Managing Early PPROM: Complexities in Maternal and Neonatal Care

Approximately 26% of women with very early preterm prelabour rupture of membranes (PPROM) who received expectant management had children who survived to hospital discharge. However, both maternal and neonatal morbidity and mortality rates remained high, according to findings from a UK-based study published in BMJ Medicine.¹

This prospective observational study aimed to examine perinatal and maternal outcomes following PPROM occurring before 23 weeks of gestation. Data were collected via the UK Obstetric Surveillance System (UKOSS), a national population-based cohort encompassing all 194 obstetric units in the UK. The study period extended from September 2019 to February 2021.

A total of 326 women with singleton pregnancies and 38 with multiple pregnancies who experienced PPROM between 16+0 and 22+6 weeks of gestation were included in the study.

Primary outcome measures for the fetus included live birth, survival to hospital discharge, and serious morbidity—defined as the requirement for supplemental oxygen at 36 weeks postmenstrual age, intraventricular hemorrhage grade 3 or 4, or both. Maternal outcomes included sepsis, intensive care unit (ICU) admission, surgical placental removal, and death. Rates of pregnancy termination for medical reasons were also recorded.

A worst-best outcome range was calculated by assuming that all terminations and cases with missing data either resulted in fetal death (worst-case) or live birth (best-case). Perinatal outcomes were also analyzed excluding pregnancies that were medically terminated.

Among singleton pregnancies, the live birth rate was 44%, with a range of 30–62%. The survival rate to hospital discharge was 26% (range: 17–53%), and 18% of neonates (range: 12–48%) survived without serious morbidity.

Maternal sepsis developed in 12% of women with singleton pregnancies, compared to 29% in those with multiple pregnancies—a statistically significant difference (P=0.004). Surgery for placental removal was required in 20% of singleton and 16% of multiple pregnancies. Five women developed severe sepsis; of these, three required ICU admission and two died.

This study underscores the complexities and challenges of managing PPROM, particularly before 23 weeks of gestation. The elevated risk of maternal sepsis is a critical concern, emphasizing the importance of vigilant maternal monitoring, early identification of chorioamnionitis, timely delivery, and appropriate antibiotic therapy. The authors highlight the need for careful counselling of families, revision of clinical guidelines in light of emerging data, and further research—especially focused on maternal sepsis, given its substantial risks for both mother and newborn.

Source: BMJ Med. 2024 Mar 19;3(1):e000729. doi: 10.1136/bmjmed-2023-000729.