Active Versus Expectant Management for Preterm Prelabor Rupture of Membranes at 34–36 Weeks of Completed Gestation: Comparison of Maternal and Neonatal Outcomes

Abstract

There is general agreement among obstetricians that women with preterm prelabor rupture of membranes (PPROM) should be expectantly managed at least until 34 completed weeks of gestation. However, there is little agreement concerning the choice between active management (AM) and expectant management (EM) from 34 to 36 weeks of gestation, and the choice during this period remains highly controversial. Four randomized trials compared EM with AM in cases of PPROM before 37 weeks. These studies reported no overall difference between these 2 types of management for length of stay in the neonatal intensive unit, respiratory distress syndrome (RDS), or confirmed neonatal sepsis, but clinical chorioamnionitis was found less frequently in AM than in EM. Because of design problems, the external validity of these 4 studies is unclear. This retrospective multicenter study compared the effect of management with AM or EM on maternal and neonatal outcomes among a population of women who had PPROM at 34 to 36 completed weeks of gestation. Outcomes examined included maternal chorioamnionitis and neonatal morbidity including neonatal infection, respiratory problems, and metabolic disorders. Respiratory problems examined included RDS and the need for oxygen supplementation for more than 2 hours. Data were obtained from medical charts for deliveries occurring between 1999 and 2005 at 3 university hospital centers. Of the 51,997 women who gave birth during the study period, 634 were admitted for PPROM at 34 to 36 completed weeks of gestation. A total of 393 women did not meet eligibility criteria and were excluded from analysis, leaving 241 women—126 in the EM group and 115 in the AM group. The incidence of clinical chorioamnionitis was significantly higher in the EM group compared with the AM group (4.8% vs. 0.9%; (P = 0.07). Although there was no significant difference between the 2 groups in RDS rates, more babies in the AM compared with the EM group required oxygen at 24 hours (7.0 vs. 1.6%, P = 0.05). Only delivery at 34 weeks of gestation remained associated with the need for neonatal oxygen at 24 hours following adjustment for gestational age at delivery. The rate of hypoglycemia or hypocalcemia was higher in the AM group (AM: 12.3% vs. EM: 5.6%, P = 0.07). No neonatal deaths occurred. These findings indicate that management of PPROM using a policy of AM, especially at 34 weeks of gestation, is associated with greater neonatal morbidity, and an EM policy with a higher rate of clinical chorioamnionitis. The choice between AM or EM at 34 to 36 weeks of gestation remains controversial.