Pre-Labor Ruptured Membranes Best Managed Expectantly: Study

By Will Boggs MD

November 19, 2015

NEW YORK (Reuters Health) - In pregnant women who present with pre-labor ruptured membranes (PROM) close to term, expectant management with surveillance of maternal and fetal wellbeing should be preferred over immediate delivery, according to the PPROMT trial.

"It has been widely assumed that prolonging pregnancy in women with late preterm rupture of membranes is associated with a significant risk of neonatal infection," said Dr. Marian Knight from the University of Oxford in the U.K. who coauthored an editorial on the study.

"However, the results of this trial showed that the absolute risk of neonatal infection was low, and this risk was not different in the infants of women who were randomized to expectant management. More surprisingly, the infants of the mothers who were randomized to immediate delivery were more likely to have a range of complications, including respiratory distress and the need for artificial ventilation," she told Reuters Health by email.

PROM occurs in 20% of all births and 40% of preterm births. Immediate delivery for PROM at term is associated with better outcomes, whereas the optimal management of women with preterm PROM before 37 weeks is not clear.

For the PPROMT trial, Dr. Jonathan M. Morris from the University of Sydney in St. Leonards, Australia, and colleagues from 65 centers in 11 countries randomly assigned 1,839 women to immediate delivery or expectant management.

Women assigned to expectant management were more likely to deliver after spontaneous onset of labor and at a later gestation than were women assigned to immediate delivery, the team reported online November 9 in The Lancet.

The incidence of definite or probable neonatal sepsis, the primary outcome, did not differ significantly between the expectant management group (29/912, 3%) and the immediate delivery group (23/923, 2%).

While the groups did not differ in the composite measure of neonatal morbidity and mortality, neonates born after immediate delivery had significantly lower birthweight, 60% greater risk of respiratory distress, 40% greater risk of mechanical ventilation, and spent more time in neonatal intensive care units or special care nurseries.

Immediate delivery cut the likelihood of antepartum hemorrhage and intrapartum fever, but increased the risk of Cesarean delivery, the researchers found.

"The findings of this trial show that for women with ruptured membranes between 34 weeks and 36 weeks and 6 days of gestation who were carrying a single fetus and who had no contraindication for expectant management, immediate delivery increased neonatal complications with no clinically significant decrease in neonatal sepsis," they write. "Therefore, in contrast to recent guideline recommendations, we advocate that expectant management is preferred to immediate delivery in women with ruptured membranes close to term. Women need to be monitored because of the increased risk of antepartum hemorrhage and a greater likelihood of developing a fever."

"This evidence would suggest that, in the absence of any evidence of fetal or neonatal compromise, a policy of expectant management of women with ruptured membranes at 34-36 weeks gestation would be associated with fewer infant complications," Dr. Knight said. "However, the women who were managed expectantly had a longer hospital stay than those who were delivered immediately, and an economic evaluation of the study needs to be undertaken to determine whether a policy of expectant management is more cost-effective than immediate delivery, taking into account the differences in outcomes for both mother and baby."

"All women with ruptured membranes in the late preterm period should have an individualized assessment concerning their planned delivery," Dr. Knight concluded. "If all monitoring is reassuring, expectant management may be the most appropriate option."

"Evidence on developmental outcomes after late preterm birth would suggest that prolonging pregnancy for a few days would be beneficial for infants in the longer term," she added. "However, the infants from this trial should be followed up to formally evaluate whether their neurodevelopment is different in the long-term compared with infants delivered immediately."

Dr. Morris did not respond to requests for comments.


Lancet 2015.