, knowledge of the changing risk of
each complication based on these variables must also be considered in
choosing the best management for each patient.
Because of the complexity of these issues, and often because the
literature is not consistent regarding the risks and benets of any given
management alternative, the choice of interventions, both diagnostic and
therapeutic, is often controversial. In 1987, Capeless and Mead4 surveyed
maternal-fetal medicine specialists nationally and found great disparity

From the Department of Obstetrics and Gynecology, University of California Irvine, Or-
ange, California

CLINICS IN PERINATOLOGY

VOLUME 28 NUMBER 4 DECEMBER 2001 837

838 GARITE

in the choices of diagnostic tests, such as ultrasound, amniocentesis, and

C-reactive protein, and therapeutic options, such as antibiotics, tocoly-
tics, and corticosteroids. Some of these issues have become substantially
claried since that time, but others remain.

INITIAL EVALUATION

The initial evaluation of the patient includes making the correct

diagnosis; determining the gestational age of the patient; and ruling out
labor, infection, and signs of fetal compromise. Overt infection, irrevers-
ible fetal hypoxia, and advanced active labor all require delivery and
only the route and urgency of delivery need to be determined. In all
other situations, care is individualized based on other secondary vari-
ables, which may help determine the relative risk of each patient.
Making the Diagnosis. Conrming the diagnosis of PROM is essen-
tial. Over 90% of patients with a typical history of a sudden gush of
uid from the vagina followed by continued leakage have the diagnosis
conrmed.8 Other possible causes including heavy vaginal discharge,
either infectious or physiologic, urinary leakage, douches or medications,
and occasionally patients with incompetent cervix with membranes pro-
truding through the cervical os complain initially with a watery vaginal
discharge.
Patients with a suspicious history should have an immediate exami-
nation to conrm the diagnosis. The examination should be performed
in such a way as to avoid introducing infection in the process. Most
authors, based on reasonably good evidence, have advised against per-
forming a digital examination over concern of introducing infection,
because vulvovaginal bacteria may be introduced into the endocervical
canal.1, 21, 35, 42 Two recent studies, however, have cast some doubt on this
teaching, nding no evidence of additional infectious risk with digital
examinations.2, 36 Because the evidence is conicting, information on the
state of the cervix is not critical in managing the patient not in obvious
active labor, and reasonably reliable information can be determined by
visual inspection alone,29 it seems reasonable to limit the examination to
speculum alone unless visual inspection suggests substantial dilation or
unless the patient seems to be having regular painful contractions. The
diagnosis during a speculum examination is conrmed by the presence
of a pool of watery uid in the vagina, a positive Nitrazine test with a
blue color appearing at a pH above 6 to 6.5, and if necessary the presence
of a microscopic ferning appearance of vaginal secretions after allowing
a few minutes for drying on a slide. Several more expensive tests, using
analysis for such markers as human chorionic gonadotropin, alpha-
fetoprotein, or fetal bronectin, are available but do not seem to offer
substantial advantages in making the diagnosis. Ultrasound conrma-
tion of reduced amniotic uid volume is useful to conrm the diagnosis,
but not essential when the diagnosis is obvious.
During the speculum examination, there is also an opportunity for
 MANAGEMENT OF PREMATURE RUPTURE OF MEMBRANES 839

additional tests including cultures for group B streptococcus, chlamydia,

and gonorrhea. Cultures for other organisms do not seem to provide
any signicant value in predicting infectious risk. In appropriate gesta-
tional ages, a sample of free-owing uid can be obtained for fetal
maturity tests. The cervix should be visualized to assess dilation and the
appearance of the presenting part or membranes and to rule out prolapse
of the umbilical cord or fetal extremity.

ESTABLISHING GESTATIONAL AGE

Because the management of PROM depends integrally on the gesta-

tional age, one should carefully review menstrual history and previous
ultrasounds, and when necessary perform an ultrasound on admission
to establish the gestational age at the time of membrane rupture. One
should understand, however, that fetal biometry may have limitations
when membrane rupture occurs. Oligohydramnios with its associated
fetal compression may alter fetal measurements, especially bronchopul-
monary dysplasia, head circumference, and abdominal circumference.

