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

Introduction

Preterm premature rupture of membranes (PPROM) refers to the spontaneous rupture of fetal membranes before labor in pregnancies less than 37 weeks, which is one of the leading causes of preterm birth. The treatment decision for PPROM is highly dependent on gestational age and the overall condition of the mother and fetus. For PPROM occurring at <23 weeks of gestation, fetal viability is extremely low, only about 28% (1). Expectant management to prolong the latency period significantly increases the risk of maternal and fetal complications (2), and maternal complications include chorioamnionitis, placental abruption, and postpartum hemorrhage, while fetal complications involve pulmonary hypoplasia and skeletal deformities (3-5). Therefore, major national and international guidelines generally recommend termination of pregnancy for PPROM at <23 weeks of gestation (6,7). With advances in neonatal intensive care unit (NICU) technology, the survival rate and quality of life of extremely preterm infants (<28 weeks) have improved significantly (8,9). This progress poses challenges to traditional guidelines: when patients have a strong desire to continue the pregnancy, obstetricians need to make individualized trade-offs between maternal-fetal risks and the potential survival benefits of the fetus. This article reported a case of twin pregnancy complicated by PPROM and cervical incompetence (10) at 18⁺⁶ weeks of gestation. Through multidisciplinary collaboration involving the departments of obstetrics, neonatology, ultrasound, and pharmacy, individualized conservative treatments were implemented. Pregnancy was successfully prolonged by nearly 10 weeks, resulting in favorable maternal and infant outcomes. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0092/rc).

Case presentation

A 35-year-old parous woman (gravidity 8, 2 term births, 5 abortions) with 18⁺⁶ weeks of gestation was admitted to our hospital on August 10, 2025, due to vaginal fluid leakage for 15+ hours. The patient accepted fertility treatment due to tubal factors and poly cyst ovarian syndrome, and got successful pregnancy with dichorionic diamniotic twins (DCDA). On August, 9, 2025, she discovered a cystic-like tissue at the introitus vaginalis, then vaginal fluid leakage afterwords, without abdominal tenderness and vaginal bleeding. Obstetrical examination: fundal height 18 cm, abdominal circumference 96 cm, fetal heart rates 154 and 142 bpm. Vaginal speculum examination: a small amount of blood in the vagina, the vaginal part of cervix was approximately 2 cm, the cervical os was closed, and pH >7.0. Fetal sonographic monitoring: Intrauterine pregnancy with twin live births, the weights of the twins are basically consistent with the gestational age, fetus A (who was near the cervix) had oligohydramnios [maximum amniotic fluid depth (AFD) was 12 mm] and was diagnosed with PPROM; closed cervical canal length was 16 mm.

Diagnoses

• Previable preterm premature rupture of membranes (pPPROM);
• Twin pregnancy (DCDA);
• In vitro fertilization (IVF) pregnancy status;
• Incidental cervical insufficiency;
• Advanced maternal age.

Patient autonomy and informed consent

After fully understanding the current diagnosis and the risks associated with continuing the pregnancy, the patient and her family expressed a strong desire to proceed with the pregnancy. Informed consent was obtained, and expectant management was initiated.

Treatments and pregnancy process

Initial management: a multidisciplinary team (MDT) was promptly established, comprising specialists from obstetrics, fetal medicine, ultrasound, neonatology, nutrition, and infectious diseases. A comprehensive pregnancy management plan was formulated, which included ongoing monitoring and assessment of maternal nutrition., fetal intrauterine growth status, and cervical insufficiency (Figure 1 and Appendix 1). Our medical team requests the Nutrition Department to provide dietary guidance for the pregnant woman’s gestational diabetes mellitus (GDM), and monitors that her fasting and postprandial blood glucose levels remain within the normal range. Corresponding interventions, such as prophylactic antibiotic administration, cervical cerclage, swabbing the perineal and vaginal with povidone-iodine solution, and hydration therapy (11,12), were implemented accordingly. Maternal intravenous fluid (500 mL/day) and increased oral fluid intake (targeted at 2,000 mL/day) were administered to expand maternal plasma volume, thereby indirectly increasing fetal amniotic fluid production.

Figure 1 Monitoring of infection indicators. CRP, C-reactive protein; IL-6, interleukin-6; NE, neutrophil; PCT, procalcitonin; WBC, white blood cell.

