Preterm Premature Rupture of Membranes (PPROM) is defined as the spontaneous rupture of fetal membranes between 24 weeks and 36 weeks 6 days of gestation but before the onset of labor (ACOG 2016) [1, 2]. The incidence of PPROM is 2-3% of all pregnancies, leading to 30-40% of preterm births [3]. PPROM is a multifactorial process influenced by risk factors such as a history of PPROM in a previous pregnancy, smoking, socioeconomic status, poor nutrition (BMI below 19.8 kg/m², copper, ascorbic acid deficiency), prior conization, cervical cerclage, second and third-trimester bleeding, prior episodes of preterm contractions, bacterial vaginosis, amniocentesis, polyhydramnios, and multiple gestations [4]. PPROM results from abnormal structural weakening of membranes in the region of the internal cervical os. It is initiated by membrane stretch and involves local inflammation and ascending bacterial colonization[5]. Genital tract pathogens associated with PPROM include Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Group B beta-hemolytic streptococcus (GBS), E. coli, and Proteus.

The current approach involves active management, which includes infection prevention, delaying delivery until fetal maturity is achieved, and active intervention in the presence of infection. The aim of the present study was to determine the maternal and fetal outcomes associated with PPROM. Babies born with sepsis have a fourfold higher mortality rate compared to babies without sepsis[6]. The decision-making process is primarily based on the patient’s preferences, taking into account her personal and moral beliefs, after a detailed discussion with her obstetrician regarding the benefits and risks of both management options.

The objectives of this study were to identify the risk factors contributing to preterm premature rupture of membranes and to determine the maternal and perinatal outcomes in cases of PPROM.

The study was conducted in the Department of Obstetrics and Gynaecology, VIMSAR, Burla, from November 2019 to October 2021. The study group included patients admitted with PPROM. The sample size was 85, with a population size of 250. The study was designed as a longitudinal study, and consecutive sampling was used.

Patients meeting the following criteria were included in the study:

• Women with gestational age between 28 and 37 weeks with preterm premature rupture of membranes.
• Malpresentation.
• Polyhydramnios.

Patients meeting the following criteria were excluded from the study:

• PROM beyond 37 weeks of gestational age.
• Fetal congenital anomaly.
• Intrauterine death.
• Uterine anomaly.
• Uterine fibroids.
• High-risk patients with diabetes mellitus or hypertension.

A comprehensive history was obtained, including age, socio-economic status at booking, parity, menstrual history, time of onset of draining, amount and characteristics of fluid lost (color, odor), association with vaginal bleeding or pain, perception of fetal movement, history of similar episodes in previous pregnancies, and indications of incompetent os.

General and systemic examinations were conducted. In obstetric examination, uterine fundal height, fetal lie, presentation and position, engagement of presenting parts, uterine condition (contracted or relaxed), and uterine tenderness (as a sign of chorioamnionitis) were noted. Fetal heart sounds were recorded. A sterile speculum examination was performed. Amniotic fluid was collected in cases of evident leakage and sent for culture and sensitivity. When amniotic fluid was not visible in the vagina, patients were asked to cough to aid collection. In cases of doubt, vaginal fluid was collected on a glass slide for microscopic examination (ferning or litmus paper test). Vaginal swabs were obtained for gram stain and culture sensitivity. A single pelvic examination assessed Bishop’s score, pelvis adequacy, presence of cephalopelvic disproportion, and ruled out cord prolapse. Clinical samples such as blood and urine were collected. Routine hematological investigations, cardiotocography, and obstetric ultrasonography were performed. Ampicillin 500 mg was administered as prophylactic antibiotic every 6 hours. Blood pressure, pulse rate, and temperature were measured every 4 hours. Fetal heart rate was monitored every half an hour initially. Labor progression was allowed to proceed spontaneously or induced with cerviprime gel or misoprostol 25 mcg based on the Bishop’s score and RCOG guidelines. Complications like fetal distress, fetal heart rate variations, and chorioamnionitis onset were observed. Cesarean section was performed in case of fetal or obstetric complications. Maternal third-stage complications, including foul-smelling lochia, puerperal sepsis, urinary tract infection, and respiratory tract infection, were monitored. Neonates were followed for the postnatal period. Neonatal mortality and morbidity, including birth injuries, signs of asphyxia, meconium aspiration, and sepsis, were noted. Both mother and baby were monitored until discharge from the hospital.

Statistical Analysis

All data were statistically analyzed using the ”Chi-square Test." Randomly selected data were tabulated in Microsoft Excel and analyzed with appropriate statistical tools using "SPSS version 24."

Results

In the age group of 20 - 25 years, 40 women (47.06%) were observed, while 24.71% were in the age group of 26 to 30 years, and 28% were in the age group of more than 30 years (Table 1). The Chi-square test showed a statistically significant P value of \(< 0.0001\). Of the cases, 70 (82.35%) were from rural areas and 15 (17.65%) from urban areas, which was statistically significant. Sixty women (70.59%) belonged to lower socio-economic status. Sixty cases (70.59%) were primigravida, and 25 (29.41%) were multigravida. Vaginal delivery was the most common mode of delivery, with 64.70% of women, compared to 35.29% undergoing LSCS (Table 1).

