Journal of Obstetrics and Gynaecology

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Comparison between maternal and neonatal

outcome of PPROM in the cases of amniotic fluid
index (AFI) of more and less than 5 cm

Ashraf Sadat Mousavi, Neda Hashemi, Maryam Kashanian, Narges

Sheikhansari, Arash Bordbar & Shayesteh Parashi

To cite this article: Ashraf Sadat Mousavi, Neda Hashemi, Maryam Kashanian, Narges
Sheikhansari, Arash Bordbar & Shayesteh Parashi (2018): Comparison between maternal and
neonatal outcome of PPROM in the cases of amniotic fluid index (AFI) of more and less than 5 cm,
Journal of Obstetrics and Gynaecology, DOI: 10.1080/01443615.2017.1394280

To link to this article: https://doi.org/10.1080/01443615.2017.1394280

Published online: 09 Feb 2018.

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY, 2018
https://doi.org/10.1080/01443615.2017.1394280

ORIGINAL ARTICLE

Comparison between maternal and neonatal outcome of PPROM in the cases of

amniotic fluid index (AFI) of more and less than 5 cm
Ashraf Sadat Mousavia, Neda Hashemib, Maryam Kashanianb, Narges Sheikhansaric, Arash Bordbard and
Shayesteh Parashib
a
Department of Obstetrics & Gynecology, Hazrate Rasoole Akram Teaching Hospital, Tehran, Iran; bDepartment of Obstetrics & Gynecology,
Akbarabadi Teaching Hospital, Tehran, Iran; cPublic Health, Faculty of Medicine, University of Southampton, Southampton, UK; dDepartment
of Pediatrics (Neonatology), Akbarabadi Teaching Hospital, Tehran, Iran

ABSTRACT KEYWORDS
The study was performed on pregnant women with a gestational age of 26–32 weeks of pregnancy, Preterm premature rupture
who had been admitted to the hospital with a confirmed diagnosis of premature rupture of mem- of membrane (PPROM);
branes. In all eligible women, ultrasounds were performed for the evaluation of amniotic fluid index. amniotic fluid index (AFI);
pregnancy; neonatal
Then, the women were divided into two groups according to amniotic fluid index of
5 cm and <5 cm. morbidity; neonatal
These women were followed and monitored up to delivery. The women of the two groups did not mortality; maternal
have significant difference between them according to age, gestational age at the time of ruptured morbidity
membrane, body mass index, gravidity, parity, gestational age at delivery and route of delivery.
Maternal morbidities including chorioamnionitis, placental abruption, uterine atony after delivery and
retention of placenta did not show significant difference between the two groups. There was no signifi-
cant difference between the two groups’ amniotic fluid index <5 cm and amniotic fluid index
5 cm,
regarding neonatal morbidities, except for neonatal sepsis and neonatal death, which were higher in
the amniotic fluid index <5 cm group [7(14.6%) versus 1(2.3%), p ¼ .039, RR ¼ 7.7 (95%CI 0.04–0.06) and
11(30.9%) versus 2(4.7%), p ¼ .013, RR ¼ 6.095 (95%CI ¼ 1.26–29.31)]. In the subgroups of two categories
of gestational ages of 260–296 and 300–346, neonatal morbidities were higher in the amniotic fluid
index <5 cm group. The results suggest that amniotic fluid index <5 cm should be considered as a
warning sign for predicting poor prognosis of pregnancy complicated by preterm premature rupture of
membranes.

IMPACT STATEMENT
 What is already known on this subject? In a retrospective study in 1993, the relationship between
oligohydramnios (which was defined as the largest single packet of fluid less than 2  2 cm) at the
time of hospital admission, and the outcome of mother, foetus and neonates in a gestational age
of less than 35 weeks of pregnancy was evaluated. In the oligohydramnios group, chorioamnionitis
and funistis were more common. Also, the mean gestational age at the time of delivery and neo-
natal weight was less than that of the normal amniotic fluid group. According to these results, it
was concluded that a low amniotic fluid volume in the women with preterm premature rupture of
membranes (PPROM) can be considered as a prognostic factor in the cases of conservative manage-
ment of PPROM. In contrast, the other study, which was performed on a larger sample size (290
patients), could not show more cases of amnionitis in the cases of amniotic fluid index (AFI) of less
than 5 cm; however, the latency period was shorter in comparison with AFI of more than 5 cm.
 What do the results of this study add? Chorioamnionitis, placental abruption and uterine atony
after delivery, retention of placenta and route of delivery did not show a significant difference
between the two groups. Respiratory distress syndrome (RDS), need of surfactant and intubation,
intra ventricular haemorrhage (IVH) and duration of neonatal intensive care unit (NICU) admission
did not show a significant difference between the two groups; however, the rate of neonatal sepsis
and neonatal death were higher in the AFI <5 cm group.
 What are the implications of these findings for clinical practice and/or further research? The
results suggest that AFI <5 cm should be considered as a warning sign for predicting poor progno-
sis of pregnancy complicated by PPROM.

