stay in the neonatal intensive care unit (nicu), and does not increase the rate of caesarean sections. if a woman strongly does not want to be induced, watchful waiting is an acceptable option as long as there is no sign of infection, the fetus is not in distress, and she is aware and accepts the risks of pprom. there is not enough data to show that the use of prophylactic antibiotics (to prevent infection) is beneficial for mothers or babies at or near term because of the potential side effects and development of antibiotic resistance. 34 to 37 weeks when the fetus is 34 to 37 weeks gestation, the risk of being born prematurely must be weighed against the risk of prom. previously it was recommended that delivery be carried out as if the baby was term. a 2017 cochrane review however found waiting resulted in better outcomes when pregnancy is before 37 weeks. 24 to 34 weeks before 34 weeks, the fetus is at a much higher risk of the complications of prematurity. therefore, as long as the fetus is doing well, and there are no signs of infection or placental abruption, watchful waiting (expectant management) is recommended. the younger the fetus, the longer it takes for labor to start on its own, but most women will deliver within a week. waiting usually requires a woman to stay in the hospital so that health care providers can watch her carefully for infection, placental abruption, umbilical cord compression, or any other fetal emergency that would require quick delivery by induction of labor. in 2017, a review of watchful waiting vs the early birth strategy was conducted to ascertain which was associated with a lower overall risk. focusing on the 24–37-week range, the review analysed twelve randomised controlled trials from the "cochrane pregnancy and childbirth's trials register", concluding that "in women with pprom before 37 weeks' gestation with no contraindications to continuing the pregnancy, a policy of expectant management with careful monitoring was associated with better outcomes for the mother and baby." there is believed to be a correlation between volume of amniotic fluid retained and neonatal outcomes before 26 weeks' gestation. amniotic fluid levels are an important consideration when debating expectant management vs clinical intervention, as low levels, or oligohydramnios, can result in lung and limb abnormalities. additionally, labor and infection are less likely to occur when there are sufficient levels of amniotic fluid remaining in the uterus. serial amnioinfusion in pregnancies with pprom-related oligohydramnios at less than 26 weeks gestation, successfully alleviates oligohydramnios, with perinatal outcomes that are significantly better than the outcome in those with the persistent condition and is comparable with gestations with pprom in which oligohydramnios never develops. recommended monitoring for infection: signs of infection include a fever in the mother, fetal tachycardia (fast heart rate of the fetus, more than160 beats per minute), or tachycardia in the mother (more than 100 beats per minute). white blood cell (wbc) counts are not helpful in this case because wbc's are normally high in late pregnancy. steroids before birth: corticosteroids (betamethasone) given to the mother of a baby at risk of being born prematurely can speed up fetal lung development and reduce the risk of death of the infant, respiratory distress syndrome, brain bleeds, and bowel necrosis. it is recommended that mothers receive one course of corticosteroids between 24 and 34 weeks when there is a risk of preterm delivery. in cases of pprom these medications do not increase the risk of infection even though steroids are known to suppress the immune system. more than two courses is not recommended because three or more can lead to small birth weight and small head circumference. in pregnancies between 32 and 34 weeks (right around the time that fetal lungs mature) vaginal fluid can be tested to determine fetal lung maturity using chemical markers which can help to decide if corticosteroids should be given. magnesium sulfate: intravenous magnesium sulfate is given to the mother in cases when there is a risk of preterm birth before 32 weeks. this has been shown to protect the fetal brain and reduce the risk of cerebral palsy. latency antibiotics: the time from prom to labor is termed the latency period, and there is an inverse relationship between gestational age and the length of latency, meaning that the earlier the rupture, the longer it will take for labor to begin naturally. as expected, antibiotics given to mothers that experience pprom serve to protect against infections during this lengthened latency period. additionally, antibiotics increase the time that babies stay in the womb. antibiotics don't seem to prevent death or make a difference in the long-term (years after the baby is born). but, because of the short-term benefits, routine use of antibiotics in pprom is still recommended. the american congress of obstetricians and gynecologists (acog) recommends a seven-day course of intravenous ampicillin and erythromycin followed by oral amoxicillin and erythromycin if watchful waiting is attempted before 34 weeks. amoxicillin/clavulanic acid increases the risk of fetal bowel death (necrotizing enterocolitis) and should be avoided in pregnancy. prophylactic antibiotics: if a woman is colonized with gbs, than the typical use of antibiotics during labor is recommended to prevent transmission of this bacteria to the fetus, regardless of earlier treatments. controversial or not recommended preventative tocolysis (medications to prevent contractions): the use of tocolytic medications to prevent labor contractions is controversial. on the one hand, this can delay delivery and allow the fetus more time to develop and benefit from antenatal corticosteroid medication, on the other hand it increases the risk of infection or chorioamnionitis. the use of tocolysis has not shown to benefit mom or baby and currently there is not enough data to recommend or discourage its use in the case of preterm prom. therapeutic tocolysis (medications to stop contractions): once labor has started, using tocolysis to stop labor has not been shown to help, and is not recommended. amnioinfusion: this treatment attempts to replace the lost amniotic fluid from the uterus by infusing normal saline fluid into the uterine cavity. this can be done through the vagina and cervix (transcervical