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Am J Perinatol
DOI: 10.1055/a-2302-8657
SMFM Fellows Research Series

Periviable Premature Rupture of Membranes—Maternal and Neonatal Risks: A Systematic Review and Meta-analysis

Alexander M. Saucedo 
1   Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin, Texas
,
Chase Calvert
1   Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin, Texas
,
Adrian Chiem
2   Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania
,
Alan Groves
3   Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, Texas
,
Kobina Ghartey
1   Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin, Texas
,
Alison G. Cahill
1   Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin, Texas
,
Lorie M. Harper 
1   Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin, Texas
› Author Affiliations Funding None.
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Abstract

Objective Periviable premature rupture of membranes (PROM) counseling should describe maternal and neonatal outcomes associated with both immediate delivery and expectant management. Unfortunately, most published data focuses on neonatal outcomes and maternal risk estimates vary widely. We performed a meta-analysis to describe outcomes associated with expectant management compared with immediate delivery of periviable PROM.

Study Design We performed a search on PubMed, MEDLINE, Web of Science, PROSPERO, Cochrane library, and ClinicalTrials.gov utilizing a combination of key terms. Published clinical trials and observational cohorts were included if published after 2000. Publications were selected if they included maternal and/or neonatal outcomes for both expectant management and immediate delivery. Gestational age range was limited from 14 to 25 weeks. The primary outcome was maternal sepsis. Secondary outcomes included chorioamnionitis, hemorrhage, laparotomy, and neonatal survival. Pooled risk differences (RDs) were calculated for each outcome using a random-effects model. Publication bias was assessed using funnel plots and Harbord test.

Results A total of 2,550 studies were screened. After removal of duplicates and filtering by abstract, 44 manuscripts were reviewed. A total of five publications met inclusion for analysis: four retrospective and one prospective. Overall, 364 (68.0%) women underwent expectant management and 171 (32.0%) underwent immediate delivery. Maternal sepsis was significantly more frequent in the expectant group (RD, 4%; 95% confidence interval, 2–7%) as was chorioamnionitis (RD 30%; p < 0.01) and any laparotomy (RD, 28%; p < 0.01). Neonatal survival in the expectant group was 39% compared with 0% in the immediate group (p < 0.01).

Conclusion Women who undergo expectant management following periviable rupture of membranes experience significantly increased risks of sepsis, chorioamnionitis, and laparotomy. Overall, 39% of neonates survive to discharge. Knowledge of these risks is critical to counseling patients with this diagnosis.

Key Points

  • Expectant management associated with 4% increased risk of sepsis.

  • Expectant management associated with 30% increased risk of chorioamnionitis.

  • A total of 39% of neonates survived to discharge with expectant management.

Keywords

periviable - previable - midtrimester - second trimester - rupture of membranes - expectant management - immediate delivery - termination

Note

This study was presented as a poster at the 2023 American College of Obstetricians and Gynecologists Annual Clinical & Scientific Meeting, Baltimore, MD, May 19, 2023.


Data Availability Statement

A.M.S. and L.M.H. had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.


Authors' Contributions

All authors take responsibility for the accuracy and completeness of reporting and for the fidelity of the report to the study protocol. Study concept and design: all authors; data collection: L.M.H. and C.C.; analysis and interpretation of data: all authors; drafting of manuscript: A.M.S.; critical revision of the manuscript: all authors.


