EXPLANATION FOR QUESTION 3

 QUESTION 3

Membrane rupture prior to the onset of labor is premature rupture of membranes (PROM), and PROM at <37 weeks gestation is

preterm PROM (PPROM) The diagnosis of membrane rupture can be confirmed with the nitrazine or fern tests or with a speculum

examination showing vaginal pooling of clear fluid or fluid emerging from the cervix. PPROM risk factors are similar to those for

preterm delivery (eg, history of prior preterm delivery, multiple gestation) but also include a history of prior PPROM, genital tract

infection (eg, bacterial vaginosis), and tobacco use. Complications of PPROM include chorioamnionitis/endometritis, cord prolapse,

and abruptio placentae.

The management of PPROM is dependent on gestational age and clinical presentation with the goal of minimizing prematurity risks

and the risks of prolonged membrane rupture (eg, infection) At <34 weeks gestation, fetuses are at greatest risk of prematurityrelated morbidity (eg, lung immaturity, intraventricular hemorrhage). Patients with PPROM at <34 weeks gestation with no signs of

infection or fetal compromise should be managed conservatively so that in utero fetal growth can continue. This patient should be

hospitalized for observation and receive corticosteroids (eg, betamethasone) to decrease the risk of neonatal respiratory distress

syndrome Antibiotics should also be administered to increase the interval between membrane rupture and delivery.

(Choices A and F) Vaginal progesterone and cerclage are used in the prevention of PPROM and preterm labor but do not help in the

management of PPROM.

(Choices Band 0) The risks of prematurity are lower at �34 weeks gestation; consequently, delivery is indicated for PPROM at this

gestational age This patient should be delivered when she reaches 34 weeks gestation or for signs of infection or fetal compromise.

(Choice C) External cephalic version should be performed at �37 weeks gestation to manually correct fetal malpresentation (eg,

breech) Decreased amniotic fluid is a relative contraindication.

Educational objective:

Patients who present with uncomplicated preterm premature rupture of membranes at <34 weeks gestation can be managed

conservatively with antenatal corticosteroids and antibiotics. Delivery should occur at 34 weeks or in the setting of intrauterine

infection or deteriorating fetal/maternal status.