Subsequent management

Serial transvaginal cervical length measurements revealed progressive shortening of the cervical canal (from 16 to 13 mm) (Figure 2). The patient had an extremely strong desire to continue the pregnancy. a MDT discussion was held, and thorough communication with the patient was carried out. Ultimately, an urgent cervical cerclage (McDonald technique) was performed on at 19⁺⁴ weeks of gestation when infection markers were within normal limits and there was no obvious active amniotic fluid leakage. Oligohydramnios of the lower fetus (Fetus A) was alleviated after hydration therapy; amniotic fluid and fetal development were monitored every three days (Figure 3). Fetus A showed persistent amniotic fluid absence without developmental delay. Multiple consultations with the fetal medicine center were conducted to evaluate the appropriateness of fetal reduction. Given the potential risk of infection from artificial reduction, expectant management was recommended at 22⁺² weeks of gestation, AFD measurement of fetus A with pPPROM had recovered to 20 mm and remained stable at 20–30 mm. The patient was discharged on her 22 gestational weeks due to stable condition. she was readmitted at 24 weeks of gestation, due to vaginal fluid leakage again without any other symptoms. Given that vaginal discharge is a result of increased amniotic fluid volume, without signs of infection or uterine contractions, we chose not to remove the cerclage for the following reasons, but proceeded the aforementioned expectant management plan. Additionally, GDM was diagnosed during hospitalization, so dietary management for GDM were also administered to this patient (13). According to the clinical guidelines for antenatal corticosteroid therapy for promote fetal lung maturation in pregnancies at risk of preterm delivery, dexamethasone 6 mg every 12 hours for two days was administered between 24⁺⁴ and 24⁺⁶ weeks of gestation (14). Escherichia coli and Klebsiella pneumoniae were detected, piperacillin-tazobactam and cefoperazone-sulbactam were used for, ultimately using ertapenem after cultures turned negative.

Figure 2 Cervical canal length monitoring on August 11, 2025 (19 weeks of gestation), the ultrasound showed a functional cervical canal measuring 16 mm, while on August 14, 2025 (19⁺³ weeks of gestation), it measured 13 mm, indicating progressive shortening.

Figure 3 Amniotic fluid depth in twin gestations, with fetus A remaining amniotic fluid-deprived for 2 weeks.

Pregnancy outcomes

At 28⁺³ weeks of gestation, the patient had some vaginal bloody discharge and cervical dilation of 3 cm. Cervical laceration was discovered after suture removed. Intravenous dexamethasone (10 mg) (14,15) and magnesium sulfate were administered, followed by an emergency cesarean section. Fetus A with pPPROM (the lower infant) was delivered conventionally, weighed 1,180 g, with Apgar scores of 8-9-10; Fetus B (the upper infant) underwent an en caul cesarean delivery (Figure S1) (16); the infant weighed 1,130 g and had Apgar scores of 10, 10, and 10. Both neonates were transferred to NICU. No signs of infection were observed in either infant.

Placental pathology indicated acute chorioamnionitis stage I (grade 1–2) (Figure S2), and all secretion cultures showed no signs of infection. The patient was discharged four days post-surgery. After 8 weeks of hospitalization, fetus B, weighing 2,650 g, was discharged successfully. Fetus A with bronchopulmonary dysplasia, despite significant improvement in cardiopulmonary function after aggressive treatment, remained dependent on non-invasive ventilation and died on day 66 due to necrotizing enterocolitis, intestinal perforation, shock, and the inability to tolerate surgical intervention.

All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of The Affiliated Guangdong Second Provincial General Hospital of Jinan University (approval No. 2024-KY-KZ-345-01). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

This case provides valuable experience in the individualized management of pPPROM in a twin pregnancy with cervical insufficiency. Several key insights emerge from this report.

Multidisciplinary collaboration and shared decision-making

Faced with the ethical dilemma of whether to consider fetal reduction, the MDT weighed the infection risk associated with retained fetal demise against the possibility of maintaining both fetuses. After extensive counseling and shared decision-making, expectant management was chosen, which ultimately proved successful. This highlights the importance of a MDT model combined with deep patient engagement in complex cases of extreme prematurity (17).

