Outpatient management of preterm prelabor rupture of membranes before 34 weeks: Maternal and neonatal outcomes

Abstract

Objective To evaluate the maternal, fetal, and neonatal outcomes of pregnant women complicated with preterm prelabor rupture of membranes (PPROM) eligible for outpatient care. Methods This study included a retrospective cohort of patients with singleton pregnancies with PPROM between 23+0 to 34+0 weeks who remained pregnant after the first 72 h. Outpatient management was considered in women with clinical, ultrasound and analytical stability, and easy access to hospital. Maternal, fetal, and neonatal results were compared between women managed as inpatients versus those managed as outpatients. Results Women eligible for the outpatient management had a better prognostic profile (no anhydramnios, longer cervical length, less intraamniotic infection, and clinical, ultrasound, and analytical stability) and presented a lower gestational age at admission and longer latency to delivery, resulting in a similar gestational age at delivery as the inpatient group. Postpartum curettage, uterine atony, respiratory distress syndrome, and bronchopulmonary dysplasia were less frequent in the outpatient group. Composite maternal‐fetal morbidity and mortality outcomes were similar in both groups, while composite neonatal morbidity and mortality outcomes were significantly lower in the outpatient group. Conclusion Outpatient management may be an option for women presenting stable PPROM before 34 weeks when adequate selection criteria are fulfilled. Differences in perinatal outcomes in the outpatient group compared with the inpatient group are probably attributable to baseline characteristics. Further prospective randomized studies are needed to confirm the benefits of outpatient management in PPROM.

Statement of the Obstetrics and Prenatal Medicine Working Group (AGG – Preterm Birth Section) on “Outpatient Management for Pregnant Women with Preterm Premature Rupture of Membranes (PPROM)”

“…The following risk factors for outpatient care are known from cohort studies [15,42]: ▪ Early GA at PPROM (< 26 GW) ▪ Oligohydramnios (maximal vertical pocket of amniotic fluid (AF-MVP) < 1 cm or AFI < 20 mm) ▪ No cephalic presentation In a retrospective study, Murillo et al analyzed pregnant women with PPROM between weeks 23 + 0 and weeks < 34 + 0 of gestation. If the women were stable for 72 h, they were discharged home according to strict selection criteria [15].…”

“…Another controversially discussed issue is how outpatient care and monitoring should be carried out [18,38]. In the different studies, suggestions ranged from daily controls (midwife or self-monitoring) to twice or just once a week [12,13,15]. As there are still no recommendations on monitoring, we propose stratifying the approach according to gestational age as follows [16,18] An outpatient approach should be discussed with the patient and recorded in the form of written informed consent in which the risks and uncertainty are described in detail.…”

“…Folgende Risikofaktoren für eine ambulante Betreuung sind aus den Kohortenstudien bekannt [15,42]: ▪ frühes GA bei PPROM (< 26 SSW) ▪ Oligohydramnion (größtes vertikales Fruchtwasserdepot (AF-MVP) < 1 cm oder AFI < 20 mm) ▪ keine Schädellage Murillo et al analysierten in einer retrospektiven Studie Schwangere mit PPROM zwischen der 23 + 0 SSW bis < 34 + 0 SSW. Wenn die Frauen 72 h stabil waren, wurden sie nach strengen Selektionskriterien nach Hause entlassen [15].…”

“…Kriterien für die ambulante Betreuung, Selektionskriterien vor Entlassung [15,38]: Monitoring/Überwachung bei der ambulanten Betreuung (Follow-up-Strategie)…”

“…Eine weitere kontrovers diskutierte Frage ist die Durchführung der ambulanten Betreuung [18,38]. In den verschiedenen Studien variiert dies von täglichen Kontrollen (Hebamme oder Self-Monitoring) über 2× bis zu 1× wöchentlich [12,13,15]. Da es bisher keine Empfehlungen zum Monitoring gibt, schlagen wir vor, das Vorgehen nach dem GA zu stratifizieren [16,18]…”