Dasgupta’s Recent Advances in Obstetrics and Gynecology Pratik Tambe, Rohan Palshetkar, Nandita Palshetkar
INDEX
Page numbers followed by f refer to figure, fc refer to flowchart, and t refer to table
A
Acanthosis nigricans 59, 59f
Acid tyrode aspiration 84f
Acne 61
Adhesions, prevention of 28
Alopecia 61
Amenorrhea 57, 68fc, 72
American College of Obstetrics and Gynecology 73
American Society for Reproductive Medicine 73
Anastrozole 63, 74
Androgen excess 55
Anemia, aplastic 90
Aneuploidy 81
Antagonists 76
Antenatal care 43
Antenatal fetal testing 48
Antepartum fetal testing 48
Antiandrogens 61
Antibiotic 6
Antioxidants 66
Aromatase inhibitors 63, 72, 74
Array comparative genomic hybridization 82
Artificially stimulating, technique of 9
Assisted reproductive technology 65
Atosiban 5
regimen 5
Australian Carbohydrate Intolerance Study in Pregnant Women Trial 42
B
Balloon
catheter 13
tamponade 35
Bariatric surgery 61
Betamethasone 4
Birth, mode of 7
Bishop's score
assessment of 11
modified 11
Blastocysts 85
Blastomere 83
removal by displacement 85f
removal by extrusion 84f
Blood
loss, arresting of 35
pressure 5
sugar 43
level 49
B-lynch brace suture 36f
Body mass index 39, 44, 73
Brace sutures 36
Breast
cancer 109
downstaging of 118
screening 109, 113, 113t, 114t, 118
control arm 112t
examination, clinical 111, 119
screening arm 112t
self-examination 110
Breech 21
Bromocriptine 74
C
Canadian National Breast Screening Study 113
Cancer diseases 90
Carboprost 35
Cardiotocography 10
Cardiovascular disease 58
Cavity, abdominal 104f
Cephalic presentation 21
Cervical
length 2
ripening 11
induction of 12
methods of 12
status 15
assessment of 11
Cervicopexy, laparoscopic 96
Cerviprime 12
Cervix 2
Cesarean 20
delivery 1, 20
operation 20
section 20
current practice of 20
previous 21
Cetrorelix 77
Classical incision, closure of 28
Clomiphene 72, 73, 75
citrate 62, 72, 73
resistant anovulation 76
Cochrane meta-analysis 77
Cochrane review 2012 4
Contraceptive
patch, transdermal 62
pills, combined oral 62
ring, transvaginal 62
Cooper's ligament 100
Cord around neck 21
Cortical tissue after transplantation, ischemia of 91
Craniopharyngiomas 72
C-reactive protein 3, 7
Cryopreservation 92
methods of 91, 93
Cryoprotectant agent 91, 93
Cyproterone acetate 61
D
D-chiro inositol 66
Dehydroepiandrosterone 75
Delivery management 7
Diabetes 1
in pregnancy 39
mellitus 56
Diet and exercise, role of 44
Dimethyl sulfoxide 93
Dinoprostone 14
vaginal pessary 12
Dystocia 20
E
Electronic fetal monitoring 20
Embryos
biopsy 83
cryopreservation of 89
Empirical therapy 6
Endometritis 26
Ergometrine 35
Erythromycin 6
Ethylene glycol 93
European Association of Perinatal Medicine 2
European Society of Human Reproduction and Embryology 73
Exercise, strenuous 72
F
Fetal
anomalies 21
assessment 48
conditions 21
distress 20
fibronectin 4
heart rate 16
indications 1
issues 3
monitoring 7
surveillance 48
Fetus, delivery of 25
Fluorescence in situ hybridization 82
Follicle-stimulating hormone 56, 64, 74, 76
Food and Drug Administration 47
Frank's straight transverse incision 23
Free fatty acids 57
G
Galactorrhea 72
General anesthesia 37
Gestational diabetes mellitus 39, 41, 43, 58
Glucocorticoids 74, 75
Glyburide 47, 48
Gonadotropin 63, 75
exogenous 75
releasing hormone 56, 73, 89
agonists 76
Göteborg breast screening trial 116
H
HELPERR pathway 50fc
Hemorrhage
obstetric 32
postpartum 32, 33
Hepatitis
B virus 22
C virus 22
Hirsutism 61
HIV 22
Hormone, luteinizing 56, 75
Human chorionic gonadotropin 64, 75
Hyperandrogenism 5759
Hyperbilirubinemia, neonatal 48
Hyperstimulation 15
Hypoglycemia, neonatal 48
Hypogonadism
hypergonadotropic 72
hypogonadotropic 72, 75
normogonadotropic 72
Hyponatremia 16
Hypothalamic-pituitary-ovarian axis 73
Hysterectomy 37
obstetric 37
subtotal 97
I
Iliac spine, anterior superior 105f
Impaired glucose tolerance 39
In vitro fertilization 80
In vitro maturation 65
Indian Council of Medical Research 45
Indomethacin 5
Infection 1
Infertility 72
anovulatory 72, 73
management of 62
unexplained 73, 76
Inflammation 1
Inguinal ligament 106f
Inositol-myoinositol 66
Insulin 45
resistance 57
therapy 47
pathways 46fc
International Federation of Gynecology and Obstetrics 42
Intrauterine
fetal growth restriction 1
insemination 73
Ion Chef instrument Thermo Fisher 87f
Ion S5 system Thermo Fisher 87f
J
Joel-Cohen's incision 23, 24
