#Grand Rounds

Immediate Delivery or Expectant Management for Late Preterm PROM?

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

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

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)

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

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