RULING OUT LABOR

Regardless of gestational age, labor is an expected sequelae to

PROM. The interval from membrane rupture to the onset of labor is
known as the latency period, and is inversely proportional to gestational
age. At term, approximately 90% of patients enter labor spontaneously
within 24 hours, at viable preterm gestational ages; 50% are in labor in
24 hours; and 80% are in labor within 1 week. At less than 24 weeks
50% labor within 1 week.10, 24 At term, labor is a hoped for consequence,
but in the premature fetus, the onset of labor threatens the consequences
of the neonatal complications of prematurity. Patient history and tocody-
namometry are important in identifying the onset of labor. In addition,
the appearance of variable decelerations of the fetal heart rate frequently
indicates labor is beginning and often precedes symptoms or the appear-
ance of contractions on the monitor.

RULING OUT INFECTION

Symptoms and signs of maternal infection include fever, uterine

tenderness, fetal or maternal tachycardia, foul-smelling vaginal dis-
charge, leukocytosis, and uterine contractions. Because many of these
signs are frequent and not specic, the usual criteria for establishing the
diagnosis of chorioamnionitis include fever (temperature greater than
100.4oC) in the presence of PROM and in the absence of any other
obvious source of fever. There has been considerable debate over the
necessity and value of attempting to diagnose intra-amniotic infection
840 GARITE

before the mother becomes febrile by amniocentesis.11, 32, 33 Following

amniocentesis, Gram stain demonstrating bacteria and an amniotic uid
glucose concentration of less than 15 mg/100 mL are sensitive and
relatively specic available tests that can be performed rapidly and
predict the likelihood of impending overt chorioamnionitis unless the
patient delivers or is delivered before the infection has time to become
clinically manifest.32, 33 What is not known is whether maternal or neona-
tal outcome can be improved substantially by treating with antibiotics
or immediate delivery at the time of established intra-amniotic infection,
but before the patient is febrile. Routine amniocentesis for this purpose
cannot be strongly advocated. In the premature gestation, if there are
subtle suggestions of infection (e.g., leukocytosis, fetal tachycardia, and
so forth) and there is no fever, or if amniocentesis is being done for fetal
lung maturity, it is advisable to perform Gram stain and glucose testing.3
As opposed to maternal and intra-amniotic infection, establishing
the presence or absence of fetal infection is very difcult. Fetal infection,
like newborn infection, can be localized or generalized sepsis, and can
range from mild to severe. Fetal infection, although more common in
the presence of maternal infection, can also occur in the absence of
clinically apparent chorioamnionitis. Fetal tachycardia is nonspecic and
virtually always is present when the mother is febrile. Amniocentesis
correlates better with maternal than fetal infection.41 The biophysical
prole has been advocated as a screening test for fetal infection, and
when values of 0 to 2 are found there is a substantially increased risk of
fetal sepsis.41 A signicantly abnormal biophysical prole (BPP) is rarely
seen when the fetal heart rate is reactive, however, and because it is
important to rule out umbilical cord compression, a daily prolonged
nonstress test (see later) is a useful screening test for fetal sepsis, reserv-
ing the BPP only for the fetus with a nonreactive tracing or in the very
premature pregnancy where the fetus is likely to be nonreactive because
of gestational age alone.17

RULING OUT FETAL DISTRESS

In the face of PROM, the fetus is at risk for hypoxic insults most
often from umbilical cord compression caused by oligohydramnios40 or
less commonly by the increased likelihood of abruptio placentae.23 The
patient with PROM who is not in labor should generally be monitored
continuously for the rst 12 to 24 hours and then frequently thereafter
watching the tracing for signs of umbilical cord compression (variable
or prolonged decelerations) and of fetal sepsis (loss of reactivity and
tachycardia). After the initial monitoring, frequent nonstress tests should
be done, although the optimal frequency has not been established with
practices ranging from continuous monitoring until delivery, to daily, to
twice weekly. The authors practice is to perform a daily 1-hour tracing
until the onset of labor, when monitoring again becomes continuous.
Once the patient is in labor, especially in the premature gestation, am-
nioinfusion can be used to decrease the umbilical cord compression
 MANAGEMENT OF PREMATURE RUPTURE OF MEMBRANES 841

associated with oligohydramnios, and possibly decrease the cesarean

section rate and improve neonatal condition at birth.31 Some have advo-
cated prophylactic amnioinfusion at the onset of labor even before signs
of cord compression occur,31 although no comparative study of prophy-
lactic versus therapeutic amnioinfusion has been done.

