218 Expectant management of preterm prelabor rupture of membranes at 34 weeks: a cost effective analysis

Abstract

To examine the outcomes and cost effectiveness of expectant management versus immediate delivery of women who experience preterm prelabor rupture of membranes (PPROM) at 34 weeks or greater. A decision-analytic model was built using TreeAge software to compare outcomes in women with PPROM at 34 weeks undergoing expectant management until maximum 37 weeks versus immediate delivery. The number of women with PPROM per year was estimated at 37,455 (1% of all births). Outcomes included stillbirth, neonatal sepsis, neonatal death, neonatal neurodevelopmental delay, maternal sepsis, maternal death, cost, and quality-adjusted life years (QALYs). Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALYs. In our theoretical cohort of 37,455 women, expectant management resulted in 3,884 more quality-adjusted life years and a cost savings of $1.2 billion per year, making it a dominant strategy. Expectant management yielded 60 fewer neonatal deaths and 172 fewer cases of neonatal neurodevelopmental delay. However, it resulted in 204 more cases of neonatal sepsis and 60 more cases of maternal sepsis. Univariate sensitivity analysis demonstrated that expectant management yielded more QALYs until the risk of neonatal sepsis reached 23% (baseline estimate: 1.7%). Univariate sensitivity analysis also demonstrated that expectant management yielded improved QALYS until the risk of maternal sepsis exceeded 35% (baseline estimate: 0.6%). Expectant management was also cost effective until the weekly cost of antepartum admission reached $30,372 (baseline estimate: $12,348). In our theoretical cohort, expectant management of PPROM at 34 weeks yielded better outcomes on balance at a lower cost than immediate delivery. This analysis is important and timely in light of recent trials suggesting improved neonatal outcomes with expectant management. However, individual risks must be considered in making this clinical decision as expectant management may increase risk of adverse outcomes once risk of infection increases.