Most of the women (35.29%) had no risk factors, with breech presentation at 23.29%, followed by UTI at 11.76%, h/o PPROM at 11.76%, polyhydramnios at 11.76%, and h/o recent coitus at 5.89%, as shown in Table 2.

In our study, the time interval between rupture of membranes and delivery was 64.70% within 24 hours, 22.35% within 25-72 hours, and 12.95% greater than 72 hours (Table 3).

There were no maternal complications in 40 cases (47%), puerperal pyrexia occurred in 23%, followed by chorioamnionitis in 15% of cases, abruption in 5.88%, and wound infection in 5.88%. This difference was statistically significant (Table 4).

A total of 58.82% of newborns had no neonatal complications. The most common complication was respiratory distress syndrome (RDS) at 17%, followed by jaundice at 11%, septicemia at 5%, and intraventricular hemorrhage (IVH) at 5%. The differences were statistically significant with a p value \(\leq\) 0.0001, as shown in Table 5.

The majority of babies born weighed \(\leq\) 2.5kg (70.59%), while 29.41% weighed \(\geq\) 2.5kg, which was statistically significant. The rate of neonatal mortality was 11%, and the p value for NICU admissions was \(<\) 0.0001 (52%), as indicated in Table 5.

The high vaginal culture sensitivity test showed no growth in the majority, at 82.35%. Other organisms detected included E. coli at 11.76%, S. aureus at 3.52%, and Klebsiella and Pseudomonas at 1.17% each. E. coli was the most frequently isolated organism, and this difference was statistically significant, as shown in Table 6.

Preterm premature rupture of membranes during pregnancy can lead to various maternal and neonatal complications. This study aims to explore labor outcomes, maternal and fetal complications, as well as identify risk factors. Out of the 85 patients evaluated, 47% were in the age group of 20–25 years. This result is similar to the 40% obtained in a study conducted by Akter et al.[7]. A higher incidence of PPROM, specifically 70%, was observed in the lower socioeconomic status group. Pandey et al. reported a similar but slightly lower rate of 61%[8]. Economic status and PPROM seem to be directly proportional, with poor hygiene, anemia, stress, high parity, overexertion, and recurrent genitourinary infections contributing to PPROM in lower socioeconomic status. Of the patients admitted with PPROM, 70% were primigravida, which correlates with the 52% reported in the study by Pandey et al.[8]. In comparison, the study by Patil et al. had unbooked cases accounting for 31% and booked cases for 69%, whereas our study had 58% [9]. Patients who did not receive proper antenatal checkups had a higher incidence of infections, although statistical significance wasn’t achieved. The cesarean section rate of 20% in this study is consistent with the findings of Tahir et al. [10]. Fetal distress was the most common indication for cesarean section, aligning with studies conducted by Pandey et al.[8].

Assessing the risk factors for PPROM, 35% of the study population had no identifiable risk factors. Breech presentation was the most common risk factor at 23%, a result similar to Gunn et al. [11].

Escherichia coli was the most frequently isolated vaginal organism in our study, in line with studies by Ramesh et al.[12] and Surayapalem et al.[13]. Surayapalem et al. reported E. coli (19%), Staphylococcus aureus (11%), Klebsiella pneumoniae and coagulase-negative Staphylococcus both at 7%, and Citrobacter and group B Streptococcus both at 2%[14]. In our study, 70.59% of newborns had birth weights below 2.5kg, consistent with the findings of Mohakar et al. [14]. Moreover, 52% of babies were admitted to the NICU for various complications, a percentage similar to that in the study by Patil et al.[8], where NICU admissions accounted for 36%. Around 64% of patients delivered within 24 hours, a figure comparable to the results of Patil et al. [8]. Only 11 cases had a latent phase of more than 3 days, and 22.35% delivered within 25–72 hours, which also correlated with the above studies. The most common cause of neonatal morbidity was respiratory distress syndrome (17%), and out of the 85 cases, 10 neonatal deaths were observed. A study by Mohokar et al.[14] also reported similar findings.

Preterm premature rupture of membranes (PPROM) is a common complication of pregnancy; however, its consequences can be mitigated by the use of antibiotics and corticosteroids. While many mothers showed no risk factors, the risk of breech presentation can be managed with external cephalic version (ECV). Avoiding coitus in the later weeks of pregnancy also reduces the risk of PPROM. Mothers diagnosed with polyhydramnios or multiple gestations are prone to suffer from PPROM. Urinary tract infections (UTIs) can be effectively treated with antibiotics. Administering antibiotics during the latent period can lower maternal complications such as chorioamnionitis, puerperal pyrexia, and septicemia. The use of corticosteroids in cases of PPROM before 34 weeks can reduce neonatal morbidity, including respiratory distress syndrome, which is the most common cause of neonatal deaths. Improving neonatal care facilities is crucial for managing neonatal emergencies and reducing neonatal mortality. Improvements in socioeconomic status, nutritional supplements, and proper antenatal care can contribute to reducing the incidence of PPROM.

Authors declare no conflict of interests.

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