MANAGEMENT OF PATIENTS WITH PREMATURE

RUPTURE OF MEMBRANES

Once the diagnosis has been established, the management of pa-

tients not in labor, not clinically infected, and with reassuring fetal
testing depends primarily on the gestational age. For the purposes of
management, patients are divided into four gestational age groups: (1)
near term and term ( 35 weeks); (2) more advanced premature (32
to 34 weeks); (3) very premature (24 to 31 weeks); and (4) previable
( 23 weeks). Obviously, the cutoff points for both the lower and
upper ends of these groups are arbitrary and debatable, and one can
make a case for adjusting these according to data, biases, outcomes at
particular institutions, or population variations, and this is acknowl-
edged without disagreement.
Term and Near Term. Because complications of prematurity are not
at issue in this gestational age group, the only real debate in the patient
with PROM at term but not in labor is should one wait for the spontane-
ous onset of labor or induce labor. If one chooses to wait (i.e., expectant
management), there is also an option of waiting for some arbitrary
period of time and then only inducing labor in those who have not
started actively contracting after that interval. If one chooses induction,
the variations in management are primarily centered around whether
and what preinduction cervical ripening agent should be used.
In the debate over induction versus expectant management, the
issues are principally whether a delay in delivery places the fetus and
the mother at substantial increased risk of infection if one waits versus
whether induction places the mother at increased risk of cesarean section
and dystocia. Certainly, there is good evidence that after 24 to 48 hours
following membrane rupture the risk of neonatal infection and mortality
is increased.16 None of these data are recent, however, and have not been
corrected for the interval from the rst cervical examination to delivery
and for patients who have received antibiotic prophylaxis for group B
streptococcal transmission. Studies on the effect of induction versus
expectant management and the impact on the cesarean section rate can
be found favoring either option and are quite confusing on this issue.
Further complicating this question are the many choices of preinduction
cervical ripening that can be used and their impact on duration of labor
and cesarean section.
There are several recent meta-analyses28, 38, 39 and one large multicen-
ter randomized controlled trial evaluating the question of the best man-
agement for patients with PROM at term.14 Most studies have included
842 GARITE

patients greater than 35 to 36 weeks. Certainly not all studies agree. In

general, however, the following conclusions can be drawn from these
extensive data. Immediate induction of labor, compared with expectant
management, results in lower overall rates of chorioamnionitis and
endometritis. The interval from admission to delivery is shorter with
oxytocin, although rates of cesarean section are similar with either ap-
proach. Although no statistically signicant reduction in neonatal infec-
tion can be seen with immediate induction, fewer babies are admitted
to neonatal ICU and fewer are treated with antibiotics for suspected
sepsis with this approach. Studies adding prostaglandins or misoprostol
followed by oxytocin within 12 hours, although mixed in their conclu-
sions, generally do show a shorter interval to delivery, but are otherwise
similar to immediate induction with oxytocin in other outcomes, includ-
ing cesarean section rates.14 The status of the cervix, in terms of Bishop
score, does not seem to affect the success rates of any of these approaches
in the setting of PROM. The question of delayed induction, waiting for
a dened limited number of hours for labor to begin, and initiating
oxytocin induction if labor has not begun, has not been studied as
extensively. At least one randomized study and the numerous studies
using prostaglandins or misoprostol suggest that this approach is equally
safe and efcacious to immediate induction with oxytocin, and has the
advantage of avoiding some labor inductions.15, 39
The most appropriate choice for patients with PROM at term in-
cludes an immediate initial evaluation to conrm the diagnosis and, as
in all gestational age groups, to rule out infection and fetal distress. If
the patient is not actively contracting and if membrane rupture occurred
just before admission, it is reasonable to allow a short period of time to
see if spontaneous labor ensues (i.e., 6 to 8 hours). During this time
cervical ripening with vaginal prostaglandin or misoprostol is a reason-
able option. Alternatively, immediate induction with oxytocin is equally
acceptable. The number of digital examinations should be limited to
avoid increasing infection rates. Group B streptococcal prophylaxis
should be administered where appropriate.
Management at 32 to 34 Weeks. This is by far the most difcult
group for which to nd either consensus or good evidence on which to
make recommendations for management. In addition to the three choices
available with PROM at term (immediate induction, expectant manage-
ment, or some arbitrary period of delay followed by induction) there
are at least two other available choices. One can selectively choose to
deliver only those with documented pulmonary maturity, either by
amniocentesis or based on studies on uid obtained by vaginal pool.6, 26, 37
Alternatively, one could subdivide this group at some point between 32
and the end of week 34 and manage the earlier half as with the less
than or equal to 31-week group (see later) and the latter half as with the
term and near term patients.20, 30 At least one study suggested that
patients greater than or equal to 34 weeks and 0 days have less infections
and equally good neonatal outcomes if delivered immediately.30 One
randomized trial compared babies between 30 and 34 weeks with imme-
 MANAGEMENT OF PREMATURE RUPTURE OF MEMBRANES 843