modified 24
K
Kallmann syndrome 72
Khanna's sling procedure, modified 101, 107f
L
Labor 3
after cesarean, trial of 28
difficult 20
induction of 9, 12, 13, 16, 17
insulin administration in 49
management in 49
pharmacological methods of induction of 14
third stage of 33
Large for gestational age 43, 58
L-carnitine 67
Left iliopectineal ligament 101f
Letrozole 63, 74, 77, 78
doses 74
Leuprolide 76
L-methylfolate 66
Low dose oxytocin infusion 13
Low transverse curvilinear incision 23
Lower segment
transverse uterine incision 24
vertical uterine incision 25
M
Macrosomia 21, 49
Magnesium sulfate 4
neuroprophylaxis 4
Maylard's incision 23, 24
Medical nutrition therapy 46
Melatonin 67
Membrane
preterm
prelabor rupture of 3
premature rupture of 1, 4
rupture of 2
stripping 13
sweeping and stretching 14
Menstrual disturbances 57
Menstrual dysfunction, management of 62
Mesh, laparoscopic view of 105f
Metformin 47, 65, 75
Midline subumbilical vertical incision 23
Misoprostol 12, 14
Monosomy 81
Multiple pregnancy 21
Myoinositol 77
Myomectomy, full thickness 10
N
N-acetyl cysteine 66
National Center for Health Statistics 39
National Institute for Health and Care Excellence 42
Necklace pattern 59
Neonatal intensive care unit 2
Neutral protamine Hagedorn insulin 45
Nipple stimulation 14
Nonabsorbable soft polypropylene 97
Nonreassuring fetal testing 1
Nonstress test 4
Normal saline 49
Nullisomy 81
O
Obesity 69fc
Oligomenorrhea 57
Oocytes, cryopreservation of 89
Oral antidiabetics 47
Oral contraceptive pills 56
pretreatment 67
Oral glucose tolerance test 40
Ovarian cortex tissue 90
Ovarian cryopreservation 89
Ovarian drilling, laparoscopic 64
Ovarian hyperstimulation syndrome 64
Ovarian tissue 90, 91, 94
cryopreservation 89, 94
techniques in 90
transplantation 93
Ovary cryopreservation 91
Ovulation induction 72
drugs for 62
Ovulatory dysfunction 68fc
Oxytocin 15, 16, 33, 35
combination of 12
induction, combination of 12
infusion 15
P
Pain relief after induction 16
Pectopexy 101, 102t
laparoscopic 100
technique 100
Pelvic floor muscle 96
Pelvic organ prolapse 96
current treatments for 96
Periodic blood glucose testing 43
Pfannenstiel incision 23
Phosphate-buffered saline 93
Placenta accreta 33
Placental extraction 26
Polar body 83
biopsy 84f
Polycystic ovarian syndrome 47, 55, 57f, 65, 67, 73
adolescent 67
fetal origin of 57
pathophysiology of 56fc
phenotypes 55
Polycystic ovary 60f
Polymenorrhea 57
Polypropylene monofilament 97
meshes 98f
Post-letrozole supplementation 74
Postprandial blood sugar 46
Pouch of Douglas 103f
Preeclampsia 1
Pregnancy
caloric requirements in 44
complications of 32
Preimplantation genetic
diagnosis 80
testing 80
Preterm birth 3
major causes of 1, 1f
Preterm labor 1, 2, 6
Progestin therapy 62
Prostaglandin 12, 14, 17
E1 12, 14
E2 12, 14
Puborectalis muscle 97
R
Recombinant follicle stimulating hormone 64
Rectovaginal fascia 97
Rescue steroids 4
Right external iliac vein 100f
Ringer's solution, lactated 34
Robertsonian translocation 80
S
Sacral promontory dissection 98f
Sacral vessels 97
Sacrocervicopexy 101, 102t
complications of 99, 99t
landmarks for 98f
laparoscopic 97
Screening
methodologies 41
pathways 43fc
Selective arterial occlusion 37
Selective estrogen receptor modulator 62, 73
Sex hormone binding globulin 56
Shanghai trial 111
Sheehan syndrome 72
Shock, irreversible 32
Shoulder dystocia 49, 50fc
Sickle cell disease 90
Single gene disorder 80, 81
Single nucleotide polymorphism 82
Skin
incision 23, 106f
length of 24
preparation 23
Slow freezing 91, 93
Small for gestational age 58
Soft polypropylene mesh 103f
Steroids 4, 7
Stockholm mammographic screening trial 116
Stress
extreme 72
urinary incontinence 102
Supravaginal cervix visualized 103f
T
Tamoxifen 63, 74
Tetrasomy 81
Thalassemia major 90
Thrombin 32
Tissue 32
Tocolytics 5
Tone 32
Transfundal uterine surgery 10
Trauma 32
Triptorelin 76
Trisomy 81
Trophectoderm
biopsy 85f
cells 85
U
Ultrasound, role of 69
Uterine
atony 17
contractions monitoring, tocodynamometer for 4
descent 96
incision 24
suturing of 27
packing 35
repair 26
rupture 15, 17
Uterus 36f
exteriorization of 26
V
Vaginal birth after cesarean 28
Vaginal incision, posterior 104f
Vaginal progesterone 2
Vault prolapse 96
Vitamin D 66
Vitrification 92
W
White blood cell 7
Wrigley's forceps 25
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Chapter Notes