Supplementary Material



Publication History

Received: 20 February 2024

Accepted: 24 March 2024

Accepted Manuscript online:
09 April 2024

Article published online:
29 April 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Raju TNK, Mercer BM, Burchfield DJ, Joseph Jr GF. Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. Obstet Gynecol 2014; 123 (05) 1083-1096
    CrossrefPubMedGoogle Scholar
  • 2 Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin no. 188: prelabor rupture of membranes. Obstet Gynecol 2018; 131 (01) e1-e14
    PubMedGoogle Scholar
  • 3 American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric care consensus no. 6: periviable birth. Obstet Gynecol 2017; 130 (04) e187-e199
    CrossrefPubMedGoogle Scholar
  • 4 Dotters-Katz SK, Panzer A, Grace MR. et al. Maternal morbidity after previable prelabor rupture of membranes. Obstet Gynecol 2017; 129 (01) 101-106
    CrossrefPubMedGoogle Scholar
  • 5 Kibel M, Asztalos E, Barrett J. et al. Outcomes of pregnancies complicated by preterm premature rupture of membranes between 20 and 24 weeks of gestation. Obstet Gynecol 2016; 128 (02) 313-320
    CrossrefPubMedGoogle Scholar
  • 6 Kiver V, Boos V, Thomas A, Henrich W, Weichert A. Perinatal outcomes after previable preterm premature rupture of membranes before 24 weeks of gestation. J Perinat Med 2018; 46 (05) 555-565
    CrossrefPubMedGoogle Scholar
  • 7 Paulsen V, Jakob M, Gembruch U, Heep A, Bartmann P. Previable preterm premature rupture of membranes: 117 cases with neonatal outcomes in light of current research. J Neonatal Perinatal Med 2023; 16 (01) 21-31
    CrossrefPubMedGoogle Scholar
  • 8 Rysavy MA, Li L, Bell EF. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Between-hospital variation in treatment and outcomes in extremely preterm infants. N Engl J Med 2015; 372 (19) 1801-1811 [published correction appears in N Engl J Med;372(25):2469]
    CrossrefPubMedGoogle Scholar
  • 9 Younge N, Goldstein RF, Bann CM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Survival and neurodevelopmental outcomes among periviable infants. N Engl J Med 2017; 376 (07) 617-628
    CrossrefPubMedGoogle Scholar
  • 10 Stoll BJ, Hansen NI, Bell EF. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 2010; 126 (03) 443-456
    Google Scholar
  • 11 Drassinower D, Friedman AM, Običan SG, Levin H, Gyamfi-Bannerman C. Prolonged latency of preterm prelabour rupture of membranes and neurodevelopmental outcomes: a secondary analysis. BJOG 2016; 123 (10) 1629-1635
    CrossrefPubMedGoogle Scholar
  • 12 Locatelli A, Ghidini A, Paterlini G. et al. Gestational age at preterm premature rupture of membranes: a risk factor for neonatal white matter damage. Am J Obstet Gynecol 2005; 193 (3 Pt 2): 947-951
    CrossrefPubMedGoogle Scholar
  • 13 Guttmacher Institute. An overview of abortion laws. Accessed August 9, 2023 at: https://www.guttmacher.org/state-policy/explore/overview-abortion-laws
    PubMedGoogle Scholar
  • 14 Easter SR, Johnson CT. A case of restrictions on comprehensive reproductive health care. NEJM Evid 2023; 2 (01) e2200294
    CrossrefPubMedGoogle Scholar
  • 15 Goulding AN, McKinney JR, Crabtree Sokol D, Beasley AD. A pregnant patient presents with leakage of vaginal fluid in the second trimester. NEJM Evid 2023; 2 (01) r2200281
    CrossrefPubMedGoogle Scholar
  • 16 Arey W, Lerma K, Beasley A, Harper L, Moayedi G, White K. A preview of the dangerous future of abortion bans - Texas Senate Bill 8. N Engl J Med 2022; 387 (05) 388-390
    CrossrefPubMedGoogle Scholar
  • 17 Sklar A, Sheeder J, Davis AR, Wilson C, Teal SB. Maternal morbidity after preterm premature rupture of membranes at <24 weeks' gestation. Am J Obstet Gynecol 2022; 226 (04) 558.e1-558.e11
    CrossrefPubMedGoogle Scholar
  • 18 Pylypjuk C, Majeau L. Perinatal outcomes and influence of amniotic fluid volume following previable, preterm prelabor rupture of membranes (pPPROM): a historical cohort study. Int J Womens Health 2021; 13: 627-637
    CrossrefPubMedGoogle Scholar
  • 19 Simons NE, de Ruigh AA, van der Windt LI. et al. Maternal, perinatal and childhood outcomes of the PPROMEXIL-III cohort: pregnancies complicated by previable prelabor rupture of membranes. Eur J Obstet Gynecol Reprod Biol 2021; 265: 44-53
    CrossrefPubMedGoogle Scholar
  • 20 Wagner P, Sonek J, Mayr S. et al. Outcome of pregnancies with spontaneous PPROM before 24+0 weeks' gestation. Eur J Obstet Gynecol Reprod Biol 2016; 203: 121-126
    CrossrefPubMedGoogle Scholar
  • 21 Wagner P, Sonek J, Mayr S. et al. Outcome of dichorionic diamniotic twin pregnancies with spontaneous PPROM before 24 weeks' gestation. J Matern Fetal Neonatal Med 2017; 30 (14) 1750-1754
    CrossrefPubMedGoogle Scholar
  • 22 Sim WH, Araujo Júnior E, Da Silva Costa F, Sheehan PM. Maternal and neonatal outcomes following expectant management of preterm prelabour rupture of membranes before viability. J Perinat Med 2017; 45 (01) 29-44
    CrossrefPubMedGoogle Scholar
  • 23 Waters TP, Mercer BM. The management of preterm premature rupture of the membranes near the limit of fetal viability. Am J Obstet Gynecol 2009; 201 (03) 230-240
    CrossrefPubMedGoogle Scholar
  • 24 Nambiar A, Patel S, Santiago-Munoz P, Spong CY, Nelson DB. Maternal morbidity and fetal outcomes among pregnant women at 22 weeks' gestation or less with complications in 2 Texas hospitals after legislation on abortion. Am J Obstet Gynecol 2022; 227 (04) 648-650.e1
    CrossrefPubMedGoogle Scholar
  • 25 Longe E. Bills in the 88th Legislative Session addressing maternal mortality. KXAN Austin. May 1, 2023. Accessed August 15, 2023 at: https://www.kxan.com/news/local/bills-in-the-88th-legislative-session-addressing-maternal-mortality/
    PubMedGoogle Scholar
  • 26 Harper LM, Leach JM, Robbins L. et al. All-cause mortality in reproductive-aged females by state: an analysis of the effects of abortion legislation. Obstet Gynecol 2023; 141 (02) 236-242
    CrossrefPubMedGoogle Scholar
  • 27 Jacques L, Heinlein M, Ralph J. et al. Complication rates of dilation and evacuation and labor induction in second-trimester abortion for fetal indications: a retrospective cohort study. Contraception 2020; 102 (02) 83-86
    CrossrefPubMedGoogle Scholar
  • 28 Whitley KA, Trinchere K, Prutsman W, Quiñones JN, Rochon ML. Midtrimester dilation and evacuation versus prostaglandin induction: a comparison of composite outcomes. Am J Obstet Gynecol 2011; 205 (04) 386.e1-386.e7
    CrossrefPubMedGoogle Scholar
  • 29 Hackney D, Lappen J, Mercer B. Outpatient antibiotics following previable rupture of membranes (pPPROM) between 18 0/7 and 22 6/7 weeks gestational age. https://clinicaltrials.gov/study/NCT05345457 . Identification no. NCT05345457
    PubMedGoogle Scholar
  • 30 van Kempen LEM, van Teeffelen AS, de Ruigh AA. et al. Amnioinfusion compared with no intervention in women with second-trimester rupture of membranes: a randomized controlled trial. Obstet Gynecol 2019; 133 (01) 129-136
    CrossrefPubMedGoogle Scholar