Conservative management leading to delivery of a twin pregnancy complicated by previable preterm premature rupture of membranes: a case report

Background: The threshold of neonatal viability is established at a gestational age of 22–23 weeks. Previable preterm premature rupture of membranes (pPPROM) occurring prior to this period is frequently associated with recommendations for pregnancy termination due to exceedingly high rates of neonatal mortality and maternal infectious morbidity.

Case Description: This report describes the case of a 35-year-old multiparous woman. A twin gestation [dichorionic diamniotic (DCDA)] was achieved via in vitro fertilization and embryo transfer (IVF-ET) secondary to tubal factor infertility. At 18 weeks and 6 days of gestation, protrusion of the amniotic sac to the vaginal introitus occurred, resulting in pPPROM. A multidisciplinary team conducted a comprehensive assessment. After detailed counseling, an active conservative management strategy was implemented. This encompassed targeted antibiotic therapy, emergent cervical cerclage, planned administration of fetal lung maturation agents, and intensive maternal-fetal surveillance. The pregnancy was successfully prolonged for nearly 10 weeks, during which infection was controlled and normal fetal growth was maintained. At 28 weeks and 3 days of gestation, preterm labor necessitated cesarean delivery. Two live neonates were delivered; notably, Fetus B was delivered using the en caul cesarean delivery technique.

Conclusions: This case illustrates that, with meticulous patient selection and individualized intervention, management of pPPROM occurring before the established limit of viability can yield favorable perinatal outcomes. These findings challenge the conventional paradigm of relying solely on gestational age criteria for decision-making.