diate delivery versus expectant management and found less chorioamni-

onitis with immediate delivery without signicant improvement with
gestational age at delivery or any parameter of neonatal outcome with
expectant management.7 This may be caused by population differences,
because this latter study was performed on an inner-city indigent popu-
lation.
This is not a gestational age group where antibiotics, tocolytics, or
corticosteroids is recommended. With this group one can reasonably
choose expectant management, delivery based on amniotic uid matu-
rity testing, or even delayed expectant management waiting to achieve
a slightly more advanced gestational age before delivery.
Management at 24 to 31 Weeks. This is the group of patients with
PPROM, in whom the most consensus has been attained in recent
years. As shown for these patients in articles elsewhere in this issue,
prophylactic broad-spectrum antibiotics prolong pregnancy, reduce ma-
ternal and perinatal infectious complications, and enhance the effects of
corticosteroids.25 Corticosteroids, although previously controversial with
PPROM, used with antibiotics reduce respiratory distress syndrome and
possibly have other benecial effects, such as reduction in intraventricu-
lar hemorrhage.5, 19 The value of tocolytics has not been demonstrated,
but tocolytics have not yet been studied in conjunction with broad-
spectrum antibiotics, which has the potential to be complementary in
prolonging pregnancy. It is certainly reasonable, although not yet well
proved, to use tocolytics for 48 hours or less while attempting to achieve
the benets of corticosteroids.
In these patients, expectant management using prophylactic broad-
spectrum antibiotics and corticosteroids is now shown to achieve the
best outcome for mothers and babies. As in all patients, careful scrutiny
for infection and fetal compromise must be ongoing and these patients
should be managed in a hospital equipped to care for babies of these
gestational ages. The question of when to deliver these patients if they
have not yet delivered and have reached 32 to 34 weeks can be answered
virtually in the same way as in the previous section on patients who
rupture at this latter gestational age time frame. They may then be
delivered immediately, delivered based on amniotic uid lung maturity
testing, or wait until 35 weeks has been attained.
Management at Less Than or Equal to 23 Weeks. This is a gesta-
tional age where membrane rupture can truly be dened as an obstetric
tragedy. Perinatal outcome in these pregnancies is dismal. The likelihood
of achieving a gestational age of viability and of the mother taking her
baby home is no more than 40%.34 This is further complicated by the
issue of pulmonary hypoplasia and the other complications of the fetal
deformation syndrome.17 Half or more of the surviving babies have
major neurologic handicaps or other serious long-term medical prob-
lems.34 Maternal complications while waiting for viability are higher
than any other gestational age group with PPROM, with a chorioamnio-
nitis rate of more than 40%, and high risk of retained placenta and
hemorrhage following delivery.34
844 GARITE