amnioinfusion) or by passing a needle through the abdominal wall (transabdominal amnioinfusion). current data suggests that this treatment prevents infection, lung problems, and fetal death. however, there have not been enough trials to recommend its routine use in all cases of pprom. home care: typically women with pprom are managed in the hospital, but, occasionally they opt to go home if watchful waiting is attempted. since labor usually starts soon after pprom, and infection, umbilical cord compression, and other fetal emergencies can happen very suddenly, it is recommended that women stay in the hospital in cases of pprom after 24 weeks. currently, there is not enough evidence to determine meaningful differences in safety, cost, and women's views between management at home vs. the hospital. sealing membranes after rupture: infection is the major risk associated with prom and pprom. by closing the ruptured membranes, it is hoped that there would be a decrease in infection, as well as encouraging the re-accumulation of amniotic fluid in the uterus to protect the fetus and allow for further lung development. common techniques include placing a sponge over the ruptured membrane and the use of oral autoimmune stimulating drugs to encourage the body's immune system to repair the rupture. there is currently insufficient research to determine whether these or other resealing techniques improve maternal or neonatal outcomes when compared to the current standard of care. before 24 weeks before 24 weeks, a fetus is not viable meaning it cannot live outside the mother. in this case, either watchful waiting at home or an induction of labor done. because the risk of infection is so high, the mother should check her temperature often and return to the hospital if she develops any signs or symptoms of infection, labor, or vaginal bleeding. these women are typically admitted to the hospital once their fetus reaches 24 weeks and then managed the same as women with pprom before 34 weeks (discussed above). when possible, these deliveries should take place in a hospital that has expertise in the management of the potential maternal and neonatal complications, and has the necessary infrastructure in place to support the care of these patients (i.e. neonatal intensive care unit). antenatal corticosteroids, latency antibiotics, magnesium sulfate, and tocolytic medications are not recommended until the fetus reaches viability (24 weeks). in cases of pre-viable pprom, chance of survival of the fetus is between 15 and 50%, and the risk of chorioamnionitis is about 30%. chorioamnionitis chorioamnionitis is a bacterial infection of the fetal membranes, which can be life-threatening to both mother and fetus. women with prom at any age are at high risk of infection because the membranes are open and allow bacteria to enter. women are checked often (usually every 4 hours) for signs of infection: fever (more than 38 °c or 100.5 °f), uterine pain, maternal tachycardia, fetal tachycardia, or foul-smelling amniotic fluid. elevated white blood cells are not a good way to predict infection because they are normally high in labor. if infection is suspected, artificial induction of labor is started at any gestational age and broad antibiotics are given. caesarean section should not be automatically done in cases of infection, and should only be reserved for the usual fetal emergencies. outcomes the consequences of prom depend on the gestational age of the fetus. when prom occurs at term (after 36 weeks), it is typically followed soon thereafter by the start of labor and delivery. about half of women will give birth within 5 hours, and 95% will give birth within 28 hours without any intervention. the younger the baby, the longer the latency period (time between membrane rupture and start of labor). rarely, in cases of preterm prom, amniotic fluid will stop leaking and the amniotic fluid volume will return to normal. if prom occurs before 37 weeks, it is called preterm prelabor rupture of membranes (pprom), and the baby and mother are at greater risk of complications. pprom causes one-third of all preterm births. prom provides a path for disease-causing organisms to enter the womb and puts both the mother and baby at risk for infection. low levels of fluid around the baby also increase the risk of umbilical cord compression and can interfere with lung and body formation of the baby in early pregnancy. infection (any age) at any gestational age, an opening in the fetal membranes provides a route for bacteria to enter the womb. this can lead to chorioamnionitis (an infection of the fetal membranes and amniotic fluid) which can be life-threatening to both the mother and fetus. the risk of infection increases the longer the membranes remain open and baby undelivered. women with preterm prom will develop an intra-amniotic infection 15–25% of the time, and the chances of infection increase at earlier gestational ages. pre-term birth (before 37 weeks) prom occurring before 37 weeks (pprom) is one of the leading causes of preterm birth. thirty to 35% of all preterm births are caused by pprom. this puts the fetus at risk for the many complications associated with prematurity such as respiratory distress, brain bleeds, infection, necrotizing enterocolitis (death of the fetal bowels), brain injury, muscle dysfunction, and death. prematurity from any cause leads to 75% of perinatal mortality and about 50% of all long-term morbidity. prom is responsible for 20% of all fetal deaths between 24 and 34 weeks' gestation. fetal development (before 24 weeks) before 24 weeks the fetus is still developing its organs, and the amniotic fluid is important for protecting the fetus against infection, physical impact, and for preventing the umbilical cord from becoming compressed. it also allows for fetal movement and breathing that is necessary for the development of the lungs, chest, and bones. low levels of amniotic fluid due to mid-trimester or previable pprom (before 24 weeks) can result in fetal deformity (e.g. potter-like facies), limb contractures, pulmonary hypoplasia (underdeveloped lungs), infection (especially if the mother is colonized by group b streptococcus or bacterial vaginosis), prolapsed umbilical cord or compression, and placental abruption. prom after second-trimester amniocentesis most cases of prom occur spontaneously, but the risk of prom in women undergoing a second trimester amniocentesis for prenatal