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Preterm LaborCHAPTER 1

Pratap Kumar
 
LEARNING OBJECTIVES
  • Understand importance of preterm birth
  • Identify who is at risk and review prevention options
  • Understand prompt management of initial presentation
  • Review management of preterm premature rupture of membranes
  • Management of preterm labor.
 
MAJOR CAUSES OF PRETERM BIRTH1
  • Preterm premature rupture of membranes (PPROM): 20–30%.
  • Iatrogenic:
    • Maternal indications (preeclampsia, diabetes, prior classical cesarean delivery)
    • Fetal indications (nonreassuring fetal testing, intrauterine fetal growth restriction): 20%.
  • Spontaneous (unexplained preterm labor: 25–30%.
  • Infection/inflammation: 20–25%.
The major causes of preterm birth (PTB) have been shown in Figure 1.
zoom view
Fig. 1: Major causes of preterm birth.
2
 
LATEST INTERNATIONAL GUIDELINES
There are several International guidelines such as the European Association of Perinatal Medicine 2017, Western Australian PTB prevention key initiative 2017, French clinical practice guidelines 2016, NICE guideline 2015, FIGO 2015, StratOG by RCOG 2014, ACOG 2012, SOGC 2008.
All the guidelines have uniformly stressed upon the use of progesterone as an alternative to cervical cerclage in women with the one who has delivered early or who has lost her pregnancy in the middle of pregnancy and a short cervix (<25 mm) on ultrasound at 20–37 weeks’ gestation.
ACOG guideline 2012 recommends daily progesterone supplementation in a woman with history of prior PTB, woman without history of prior PTB but at risk due to short cervix (≤20 mm at ≤24 weeks).
 
PREVENTION
Emphasis on cervical length (CL) screening has been done based on prior studies. Incidence of birth <35 weeks is 30% in women with CL 20–24 mm, 50% with CL 10–19 mm, and 90% with CL <10 mm. The incidence of birth <35 weeks is only 16% in women with CL >25 mm.2
For short cervix <20 mm with no prior PTB, vaginal progesterone/oral/injectable can be given in any form as follows after identification until 36 weeks: dose of 200 mg suppositories, tablets either oral or vaginally, weekly injections of 17-alpha hydroxyprogesterone caproate. Recent introduction of oral sustained-release seems to be effective, but randomized trials are not done.
 
