Maternal mortality in women with pre‐viable premature rupture of membranes: An analysis from the French confidential enquiry into maternal deaths

Abstract

Introduction: Pre-viable premature rupture of membranes (pre-viable PROM) is a rare event occurring in less than 1% of pregnancies. Nevertheless, it can be responsible for severe maternal complications, the risk of which needs to be balanced with the possibility to prolong the pregnancy up to viable gestational age. Maternal sepsis was reported in 1%-5% of women who received conservative management and prophylactic antibiotics, but information on maternal mortality is lacking. Our objective was to identify maternal deaths in women who had pre-viable PROM, describe the characteristics of the women, explore preventability factors within the care they received, and estimate the lethality of pre-viable PROM. Material and methods:We identified all maternal deaths associated with pre-viable PROM from the 2001-2015 French National Confidential Enquiry into Maternal Deaths (NCMM). Data on women's characteristics and the care they received were extracted from the ENCMM database. The lethality was determined after estimating the total number of pregnant women with pre-viable PROM from the national hospital discharge database.Results: Between 2001 and 2015, we identified seven maternal deaths associated with pre-viable PROM, representing 0.6% of all maternal deaths over this period (ie, maternal mortality ratio 0.06/100 000 live births). Six maternal deaths were attributed to sepsis after genital infection by Gram-negative bacilli and one to postpartum hemorrhage due to placenta accreta. Four of these seven cases were considered preventable. The main preventability factors were delayed diagnosis, delayed fetal extraction, and inappropriate antibiotic treatment. The estimated lethality was 4.5/10 000 women with pre-viable PROM.Conclusions: Maternal death associated with pre-viable PROM is rare but possible.Most of these deaths seem preventable, with areas for improvement related to earlier diagnosis and better treatment of uterine infections, which can evolve rapidly.

Preterm prelabour rupture of membranes before 23 weeks’ gestation: prospective observational study

“… 14 26 27 Population level data have also identified seven maternal deaths after PPROM at 14+0-24+6 weeks' gestation from 2001 to 2015 in France, giving an estimated risk of death of 45 per 100 000 maternities with this complication. 27 Similar causes of death to our cohort were found: six were attributed to sepsis and one to haemorrhage secondary to placenta accreta spectrum. Hence the population based literature suggests that these deaths are not isolated incidents and might have previously been under-reported, potentially because the literature has been based on data from a small number of centres.…”

“…A recent analysis of hospital episode statistics for the whole of France found a prevalence of 0.2% of PPROM at 14+0-24+6 weeks' gestation, which was considered to be likely underestimated because to fully validate the diagnosis with coded data is not possible. 27 Within our study the incidence of PPROM was lowest between July and December 2020, possibly because of staffing pressures or potentially a lower rate of PPROM secondary to public health control measures, such as lockdowns.…”

Preterm Prelabour Rupture Of Membranes (PPROM) before 23 weeks gestation: A prospective observational study

“…[25–27] Population level data has also identified seven women who died after PPROM between 14 +0 and 24 +6 weeks gestation from 2001 to 2015 in France, giving an estimated chance of death of 45 per 100 000 maternities with this complication. [21] These women had similar causes of death to the current cohort; six were attributed to sepsis and one to haemorrhage secondary to placenta accreta spectrum. Therefore, whilst the absolute risk of maternal death with very early PPROM is likely to be within the lower range of our confidence intervals the population-based literature suggests that these are not isolated incidents, and may have previously been under-recognised because the literature has been based on data from a small number of centres.…”

“…A recent French analysis of hospital episode statistics for the whole nation found a prevalence of 0.2% of PPROM 14 +0 -24 +6 weeks, and the authors considered this figure to be likely an under-estimation, noting that it is impossible with coded data to fully validate the diagnosis. [21] The number of cases reported was lowest between July 2020 and December 2020, possibly because of staffing pressures, or potentially due to a lower rate of PPROM secondary to public health control measures such as lockdowns.…”

Early PPROM: women and babies who should not be lost in the system

“…Therefore, immediate terminations might not avoid all maternal deaths, and these patients should be recognised as high risk with early involvement of senior members of staff in their care. Mid-trimester PPROM has featured in five UK maternal mortality reports,2021222324 in a recent report of maternal deaths in France,25 and in the media,2627 mostly due to sepsis. Furthermore, the 2016-18 UK Confidential Enquiry into maternal deaths recommended that women with early PPROM should be sensitively counselled about the risks, symptoms, and management of sepsis, including maternal mortality and potential for serious morbidity such as hysterectomy 22.…”