Nonetheless, babies do survive, and many develop normally. One

cannot remove hope, or deny the parents the option of waiting and
hoping to achieve a viable gestational age. Nor can the parents who
reasonably choose not to take the risk of maternal complications or a
handicapped baby be denied the option of not continuing the pregnancy.
Once the patient has been counseled extensively enough and often
enough to understand the complexity of the complications and manage-
ment options, she can make the choice of termination or expectant
management. Termination can be done as with any second-trimester
approach.
The option of expectant management opens up other questions.
There are no data available as to whether there is benet, or risk, to
using broad-spectrum antibiotics in this situation. The general benets
of prolonging pregnancy for the average of 1 week probably are not
worth the potential risk of developing infections with resistant organ-
isms. Tocolytics probably do not achieve any long-term benet. Cortico-
steroids should be reserved until the patient reaches a gestational age
where there is some chance of perinatal survival. Because intervention
for fetal indications is not a reasonable option, home management of
this one group of patients is quite acceptable. The author often admits
these patients for a day or two for initial evaluation and counseling and
to see if infection or labor develops immediately. After that, patients can
be sent home with precautions to maintain bed rest, pelvic rest, and to
watch for signs of labor or infection. If the patient achieves a viable
gestational age, she can be readmitted at that point for the duration of
the pregnancy and managed as with the greater than 24 weeks group.

MANAGEMENT OF CHORIOAMNIONITIS

The nal group of patients where some confusion of management

exists is in those who develop chorioamnionitis. Once this diagnosis is
conrmed, several questions arise. It is universally agreed that treatment
for this complication includes broad-spectrum antibiotics and delivery.12, 13
Although there are isolated case reports where mothers refused delivery
and the infection apparently resolved and delivery was delayed by
several weeks, these are rare and serious maternal complications and
death have more often resulted in delay in delivery.27 The choice of
antibiotics should be based on a knowledge of the spectrum of bacteria
involved and the penetration of the antibiotics to the fetus, decidua, and
amniotic uid.12 A combination of ampicillin and gentamycin is the most
common recommendation, although for uncomplicated chorioamnionitis
at term, especially when it develops in labor, ampicillin or a cephalospo-
rin alone is reasonable.13
The indications for cesarean section should not be affected by the
presence of chorioamnionitis. Studies in both term13 and preterm9 pa-
tients indicate that if immediate induction is undertaken, the rates of
fetal-neonatal complications are not altered by the improvement of a few
 MANAGEMENT OF PREMATURE RUPTURE OF MEMBRANES 845

hours that immediate cesarean delivery confers. Furthermore, maternal

morbidity is clearly increased when patients undergo cesarean section
in the setting of chorioamnionitis, with endometritis, wound infection,
and other serious morbidities all increased.
The frequency of fetal acidosis is not increased in patients with
chorioamnionitis.22 Although fetal infections are increased in patients
with chorioamnionitis, there is no evidence that beyond the antibiotics
given to the mother that immediate delivery confers benet if the fetus
is infected. Because there is no specic marker for fetal sepsis, many
patients would require cesarean section without benet to help those
few who might. Fetal tachycardia and some associated loss of variability
virtually always occur in the presence of maternal fever, and these
ndings alarm the clinician. The knowledge that acidosis is not increased
in this setting helps in reserving the decision to reserve operative deliv-
ery for those fetuses with additional signs of compromise, such as
persistent late, or nonreassuring variable or prolonged decelerations.
Fetal pulse oximetry in this situation may also be helpful to sort out the
fetus in need of intervention (Prietto et al, unpublished data).

SUMMARY

The management of patients with PROM, regardless of gestational

age, remains controversial. Generally, when patients are in labor, have
infection, or there is irreversible fetal distress, there are few options
other than delivery. For those not in labor, especially in premature
gestational ages, the complexities of the many combinations of decisions
to be made regarding the best methods for evaluating patients, pro-
longing gestation, reducing complications of prematurity, and choosing
the timing and route of delivery make studying and solving the problem
of the best option for management difcult at best. The administration
of corticosteroids and broad-spectrum antibiotics to those patients in the
very early premature gestational age groups has now been shown clearly
to improve outcome. Beyond that, the remainder of these problems are
somewhat unresolved and several reasonable options often exist and are
likely to remain so for some time to come.

