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Grand Rounds

Immediate Delivery or Expectant Management for Late Preterm PROM?

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BACKGROUND AND PURPOSE:

  • Guidelines differ on when best to deliver late preterm PROM
  • ACOG
    • Expectant management, if no infection, between 23 and 34 weeks of gestation
    • Suggested delivery at 34 weeks
  • The Royal College of Obstetricians and Gynecologists guidelines and the Dutch Society of Obstetrics and Gynecology suggest that at 34 or 35 weeks of gestation
    • Plan for delivery OR
    • Await labor using a shared care decision model
  • Quist-Nelson et al. (Obstetrics & Gynecology, 2018) compared the effects of immediate delivery vs expectant management for late preterm period PROM

METHODS:

  • Individual participant data meta-analysis
  • All randomized controlled trials with individual participant data reporting on late preterm PROM with randomization to immediate delivery or expectant management were included
  • Late preterm period: between 34 0/7 and 36 6/7 weeks
  • Primary outcome was a composite of adverse neonatal outcomes
    • Probable or definitive neonatal sepsis
    • Necrotizing enterocolitis
    • Respiratory distress syndrome
    • Stillbirth or neonatal death

RESULTS:

  • 3 eligible trials were included, totaling 2563 mothers and 2572 neonates
  • Composite adverse neonatal outcome not significant
    • 9.6% of the immediate delivery group
    • 8.3% of the expectant management group
      • relative risk [RR] 1.20, 95% CI 0.94-1.55
  • Neonatal sepsis rates did not differ
    • 2.6% of the immediate delivery group
    • 3.5% of the expectant management group
      • RR 0.74, 95% CI 0.47-1.15
  • Neonates in the immediate delivery group were more likely to be
    • Diagnosed with respiratory distress syndrome (RR 1.47, 95% CI 1.10-1.97)
    • Admitted to the neonatal intensive care unit or special care nursery (RR 1.17, 95% CI 1.11-1.23) with longer admission stays
  • Mothers randomized to immediate delivery were
    • Less likely to have an antepartum hemorrhage (RR 0.57, 95% CI 0.34-0.95)
    • Less likely to have chorioamnionitis (RR 0.21, 95% CI 0.13-0.35)
    • More likely to undergo cesarean delivery (RR 1.26, 95% CI 1.08-1.47)

CONCLUSION:

  • Authors note this study does not assess long-term consequences
    • Potential benefit of immediate delivery: Avoid potential risk for poor long-term neurologic outcomes after preterm PROM, even in the absence of infection
    • Potential benefit of expectant management: Late preterm birth associated with higher risks of morbidity and academic difficulties
  • A limitation of this study was the inconsistent definition of neonatal sepsis between studies
  • For women with late preterm PROM, immediate delivery and expectant management had comparable rates of adverse composite neonatal outcome
  • Individual secondary outcomes compared to primary composite outcome showed mixed results

Learn More – Primary Sources:

Immediate Delivery Compared With Expectant Management in Late Preterm Prelabor Rupture of Membranes: An Individual Participant Data Meta-analysis.  

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Related ObG Topics:

ACOG Guidance Update: Diagnosis and Management of PROM (Prelabor Rupture of Membranes)
Should Tocolytics Be Used Following PPROM?
PROM 37 Weeks and Beyond: Induction or Watchful Waiting?

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