Introduction neonatal mortality and morbidity (ACOG, Practice bulletins

Preterm premature rupture of membranes (PPROM) is defined No. 139: 2013; Bahasadri et al. 2013) and while it happens in
as rupture of the membranes before 37 weeks of pregnancy only 3% of pregnancies, it leads to 20% of all perinatal mor-
and before the beginning of uterine contractions (ACOG talities (ACOG, Practice bulletins No. 139: 2013), including
2013). It is one of the most important factors in maternal and 20–40% of premature rupture of membranes (PROM) cases

CONTACT Maryam Kashanian maryamkashanian@yahoo.com No 9 Mostaghimi Alley, Khajeh Nasir Toosi Avenue, 16117, Tehran, Iran
ß 2018 Informa UK Limited, trading as Taylor & Francis Group
2 A. S. MOUSAVI ET AL.
(Merenstein and Weisman 1996) and complicates about
120,000 pregnancies annually in the United States (Mercer
2003). In 7% of women with PPROM, delivery can be post-
poned for 48 hours and more; and this group of women ben-
efits from delaying their delivery (ACOG, Practice bulletins No.
139: 2013).
After confirming PPROM, risks and benefits of conservative
management should be evaluated carefully (Mercer 2003),
and should be considered for lowering neonatal mortality
and morbidity. Mother and foetus should be monitored care-
fully, for the complications of PPROM including maternal
infection, placental abruption, cord compression and non-
reassuring foetal heart rate (Mercer 2003; Simhan and
Canavan 2005; Waters and Mercer 2011).
Concurrently, antibiotics for lowering the risk of infection,
and corticosteroids for lowering the risk of neonatal respira-
tory distress syndrome (RDS), should be administered (Mercer
2003; Kenyon et al. 2013), however, the role of tocolysis is
not determined yet (ACOG, Practice bulletins No. 139: 2013;
Mercer 2003; Simhan and Canavan 2005). After completing
34 weeks of gestation, it is more beneficial to terminate the
pregnancy, rather than continuing with conservative manage-
ment (Simhan and Canavan 2005).
In a retrospective study (Lao and Cheung 1993) on women
with a gestational age of less than 35 weeks of pregnancy;
the relationship between oligohydramnios (which was
defined as the largest single packet of fluid of less than
2  2 cm) at the time of hospital admission and perinatal out-
come was evaluated. In the oligohydramnios group, cho-
rioamnionitis and funistis were more common. Also, mean
gestational age at the time of delivery and neonatal weight
were lower than the normal amniotic fluid group. According
to these results, it was concluded that low amniotic fluid vol-
ume in PPROM can be considered as a prognostic factor in
the cases of conservative management of PPROM. The other
study (Kurdoglu et al. 2010), proposed that AFI <5 cm in the
cases of PPROM between 24 and 34 weeks of pregnancy is a
valuable marker for predicting the maternal and neonatal
adverse outcomes.
In contrast, the other study (Mercer et al. 2006), which was
performed on a larger sample size (290 patients), could not
show more cases of amnionitis in the cases of amniotic fluid
index (AFI) of less than 5 cm, however, latency period was
shorter in this group (Mercer et al. 2006). Also, neonatal RDS,
but not neonatal sepsis and pneumonia, were more fre-
quently reported. Therefore, there are some controversies
regarding the significance of volume of amniotic fluid in the
cases of PPROM.
The purpose of the present study was to compare the
maternal and neonatal outcomes in cases of PPROM between