TERMINOLOGIES
When preterm labor has been diagnosed?
Diagnosis is when there is a positive evidence of preterm labor.
When preterm labor is established?
If the cervix is dilated more than 4 cm with uterine frequent contraction.
When rupture of membranes occurs preterm?
If there is amniotic fluid leak before 37 weeks of pregnancy.
The following points should be assessed:
If the pregnancy is less than 28 weeks, transfer the women to a tertiary level where the neonatal intensive care unit (NICU) facility to present.
 
CONTRAINDICATIONS TO STOP LABOR
If there is a harm by continuation of her pregnancy:
  • When pregnancy is nonviable
  • Cervix is more than 4 cm dilated3
  • Bleeding from uterus
  • Infection is suspected
  • Fetal distress
  • Rupture of membranes—frank leak of fluid.
 
INDICATED PRETERM BIRTH3
 
Placental/Obstetric Issues
  • Previa alone
  • Preterm premature rupture of membranes.
 
Maternal Issues
  • Chronic hypertension (HTN)
  • Gestational HTN
  • Preeclampsia + severe features.
 
Fetal Issues
  • Intrauterine growth restriction (IUGR) alone
  • Multiple pregnancy with IUGR
  • Severe oligohydramnios.
 
DIAGNOSIS
Only 30–60% of women presenting with preterm labor will lead to a PTB. Five main areas of concern that make a difference in survival of infant and they are: (i) transfer to hospital with NICU capabilities, (ii) tocolytics, (iii) antibiotic prophylaxis, (iv) administration of steroids, and (v) magnesium for neuroprotection.4,5
Are the membranes ruptured?
The following are observed: pooling of fluid in posterior fornix, ultrasound for amniotic fluid index if unsure.
Is an infection present?
Total count and C-reactive proteins (CRPs) can be done.
Is the patient in labor?
Regular contractions are present or not. If there is contractions, check the cervical dilation.
Diagnosing preterm prelabor rupture of membranes:
A genital examination by a speculum has to be done. If the fluid is pooled in posterior fornix, there is no need to do more tests.4
 
Fetal Fibronectin—24+0 to 33+6 Weeks
Negative predictive value 99% for delivery within 14 days. Positive predictive value 13–30% for delivery in 7–10 days. Can only be done if nothing in vagina in past 24 hours. False positives are seen with amniotic fluid or blood or vaginal infection. Fetal fibronectin (fFN) if available can be offered, which tells that the delivery can occur within 48 hours.
 
Nonstress Test along with Tocodynamometer for Uterine Contractions Monitoring
 
Preterm Premature Rupture of Membranes6
Preterm premature rupture of membranes prior to 37 weeks and prior to onset of contractions >50% will give birth within 1 week of rupture, 70–80% in 2–5 weeks after intra-amniotic infection in 15–25%, more likely when more preterm.
PPROM—management 24–33+6 weeks: Admission, expectant management unless, nonreassuring fetal status, overt infection, abruption, onset of labor. Single course steroids should be considered. Tocolysis is not recommended in PPROM.
PPROM—other management: Antibiotics, if imminent risk of delivery, magnesium sulfate (MgSO4) for neuroprotection under 32 weeks, delivery by 34 weeks for all PPROM at earlier gestational ages.
Prognosis: Among the preterm labor, 30% resolves spontaneously, 50% of patient hospitalized for preterm labor birth at term, intervention will benefit baby.
 
Steroids
 
Single Course 24–34 Weeks at Risk for Delivery in 7 Days
Betamethasone 12 mg intramuscularly (IM) q 24 hours × 2 doses, dexamethasone 6 mg IM q 12 hours × 4 doses. It improves neonatal outcomes. It decreases—mortality, incidence and severity of respiratory distress syndrome (RDS), intraventricular hemorrhage, necrotizing enterocolitis.
Cochrane review 2012: Repeat single course >7 days after initial course.
Rescue steroids: Further reduces RDS without adverse outcomes, should be reserved for imminent delivery. There is no evidence for multiple repeat courses.7
 
Magnesium Sulfate Neuroprophylaxis
Administer when birth is anticipated <32 weeks. MgSO4 reduces severity and risk of cerebral palsy when given for neuroprotection in three meta-analysis. Initially 4 g loading dose then 1 g/hour infusion. Toxicity to be monitored, to 5be done. This has to be once in 4 hours for pulse, blood pressure (BP), respiration and deep tendon patellar reflexes done. If there is less urine output, reduce MgSO4 dose.
 
