An aggressive interventional protocol for early midtrimester premature rupture of the membranes using gelatin sponge for cervical plugging

Abstract

Objective: This study was performed to evaluate a protocol for treatment of previable premature rupture of membranes (PROM) that includes the administration of gelatin sponge to retard the loss of fluid from the amniotic cavity. Study Design: Women with PROM at ≤21 weeks' gestation with a structurally normal singleton; having no evidence of infection, active bleeding, or labor; and a maximum vertical fluid pocket of less than 1.5 cm were candidates. Interventions included hospital admission, amnioinfusion, cervical cerclage, administration of gelatin sponge (Gelfoam) into the amniotic cavity, antibiotic administration, and perioperative tocolysis. Weekly assessment of fluid status was performed and if oligohydramnios returned, patients were offered repeat amnioinfusion. Results: Fifteen women with PROM at 17.9 ± 2.2 weeks' gestation (range 13-21 weeks) underwent this protocol. Spontaneous PROM was diagnosed in 14 patients and one had iatrogenic PROM after fetoscopy. Eight fetuses reached a viable gestational age (≥24 weeks, 53%), with six of these newborn infants surviving to hospital discharge (30%) and two suffering intrauterine death. The average gestational age of delivery for survivors was 31.8 ± 4.3 weeks, range 25 to 36 weeks. Talipes equivarus was observed in three survivors (50%). Bilateral hip dysplasia and torticollis were also diagnosed in two infants. Respiratory distress syndrome was diagnosed in all cases delivered at less than 32 weeks but was not observed thereafter. No adverse sequelae have been attributed to gelatin sponge exposure. Conclusion: The observed survival rate with this interventional approach in a population at highest risk for pregnancy loss justifies further study of this treatment strategy. This protocol may not reduce the rate of musculoskeletal abnormalities. (Am J Obstet Gynecol 2002;187:1143-6.)