26 and 34 weeks of pregnancy according to AFI of
5 cm and
<5 cm.
Materials and methods
The study was performed as a prospective cohort study in
Akbarabadi Teaching Hospital, in Tehran, Iran, between March
2014 and March 2016. The study populations were women
who had been admitted in the maternity unit with the
diagnosis of confirmed rupture of membranes. Written
informed consent was obtained from all participants, and
institutional board approval and also institutional ethics com-
mittee approval was given to the study.
Inclusion criteria were gestational age between 26 and
32 weeks, according to last reliable menstrual period (LMP)
and ultrasound confirmation of the first trimester of preg-
nancy and confirmed PPROM. Exclusion criteria were sign and
symptoms of infection including fever, uterine contractions
and cervical changes, any complications of pregnancy and
high-risk pregnancies, such as maternal hypertension, dia-
betes, any known maternal disorders and the signs of foetal
distress which demanded inevitable termination of preg-
nancy. Ultrasound was performed for eligible women. Then,
the women were divided into two groups according to AFI
<5 cm and
5 cm.
Betamethasone was administered, 12 mg intramuscular
(IM) and was repeated 24 hours later (Kashanian et al. 2011).
Antibiotics were also administered as per protocol (ampicillin,
2 grams intravenously every 6 hours for 48 hours; followed by
amoxicillin 500 mg orally three times daily for an additional
5 days, plus 400 milligrams of erythromycin every 6 hours
for 7 days) (https://www.nice.org.uk/guidance/ng25/chapter/
Recommendations#antenatal-prophylactic-antibiotics-for-
women-with-pprom; Mercer 2003; Kenyon et al. 2013; ACOG
Practice Bulletin #160; 2016).
Mother and foetus were monitored carefully for vital signs
and foetal heart rate (FHR) (four times a day). Complete
blood counts (CBC), erythrocyte sedimentation rate (ESR), C
reactive protein (CRP) were also measured every other day.
Pregnancy was terminated in the cases of infection or foetal
distress.
All women were followed up to delivery or 34 completed
weeks of pregnancy (time of pregnancy termination).
Maternal and neonatal mortality and morbidity were com-
pared between the two groups. Maternal morbidities which
were evaluated included latency period, chorioamnionitis, pla-
cental abruption, post-partum uterine atony and retained
placenta.
PPROM was defined as rupture of membranes before
34 weeks of pregnancy. Chorioamnionitis was diagnosed
when the women had fever, tachycardia [pulse rate
(PR) > 100], uterine tenderness, malodour lochia, leucocytosis
[white blood cells (WBC) > 20,000/ml] and shift to left, pro-
gressive rising in ESR and CRP. Non-reassuring FHR was
defined as foetal tachycardia (FHR >160 bit/min) and suspi-
cious pattern of FHR in cardiotocography (CTG).
Neonatal morbidity and mortality were recorded accord-
ing to data sheets of neonates and neonatologist’s diagno-
sis. RDS was defined as respiratory distress in clinical
examination, which has been confirmed by chest X-ray and
need for ventilator supports. Intra ventricular haemorrhage
(IVH) has been confirmed by ultrasound examination of
skull. Neonatal sepsis had been confirmed by positive cul-
ture of blood, cerebrospinal fluid (CSF) or urine and clinical
signs of cardiovascular collapse. Necrotising enterocolitis
(NEC) was diagnosed by clinical symptoms of intolerance to
oral fed, frequent vomiting, abdominal distension and radio-
logic findings.
 JOURNAL OF OBSTETRICS AND GYNAECOLOGY 3