Tocolytics
Used to allow time to give steroids and magnesium, arrange transport if needed.
Contraindications for the same are: previability, IUFD, lethal anomaly, nonreassuring fetal status, chorioamnionitis, preeclampsia with severe features, eclampsia, hemodynamic instability of mother, PPROM, maternal contraindications.
Tocolytic reduce birth within 48 hours but do not improve neonatal outcomes, no evidence for maintenance therapy outside 48–72 hours while inpatient and many risks. Magnesium should no longer be given for tocolysis. When using for neuroprotection, watch interactions with tocolytics.
For tocolysis ideally nifedipine to be started. Atosiban is an alternative. Do not give two drugs together. Dose of nifedipine is 20 mg stat orally and later 10 mg three times a day. Watch for fall of BP.
 
Indomethacin
Usually used under 32 weeks, after this concern for premature closure of ductus arteriosus. Loading dose 50–100 mg PO, then 25 mg PO q 4–6 hours. This can be used with MgSO4.
 
NICE Guidelines 20158
Consider nifedipine for tocolysis for women who have intact membranes and are in suspected preterm labor. When nifedipine is contraindicated, atosiban can be used.
 
Atosiban
The recent drug is atosiban which is an oxytocin receptor antagonist. It is a synthetic peptide.
The action is by a competitive antagonist of oxytocin at uterine oxytocin receptors.
 
Atosiban Regimen
Preparation of intravenous (IV) infusion of atosiban. Each 0.9 mL vial of atosiban injection contains 6.75 mg. Each 5 mL vial of atosiban solution for infusion contains 37.5 mg (7.5 mg/mL).
Loading dose: Injection Tosiban (37.5 mg/5 mL) 1.5 vials (7.5 mL) in 92.5 mL NS at 12 drops per minute IV infusion for 3 hours (of this 7.5 mL, 0.9 mL may be given over half a minute as an IV bolus starting the 3-hour infusion).6
Maintenance dose: Injection Tosiban (37.5 mg/5 mL) 1.5 vials (7.5 mL) in 92.5 mL NS at 4 drops per minute IV infusion for 9 hours. Repeat maintenance dose up to five times—45 hours. Loading + one maintenance dose of 3 + 9 = 11 hours. This regimen is expensive but very effective.
 
Antibiotic in Preterm Labor
Empirical therapy: There was a reduction in maternal infection (relative risk 0.74, 95% CI 0.64–0.87), but no statistically significant differences in mean gestational age at delivery, frequency of PTB, and neonatal outcomes including mortality. In addition, no differences were noted in a subgroup analysis between the types of antibiotics.
 
WHO Recommendation on the Prophylactic Antibiotic of Choice in those Pregnant Women with Preterm Prelabor Rupture of Membranes
Erythromycin is recommended as the antibiotic of choice for prophylaxis. Conditional recommendation based on moderate-quality evidence. The use of a combination of amoxicillin and clavulanic acid (“co-amoxiclav”) is not recommended.
Analysis of 17 controlled trials which was a meta-analysis of antibiotics in patients at risk of premature birth because of abnormal vaginal flora, previous PTB, or positive fFN, found that there was no association between antibiotic treatment and reduction in PTB irrespective of the criteria used to assess risk, the antimicrobial agent administered, or gestational age at the time of treatment.9
A new antibiotic regimen treats and prevents intra-amniotic inflammation/infection in patients with preterm PROM10,11 (Joon-Ho et al. Published online: 02 December 2015).
Study design—from 1993–2003, ampicillin and/or cephalosporins or a combination was used (“regimen 1”). A new regimen (ceftriaxone, clarithromycin and metronidazole) was used from 2003–2012 (“regimen 2”).
 