Precision-based infection control

Up to 50% of PPROM cases have subclinical infections. Current antibiotic guidelines are largely based on the 2001 ORACLE trial by Kenyon et al. (18). however, bacterial epidemiology and resistance patterns evolve over time. In this case, we adopted a precision antimicrobial therapy approach, adjusting antibiotics based on serial cervicovaginal culture and susceptibility results, in consultation with clinical pharmacy. Although various opportunistic pathogens (e.g., Escherichia coli, Klebsiella species) were detected, targeted treatment prevented clinical chorioamnionitis and enabled prolonged latency. Importantly, we did not terminate the pregnancy solely because of positive cultures, but rather managed the patient with close monitoring and informed consent.

Cervical cerclage in the setting of pPPROM

Traditionally, cervical cerclage is considered contraindicated after membrane rupture. However, in this case, pPPROM was likely precipitated by underlying cervical insufficiency (progressive shortening to <15 mm, with membrane protrusion prior to rupture). With strict infection surveillance and no signs of clinical infection, we performed a rescue cerclage. The procedure effectively restored cervical barrier function and provided mechanical support to prolong gestation (18). This may have been a key factor contributing to the successful outcome.

En caul cesarean delivery

For the second twin (Fetus B) in this extremely preterm delivery, an en caul (intact amniotic sac) cesarean section was performed. This technique buffers birth canal pressure and may reduce delivery-related injuries such as intracranial hemorrhage (16,19,20). Fetus B had a perfect Apgar score, was weaned from respiratory support shortly after admission to the neonatal unit, and achieved a favorable prognosis. This suggests that en caul delivery is a valuable option for preterm twins.

Long-term outcome of Fetus A

Although both infants were liveborn with favorable Apgar scores and appropriate birth weights, Fetus A died on day 66 of life. This outcome requires careful consideration. The prolonged period of severe oligohydramnios (nearly two weeks with AFD <10 mm) likely contributed to pulmonary hypoplasia and associated complications, including pulmonary hypertension and cardiac dysfunction. Existing literature indicates that early-onset, prolonged oligohydramnios after pPPROM is a major risk factor for adverse neonatal respiratory and neurodevelopmental outcomes, even when pregnancy is significantly prolonged (21,22). In this case, despite intensive neonatal care, the cumulative effects of oligohydramnios and possible subclinical intra-amniotic inflammation may have led to irreversible lung damage. This highlights that while extending gestation is beneficial, it does not completely mitigate the consequences of very early membrane rupture.

Limitations

This study has several limitations. First, as a single case report, the findings cannot be generalized to all patients with pPPROM. Second, the management strategy—particularly the decision to perform cervical cerclage after membrane rupture and to retain the cerclage despite positive cervical cultures—does not follow established guidelines and may be considered experimental. Third, the patient had an exceptionally strong desire to continue the pregnancy, which influenced decision-making; thus, selection bias is inherent. Fourth, we did not perform placental or fetal autopsy, which might have provided additional insights into the cause of Fetus A’s late death. Finally, long-term neurodevelopmental follow-up of the surviving twin is not yet available. Despite these limitations, this case demonstrates that in carefully selected patients with strong motivation and under rigorous multidisciplinary monitoring, aggressive management of pPPROM can achieve meaningful prolongation of pregnancy and an overall favorable maternal outcome.

Conclusions

For previable pPPROM, particularly when combined with intervenable factors such as cervical insufficiency, gestational age alone may not dictate management decisions. Through strict patient selection, multidisciplinary collaboration, precise infection control guided by serial cultures, and proactive interventions including rescue cerclage and en caul delivery, meaningful prolongation of pregnancy and acceptable perinatal outcomes may be achieved. However, the neonatal prognosis remains guarded, as evidenced by the death of one infant at 66 days, which underscores the need for further research to optimize both antenatal and neonatal management. Future studies should focus on identifying patient subgroups that may benefit from such an aggressive approach and on developing strategies to reduce long-term morbidity associated with extreme pPPROM.

Acknowledgments

We thank all medical staff of the Department of Obstetrics at The Affiliated Guangdong Second Provincial General Hospital of Jinan University.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0092/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0092/prf

Funding: The study was supported by “Internal talent Introduction fund” of The Affiliated Guangdong Second Provincial General Hospital of Jinan University (No. 20240903-IIT-CK-menglili-02).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0092/coif). All authors report that this study was supported by “Internal talent Introduction fund” of The Affiliated Guangdong Second Provincial General Hospital of Jinan University (No. 20240903-IIT-CK-menglili-02). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of The Affiliated Guangdong Second Provincial General Hospital of Jinan University (Approval No. 2024-KY-KZ-345-01). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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