Foetal and neonatal factors which were evaluated included morbidities did not show significant difference in the two
non-reassuring FHR, neonatal weight, Apgar scores in minute groups (Table 1), however, caesarean delivery rate was higher
1 and 5, RDS, IVH, NEC, sepsis, duration of NICU admission in the group of AFI
5 cm (p ¼ .038) (Table 1). The reason for
and neonatal death. higher rate of caesarean sections in this subgroup was the
Data analysis was performed using IBM SPSS Statistics for request of mothers.
Windows, version 19, (IBM Corp., Armonk, NY, USA). Neonatal baseline data and morbidities did not show sig-
Independent t-test, Chi square test were used for comparing nificant difference in the two groups, except for neonatal
data. p value of less than .05 was considered significant. sepsis and neonatal death, which were more in the group of
AFI <5 cm (Table 2).
Considering the confounding factor of gestational age in
Results neonatal morbidities, the neonates of the two groups were
compared in the two gestational age category groups of
A total of 91 women finished the study (48 in AFI <5 cm
260–296 and 300–346 (Tables 3 and 4).
group and 43 in AFI
5 cm). The women of the two groups
In the gestational age group of 26–29 weeks, Apgar score
did not have significant difference according to base line
of minute 1 and 5 were less in the AFI <5 cm group.
data including age, gravidity, parity, gestational age at the
Chorioamnionitis, NICU admission, duration of hospital stay,
time of ruptured membrane, gestational age at the time of
neonatal intubation, neonatal sepsis, NEC and neonatal death
pregnancy termination and latency period (Table 1).
were more in AFI <5 cm group (Table 3).
Indications for pregnancy termination and maternal In the gestational age group of 30–34 weeks, Apgar scores
of minutes 1 and 5 were less in the AFI <5 cm group.
Table 1. The characteristics of women in both groups.
Duration of NICU and hospital stay, RDS, surfactant use,
AFI <5 AFI
5
Characteristics N ¼ 48 N ¼ 43 p value intubation, neonatal sepsis, IVH and neonatal death were
Age (year) M ± SD 27.1 ± 6.38 27.6 ± 5.2 .673 higher in the AFI <5 cm group (Table 4).
Gravidity M ± SD 2.08 ± 1.27 2.33 ± 1.12 .309
Parity M ± SD 1.65 ± 0.83 1.54 ± 0.88 .632
Lived child M ± SD 1.43 ± 0.66 1.41 ± 0.69 .888
GA at admission(weeks) M ± SD 29.88 ± 2.05 29.8 ± 2.17 .993 Discussion
GA at termination(weeks) M ± SD 30.37 ± 2.78 31.1 ± 2.05 .123
Previous c section M ± SD 1.14 ± 0.37 1.11 ± 0.32 .835 In the present study, there was no significant difference
Mean AFI(cm) M ± SD 3.01 ± 0.83 7.54 ± 2.12 .0001 between the two groups of AFI <5 cm and AFI
5 cm,
Latent period (day) 7.00 ± 6.7 9.05 ± 8.7 .211
regarding maternal morbidities, however, with respect to
M ± SD
Caesarean delivery N (%) 22 (45.8%) 29 (67.4%) .038 neonatal morbidities; neonatal sepsis and neonatal death
RR ¼ 2.448 were higher in the AFI <5 cm group. Also, in the two gesta-
CI95% ¼ 1.042–5.750
tional age subgroups of 260–296 and 300–346, neonatal mor-
Labour pain 20 (41.7%) 25 (58.1%) .117 bidities were higher in the AFI <5 cm group. These results
Indications of pregnancy Termination N (%) suggest that AFI <5 cm should be considered as a warning
Vaginal bleeding 1 (2.1%) 2 (4.7%) .493
Chorioamnionitis 15 (31.3%) 10 (23.3%) .394 sign for predicting poor prognosis of pregnancy complicated
Foetal distress 7 (14.6%) 5 (11.6%) .677 by PPROM. There are some controversies regarding the sig-
VB þ Foetal distress 5 (10.4%) 1 (2.3%) .120
nificance of AFI <5 cm in different studies.
Complications N (%)
In a study by Piazze et al. (2007), the validity of AFI in the
No 42 (87.5%) 34 (79.1%) .191
Abruption 4 (8.3%) 5 (11.6%) .859 cases of PPROM has been evaluated. They suggested that AFI
Uterine Atony 1 (2.1%) 3 (7%) .131 <5 cm at the time of patient admission can be a valuable
Placental retention 1 (2.1%) 1 (2.3%) .256
prognostic factor in the management of the patients. In

Table 2. The characteristics of neonates in both groups.