Results
  1. With the regimens studied there was significance drop in infection with regimen 2, from 68.8 to 52.1% and from 75 to 54.2%, respectively.
  2. Intra-amniotic inflammation/infection was eradicated in 33.3% of patients who received regimen 2, but in none who received regimen 1.
Erythromycin is offered by NICE guidelines with PPROM (250 mg) four times a day for a maximum of 10 days or until the woman is in established labor (whichever is sooner).
For women with PPROM who cannot tolerate erythromycin or in whom erythromycin is contraindicated, consider an oral penicillin for a maximum of 710 days or until the woman is in established labor (whichever is sooner) (2015, amended 2019).
 
RCOG RECOMMENDATION
To diagnosed clinical infection vitals have been monitored along with white blood cell (WBC) and CRP. Fetus should be monitored by cardiotocography (CTG).
 
Steroids and WBC Count
The WBC count rises following steroid administration and return to normal in 3 days.
 
C-Reactive Protein
C-reactive protein is the most sensitive marker than total count.12
 
Identifying Infection in Women with PPROM
Assessment of vitals and tests (CRP 1–3 mg/dL) is normal, WBC count, measurement of fetal heart rate using CTG (2015).
When there is a disparity of tests, observation is continued and repeat tests (2015).
 
DELIVERY MANAGEMENT
Important considerations for preterm delivery, contact NICU, no vacuums <34 weeks, control head extension. Delayed cord clamping is recommended as there is less need for transfusion, less hypotension, less intraventricular hemorrhage, no difference in death. Cord clamping is done after 30 seconds but not longer than 3 minutes. Ideally baby has to be kept below level of the placenta before the cord is clamped.
Fetal monitoring: Fetus should be monitored by CTG or intermittent auscultation.
Mode of birth: Cesarean section if there is no labor pains with severe preterm, malpresentations and if there is severe maternal problems compromising labor.
Cesarean section or normal delivery has to be discussed well.
 
SUMMARY
  • Preterm birth is a serious public health problem. Progesterone is effective in preventing preterm birth. In prior preterm birth, progestogens, cervical length measurements and possible cerclage are the therapeutic alternatives.
  • Incidental short cervix: progesterone. Preterm labor: management with intact or not intact membranes, steroids, tocolysis, magnesium for neuroprotection. Management of PPROM is steroids and antibiotics.8
REFERENCES
  1. Norwitz ER, Caughey AB. Progesterone supplementation and the prevention of preterm birth. Rev Obstet Gynecol. 2011;4(2):60–72.
  1. Iams JD. Identification of candidates for progesterone: why, who, how, and when? Obstet Gynecol. 2014;123(6):1317–26.
  1. American College of Obstetricians and Gynecologists ACOG committee opinion no. 560: medically indicated late-preterm and early-term deliveries. Obstet Gynecol. 2013;121(4):908–10.
  1. Sayres W. Preterm labor. Am Fam Physician. 2010;81:477–84.
  1. American College of Obstetricians and Gynecologists; Committee on Practice Bulletins—Obstetrics ACOG practice bulletin no. 127: management of preterm labor. Obstet Gynecol. 2012;119(6):1308–17.
  1. ACOG practice bulletins no. 139: premature rupture of membranes. Obstet Gynecol. 2013;122(4):918–30.
  1. McKinlay CJ, Crowther CA, Middleton P, et al. Repeat antenatal glucocorticoids for women at risk of preterm birth: a Cochrane systematic review. Am J Obstet Gynecol. 2012;206(3):187–94.
  1. NICE Preterm labour and birth: NICE guideline [NG25]. (2015). [online] Available from: https://www.nice.org.uk/guidance/ng25 [Last accessed January, 2020].
  1. Simcox R, Sin WT, Seed PT, et al. Prophylactic antibiotics for the prevention of preterm birth in women at risk: a meta-analysis. Aust N Z J Obstet Gynaecol. 2007;47:368–77.
  1. Lee J, Romero R, Kim SM, et al. A new antibiotic regimen treats and prevents intra-amniotic inflammation/infection in patients with preterm PROM. J Matern Fetal Neonatal Med. 2016;29(17):2727–37.
  1. Mercer B. Antibiotics in the management of PPROM and preterm labor. Obstet Gynecol Clin North Am. 2012;39(1):65–76.
  1. Royal College of Obstetricians and Gynaecologists (RCOG) Care of women with PROM guideline no 73 (Care of women presenting with suspected preterm prelabour rupture of membranes from 24+0 weeks of gestation (Green-top guideline no. 73). 2019.