Expectant Management of Preterm Premature Rupture of Membranes and Nonvertex Presentation: What Are the Risks?

Abstract

Preterm premature rupture of membranes (PPROM) still is a major cause of preterm births. Most authorities recommend extending expectant management to 34 weeks' gestation, but in cases of nonvertex pregnancy, numerous possible complications must be kept in mind. They include umbilical cord prolapse, a low Apgar score, neurological injuries, and fetal anomalies. This retrospective analysis compared 74 patients with PPROM and nonvertex presentation with the same number of control patients having PPROM with vertex presentation. Case and control patients were matched for gestational age, which at delivery ranged from 23 to 34 weeks. All participants were managed in a similar way. The estimated mean gestational age at the time of membrane rupture was 27 to 28 weeks in both the vertex and nonvertex groups. All but one of 9 pregnancies with a prolapsed umbilical cord were in the nonvertex group. The incidence of cord prolapse in the nonvertex group was 28% before, and about 5% after 26 weeks' gestation, a statistically significant difference. The risk of neonatal death did not differ significantly between the vertex and nonvertex groups. The only adverse outcomes that were more frequent in the study group were a low 5-minute Apgar score and a cord blood gas value of 7.2 or less. Precipitous and unplanned vaginal delivery took place in 5 cases of breech presentation. Four of these infants had hyaline membrane disease and 3 had culture-positive sepsis. None, however, had intraventricular hemorrhage, and all 5 infants were healthy when discharged. Pregnant women with PPROM and a nonvertex presentation are at significantly increased risk and should be assessed on a daily basis. Whether more frequent nonstress testing and color-flow Doppler ultrasonography will improve the outcome in these cases remains uncertain.