Characteristics AFI <5 N ¼ 48 AFI
5 N ¼ 43 p value
GA at termination(weeks) M ± SD 30.37 ± 2.78 31.1 ± 2.05 .123
APGAR score minute 1 M ± SD 7.58 ± 1.91 7.74 ± 1.59 .666
APGAR score minute 5 M ± SD 8.83 ± 1.83 9.16 ± 1.13 .313
Neonatal Weight(gram) M ± SD 1575.2 ± 483.8 1730.9 ± 511.45 .141
NICU admission (days)M ± SD 6.93 ± 8.43 6.13 ± 7.52 .710
Hospital stay (day) M ± SD 14.54 ± 11.2 14.58 ± 12.56 .454
Neonatal Intubation N (%) 8 (16.7%) 7 (16.3%) .96
Surfactant use N (%) 10 (20.8%) 11 (25.6%) .591
RDS N (%) 18 (37.5%) 16 (37.2%) .977
SEPSIS N (%) 7 (14.6%) 1 (2.3%) .039
RR ¼7.171
CI95%¼0.042–0.062
IVH N (%) 1 (2.1%) 2 (4.7%) .493
NEC N (%) 4 (8.3%) 0 (0%) .053
DEATH N (%) 11 (22.9%) 2 (4.7%) .013
RR ¼6.095
CI95%¼1.267–29.319
4 A. S. MOUSAVI ET AL.

Table 3. The characteristics of both groups in gestational age of 26–29 weeks. Table 4. The characteristics of both groups in gestational age of 30–34 weeks.
AFI <5 AFI
5 AFI <5 AFI
5
Characteristics N ¼ 23 N ¼ 19 p value N ¼ 25 N ¼ 24 p value
Age (year) (m ± sd) 27.43 ± 7.07 26.38 ± 5.40 .354 Age (year) (m ± sd) 26.8 ± 5.8 29.21 ± 4.67 .790
Gestational Age at admission (weeks) 28.07 ± 1.18 29.71 ± 1.11 .328 GA at admission (weeks) (m ± sd) 31.55 ± 0.94 31.59 ± 0.86 .878
(m ± sd) Latent period (days) (m ± sd) 4.72 ± 4.1 6.96 ± 5.48 .112
Latent period (days) (m ± sd) 9.48 ± 8.07 11.68 ± 11.2 .465 GA at termination (weeks) (m ± sd) 32.09 ± 0.98 32.57 ± 0.94 .084
GA at termination (weeks) (m ± sd) 28.50 ± 2.92 29.41 ± 1.68 .237 Neonatal weight (gram) (m ± sd) 1882 ± 312.5 2002 ± 297.44 .175
Caesarean delivery N (%) 10 (53.5%) 12 (63.2%) .415 APGAR score minute 1 (m ± sd) 8.36 ± 1.07 8.94 ± 1.26 .0001
Neonatal Weight (gram) (m ± sd) 1226.14 ± 401.42 1387.8 ± 524.18 .0001 APGAR score minute 5 (m ± sd) 9.56 ± 0.76 9.96 ± 0.72 .0001
APGAR score minute 1 (m ± sd) 6.74 ± 2.26 7.37 ± 1.89 .0001 NICU admission (days) (m ± sd) 2.56 ± 3.48 2.18 ± 4.49 .0001
APGAR score minute 5 (m ± sd) 8.04 ± 2.30 8.79 ± 1.43 .0001 Hospital stay (days) (m ± sd) 8.52 ± 8.11 7.04 ± 6.05 .0001
NICU admission (days) (m ± sd) 13.22 ± 8.1 12.68 ± 11.09 .0001 Indications of pregnancy termination N (%)
Hospital stay (days) (m ± sd) 16.91 ± 10.2 12.84 ± 13.87 .0001 Labour pain 14 (56.0%) 13 (54.2%) .673
Indications of pregnancy termination N (%) Vaginal bleeding 0 (0%) 2 (8.3%) –
Labour pain 6 (26.1%) 12 (63.2%) .0001 Chorioamnionitis 6 (24.0%) 6 (25.0%) .610
Vaginal bleeding 1 (4.3%) 0 (0%) – FHR deceleration 4 (16.0%) 3 (12.5%) –
Chorioamnionitis 9 (39.1%) 4 (21.1%) .045 VB þ FHR deceleration 1 (4.0%) 0 (0%) –
FHR deceleration 3 (13%) 2 (10.5%) .085 Route of delivery N (%)
VB þ FHR deceleration 4 (17.4%) 1 (5.3%) .065 NVD 13 (52.0%) 7 (29.2%) .104
Complications N (%) C/S 12 (48.0%) 17 (70.8%) .010
Placental Abruption 4 (17.4%) 3 (15.8%) .553 Complication N (%)
Uterine Atony 0 (0%) 1 (5.3%) – NO 20 (83.3%) 24 (96%) .0001
Placental retention 1 (4.3%) 1 (5.3%) – Placental Abruption 0 (0%) 2 (8.3%) –
Neonatal intubation N (%) 7 (30.43%) 3 (15.78%) .0001 Uterine Atony 1 (4%) 2 (8.3%) –
Surfactant N (%) 11 (47.82%) 5 (26.3%) .192 Placental retention 0 (0%) 0 (0%) –
RDS N (%) 16 (69.5%) 10 (52.63%) .093 Neonatal intubation N (%) 3 (12%) 2 (8.3%) .0001
SEPSIS N (%) 6 (26.1%) 1 (5.3%) .006 Surfactant N (%) 3 (12%) 2 (8.3%) .001
IVH N (%) 2 (0%) 0 (0%) – RDS N (%) 6 (24%) 2 (8.3%) .001
NEC N (%) 4 (17.4%) 0 (0%) .0001 SEPSIS N (%) 1 (4%) 0 (0%) .0001
DEATH N (%) 7 (30.4%) 2 (10.5%) .0001 IVH N (%) 1 (4%) 0 (0%) .002
NEC N (%) 0 (0%) 0 (0%) –
DEATH N (%) 4 (16%) 0 (0%) .0001