References

1. Adoni A, Chetrit AB, Zacut D, et al: Prolongation of the latent period in patients with
premature rupture of the membrane by avoiding digital vaginal examination. Int J
Gynecol Obstet 32:19, 1990
2. Alexander JM, Mercer BM, Miodovnik M, et al: The impact of digital cervical examina-
tion on expectantly managed preterm rupture of membranes. Am J Obstet Gynecol
183:1003, 2000
3. Asrat T, Nageotte MP, Garite TJ, et al: Gram stain results from amniocentesis in
patients with preterm premature rupture of membranes: Comparison of maternal and
fetal characteristics. Am J Obstet Gynecol 163:887, 1990
846 GARITE

4. Capeless EL, Mead PB: Management of preterm premature rupture of membranes:

Lack of a national consensus. Am J Obstet Gynecol 157:11, 1987
5. Cotton DB, Hill LM, Strassner HT, et al: Use of amniocentesis in preterm gestation
with ruptured membranes. Obstet Gynecol 63:38, 1984
6. Cox SM, Leveno KJ: Intentional delivery versus expectant management with preterm
ruptured membranes at 30-34 weeks gestation. Obstet Gynecol 86:875, 1995
7. Crowley P: Antenatal corticosteroid therapy: A meta-analysis of the randomized trials,
1972 to 1994. Am J Obstet Gynecol 173:322, 1995
8. Friedman ML, McElin TW: Diagnosis of ruptured fetal membranes: Clinical study and
review of the literature. Am J Obstet Gynecol 104:544, 1969
9. Garite TJ, Freeman RK: Chorioamnionitis in the preterm gestation. Obstet Gynecol
54:539, 1982
10. Garite TJ, Freeman RK, Linzey EM, et al: Prospective randomized study of corticoste-
roids in the management of premature rupture of the membranes and the premature
gestation. Am J Obstet Gynecol 141:508, 1981
11. Garite TJ, Freeman RK, Linzey EM, et al: The use of amniocentesis in patients with
premature rupture of membranes. Obstet Gynecol 54:226, 1979
12. Gibbs RS, Blanco JD, St. Clair PJ, et al: Quantitative bacteriology of amniotic uid
from patients with clinical intra-amniotic infection at term. J Infect Dis 145:1, 1982
13. Gibbs RS, Castillo MS, Rodgers PJ: Management of acute chorioamnionitis. Am J
Obstet Gynecol 136:709, 1980
14. Hannah ME, Ohlsson A, Garine D, et al: Induction of labor compared with expectant
management for prelabor rupture of the membranes at term. N Engl J Med 334:1005,
1996
15. Hjertberg R, Hammarstrom M, Moberger B, et al: Premature rupture of the membranes
(PROM) at term in nulliparous women a ripe cervix: A randomized trial of 12 or 24
hours of expectant management. Acta Obstet Gynecol Scand 75:48, 1996
16. Johnson JWC, Daikoku NH, Niebyl JR, et al: Premature rupture of the membranes and
prolonged latency. Obstet Gynecol 57:547, 1981
17. Kilbride HW, Yeast J, Thibeault DW: Dening limits of survival: Lethal pulmonary
hypoplasia after midtrimester premature rupture of membranes. Am J Obstet Gynecol
175:675, 1996
18. Lewis DF, Adair CD, Weeks JW, et al: A randomized clinical trial of daily nonstress
testing versus biophysical prole the management of preterm premature rupture of
membranes. Am J Obstet Gynecol 181:1495, 1999
19. Lewis DF, Brody K, Edwards MS, et al: Preterm premature ruptured membranes: A
randomized trial of steroids after treatment with antibiotics. Obstet Gynecol 88:801,
1996
20. Lewis DF, Futayyeh S, Towers CV, et al: Preterm delivery from 34-37 weeks of
gestation: Is respiratory distress syndrome a problem? Am J Obstet Gynecol 174:525,
1996
21. Lewis DF, Major CA, Towers CV, et al: Effects of digital vaginal exams on latency
period in preterm premature rupture of membranes. Am J Obstet Gynecol 164:381, 1991
22. Mabery MC, Ramin SM, Gilstrap LC, et al: Intrapartum asphyxia in pregnancies
complicated by intra-amniotic infection. Obstet Gynecol 76(3 pt 1):351, 1990
23. Major CA, deVeciana M, Lewis DF, et al: Preterm premature rupture of membranes
and abruptio placentae: Is there an association between these pregnancy complications?
Am J Obstet Gynecol 172(2 pt 1):672, 1995
24. Mead PB: Management of the patient with premature rupture of the membranes. Clin
Perinatol 7:243, 1980
25. Mercer B, Arheart K: Antimicrobial therapy in expectant management of preterm
premature rupture of the membranes. Lancet 346:1271, 1995
26. Mercer BM, Crocker LG, Boe NM, et al: Induction versus expectant management in
premature rupture of the membranes with mature amniotic uid at 32 to 36 weeks: A
randomized trial. Am J Obstet Gynecol 169:775, 1993
27. Monif GRG: Recurrent chorioamnionitis and maternal septicemia: A case of successful
in utero therapy. Am J Obstet Gynecol 146:334, 1983
 MANAGEMENT OF PREMATURE RUPTURE OF MEMBRANES 847

