Intentional delivery versus expectant management of women with preterm premature rupture of the membranes: A meta-analysis of randomized, controlled trials

Abstract

PRETERM PREMATURE RUPTURE OF THE MEMBRANES: A META-ANALYSIS OF RANDOMIZED, CONTROLLED TRIALS JEAN-CHARLES PASQUIER, EMMANUEL BUJOLD, CHANTAL ROY, ALEXANDRE DUMONT, FRANCOIS AUDIBERT, WILLIAM FRASER, Universite de Sherbrooke, obstetric gynecology, Sherbrooke, Quebec, Canada, Universite de Montreal, obstetric gynecology, Montreal, Quebec, Canada OBJECTIVE: To establish, by meta-analysis, whether there is any evidence of the efficacy of intentional delivery in women with preterm premature rupture of the membranes (PPROM). STUDY DESIGN: Published reports of controlled clinical trials available from 1980 to 2004 were identified by searching bibliographic databases (Medline, Ovid) and reference lists of selected papers. The selection criteria were randomized, controlled trials in which the efficacy of intentional delivery was assessed relative to expectant management in women with PPROM before 34 weeks’. Twenty randomized trials were identified and evaluated for inclusion. Four trials, including a total of 315 evaluated women, fulfilled the inclusion criteria. Data were extracted independently by 2 reviewers using summary forms. Women assigned to the intentional delivery group underwent oxytocin labor stimulation or C-section. Women in the expectant management group were admitted to the high-risk antepartum unit, and the delivery criteria included spontaneous labor or medical complications. Neither antenatal antibiotics nor antenatal steroids were used in these studies. Data were entered with Review Manager software for analysis for clinical chorioamnionitis and neonatal infection with positive blood, urine or spinal fluid culture. RESULTS: Intentional delivery was associated with a decreased risk of clinical chorioamnionitis (odds ratio, 0.30; 95%CI 0.15-0.60). There was no significant effect on neonatal sepsis (odds ratio, 0.75; 95%CI, 0.31-1.82). CONCLUSION: Our results indicate that intentional delivery is associated with a lower rate of clinical chorioamnionitis. Recent evidence has linked clinical chorioamnionitis to an increased risk of adverse neurological outcomes in premature infants. Further investigations are necessary to assess if intentional delivery with contemporary management using antibiotics and steroids improves long-term infant neurodevelopment. 177 OBSTETRICAL AND INFANT OUTCOMES OF WOMEN WITH A SECOND EPISODE OF PRETERM PREMATURE RUPTURE OF THE MEMBRANES IN A PROSPECTIVE REGIONAL COHORT STUDY JEAN-CHARLES PASQUIER, OLIVIER CLARIS, STEPHANIE MORET, MURIEL RABILLOUD, JEAN-CHARLES PICAUD, RENE ECOCHARD, GEORGES MELLIER, Universite de Sherbrooke, Obstetrics/ Gynecology, Sherbrooke, Quebec, Canada, Universite de Lyon, neonatology, Lyon, Rhone, France, Hospices civils de Lyon, obstetric gynecology, Lyon, France, Universite de Lyon, biostatistic, Lyon, France, Arnaud de Villeneuve Hospital and Montpellier University, Department of Neonatology,, Montpellier, France OBJECTIVE: Little research has been directed at women with prior preterm premature rupture of the membranes (PPROM). We aimed to compare obstetrical and infant outcomes of women with a second episode of PPROM with multiparous women with a first episode of PPROM. STUDY DESIGN: A prospective regional cohort study of all PPROM cases between 24 and 34 weeks of gestation was conducted in 81 maternity wards. In each centre, a research study midwife informed and enrolled women with PPROM. Women with a prior history of PPROM (cases) were compared to multiparous women with no prior history of PPROM, term PPROM or spontaneous preterm birth (control group). Neonatal outcome was a composite of death or major adverse outcome–periventricular leukomalacia, grade III/IV intraventricular hemorrhage, sepsis, oxygen requirement at the equivalent of 36 weeks before discharge from hospital. Long-term outcome was evaluated by a 2-year neurological questionnaire filled by the physician in charge of the infant. Data were analyzed by univariate and multivariable logistic regression analysis. RESULTS: Cases had significantly earlier PPROM (29.1G0.41 vs 30.1G0.2 weeks, P = 0.03) and a shorter latency period (142G15 vs 225G55 hours, P = .04) than women in the control group. There was no difference in the distribution of antenatal steroids, antibiotics and mode of delivery, but cerclage was more frequent in the cases group (17.4% vs 1.7%, P!0.01). After adjustment for confounding variables, no difference in neonatal outcome (Adj OR 0.75, 95%CI 0.3-1.88, P=0.54) and long-term outcome (Adj OR 0.70, 95%CI 0.29-1,73, P=0.44) was found between case and control infants. CONCLUSION: Women with a second PPROM episode presented earlier rupture with a shorter latency period than multiparous women without prior PPROM. However, neonatal and long-term morbidity were no different in case of a second PPROM.