this study, latency period was significantly shorter in AFI
<5 cm group. Other studies (MacMillan et al. 1994; Vermillion
et al. 2000; Park et al. 2001; Tavassoli et al. 2010; Ekin et al.
2015) have reported similar results. Maternal morbidities
(adverse effects) have not been evaluated in these studies.
Borna et al. (2004) reported that AFI <5 cm, between 26
and 34 weeks of pregnancy, increases the risk of maternal
infection and caesarean delivery, which is in accordance with
the present study. In the present study, the number of cae-
sarean deliveries was higher in the AFI >5 cm group. The rea-
son for higher rate of caesarean sections in this subgroup
was the personal request of mothers.
Neonatal sepsis was higher in the present study. Other
studies reported similar results (Vermillion et al. 2000; Borna
et al. 2004; Ekin et al. 2015). Yoon et al. (1999) proposed that
oligohydramnios, in the cases of PPROM, is accompanied by
inflammatory reactions in foetus, amniotic fluid and mother.
This can explain the higher rate of neonatal sepsis in these
cases.
In contrast, Coolen et al. (2010) evaluated PPROM in
30–36 weeks of pregnancy and reported the effects of oligo-
hydramnios on pregnancy outcome. They proposed that
amniotic fluid volume at the time of hospital admission did
not have significant effects on maternal and neonatal infec-
tion, in spite of a shorter latency period, and cannot discrim-
inate which patients can benefit from expectant
management. Kacerovsky et al. (2014) reported similar results.
Ekin et al. 2014 reported a longer latency period of more
than 72 hours that lead to a higher rate of chorioamnionitis
and placental abruption, but no significant increase in the
rate of adverse neonatal outcome.
A shorter latency period can lead to the delivery of a
younger neonate with a lower gestational age; and conse-
quently, more neonatal morbidities can be anticipated.
Neonatal morbidities should be adjusted and compared
regarding the gestational age, and then finding that AFI
<5 cm alone could have an impact on pregnancy outcome in
the cases of PPROM.
On the other hand, less amniotic fluid increases the risk of
cord compression and foetal distress and the necessity for
pregnancy termination in a lower gestational age and conse-
quently shorter latency period. These parametres should be
considered when evaluating the effects of AFI on neonatal
outcome. Therefore, the role of AFI alone should be proposed
cautiously. Various results of different studies can be
explained this way. In fact, important confounding factors,
such as maternal morbidities and foetal distress culminate to
pregnancy termination and therefore lead to shorter latency
period and delivery of a foetus with a lower gestational age,
which is the most important factor in neonatal adverse
effects. Also, maternal adverse effects per se can have impact
on the foetus and lead to more neonatal morbidities
(Bordbar and Farjadnia 2015).
The strength of the present study is in comparing neo-
natal morbidities in two gestational age subgroups. In these
two subgroups, neonatal morbidities were more in the AFI
<5 cm group, however, a larger sample size could detect the
effects much better.

In conclusion, different results of the different studies can
suggest that until today, AFI <5 cm per se, cannot change the
management of PPROM, however, it should be considered as
a warning sign.
Disclosure statement
No potential conflict of interest was reported by the authors.
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