28. Mozurkewich EL, Walf FM: Premature rupture of membranes at term: A meta-analysis
of three management schemes. Obstet Gynecol 89:1035, 1997
29. Munson LA, Granam A, Koos BJ, et al: Is there a need for digital examination in
patients with spontaneous rupture of the membranes? Am J Obstet Gynecol 153:562,
1985
30. Naef RW, Allbert JR, Ross EL, et al: Premature rupture of membranes at 34-37 weeks
gestation: Aggressive versus conservative management. Obstetrics 178:126, 1998
31. Nageotte MP, Freeman RK, Garite TJ, et al: Prophylactic intrapartum amnioinfusion
in patients with preterm premature rupture of membranes. Am J Obstet Gynecol
153:557, 1985
32. Ohlsson A, Wang E: An analysis of antenatal tests to detect infection in preterm
premature rupture of membranes. Am J Obstet Gynecol 162:809, 1990
33. Romero R, Emamian M, Quintero R, et al: The value and limitations of the Gram
stain examination in the diagnosis of intra-amniotic infection. Am J Obstet Gynecol
159:114, 1988
34. Schucker JL, Mercer BM: Midtrimester premature rupture of the membranes. Semin
Perinatol 20:389, 1996
35. Schutte MF, Treffers PE, Kloosterman GI, et al: Management of premature rupture
of membranes: A risk of vaginal examination to the infant. Am J Obstet Gynecol
146:395, 1983
36. Seaward PG, Hannah ME, Myhr TL, et al: International multicenter term PROM study:
Evaluation of predictors of neonatal infection in infants born to patients with prema-
ture rupture of membranes at term. Am J Obstet Gynecol 179:635, 1998
37. Spinnato JA, Shaver DC, Bray E, et al: Preterm premature rupture of the membranes
with fetal pulmonary maturity present: A prospective study. Obstet Gynecol 69:196,
1987
38. Tan BP, Hannah ME: Oxytocin for prelabour rupture of membranes at or near term
(Chochrane Review). In The Cochrane Library, Issue 3. Oxford, Update Software, 1998
39. Tan BP, Hannah ME: Prostaglandins versus oxytocin for prelabour rupture of mem-
branes at or near term (Cochrane Review). In The Cochrane Library, Issue 3. Oxford,
Update Software, 1998
40. Vintzileos AM, Campbell WA, Nochimson DJ, et al: Degree of oligohydramnios and
pregnancy outcome in patients with premature rupture of the membranes. Obstet
Gynecol 66:162, 1985
41. Vintzileos AM, Campbell WA, Nochimson DJ, et al: The fetal biophysical prole in
patients with premature rupture of the membranes: An early predictor of fetal infec-
tion. Obstet Gynecol 152:510, 1985
42. Wagner MV, Chin VP, Peters CJ, et al: A comparison of early and delayed induction
of labor with spontaneous rupture of membranes at term. Obstet Gynecol 74:93, 1989

Address reprint requests to

Thomas J. Garite, MD
Department of Obstetrics and Gynecology
UC Irvine Medical Center
101 The City Drive, Building 25
Orange, CA 928683298