Outpatient versus inpatient care for PPROM

June 3, 2019

A retrospective study compared several obstetric and neonatal outcomes of women with PPROM to determine whether outpatient or hospitalization should be the standard of care.

Neonatal outcomes of women with uncomplicated preterm premature rupture of membranes (PPROM) prior to 34 weeks of gestation are comparable for outpatient care or hospitalization, according to a French study.

The retrospective study in Scientific Reports was conducted over a 4-year period between January 2009 and December 2012 at six French tertiary-care referral centers. Three of the six centers had an inpatient care policy (ICP) and the other three an outpatient care policy (OCP).

A total of 587 women with PPROM before 34 weeks of gestation and lasting longer than 48 hours were divided into two groups: 246 (41.9%) women managed by an ICP and 341 (58.1%) women treated by an OCP.

Women eligible for outpatient care were initially discharged from the hospital after spending an average of 11.4 days. Outpatient management consisted of daily fetal cardiotocography, a laboratory blood sample twice a week, and a weekly clinical and ultrasound exam. 

Women assigned to inpatient care had the same protocol, but were not discharged until after delivery.

At PPROM, all study patients received betamethasone (two intramuscular doses of 12 mg, 24 hours apart) for fetal lung maturation; plus antibiotic prophylaxis (ampicillin or cefixime), depending on the unit’s protocol.

All patients were also managed expectantly until spontaneous labor, signs of chorioamnionitis, fetal heart rate anomalies or acute complications (placental abruption, cord prolapse). 

If delivery did not occur by 37 weeks of gestation, induction of labor or cesarean section was performed.

A composite measure of neonatal outcome was based on at least one of the following criteria: perinatal death, early neonatal infection with sepsis, respiratory distress syndrome, bronchopulmonary dysplasia at discharge, grade 3 or 4 intraventricular hemorrhage, and necrotizing enterocolitis.

Other neonatal outcomes were birth weight, gestational age at delivery and Apgar scores.

Obstetric outcomes also included latency duration (the time interval between PPROM and delivery), chorioamnionitis, leukocytosis, placental abruption, cord prolapse, delivery mode, maternal sepsis and postpartum endometritis.

The study found no significant differences in latency duration, gestational age at birth, induction of labor or delivery mode between the ICP and OCP group.

However, the rate of births after 32 weeks of gestation was lower in the ICP group: 47.3% versus 55.4% in the OCP group (p = 0.05). 

Conversely, the rate of births before 28 weeks of gestation was higher in the ICP group: 18.9% versus 12.9% in the OCP group (p = 0.05). 

The median birth weight was also lower for neonates in the ICP group: 1,632 g versus 1,790 g in the OCP group (p = 0.04).

The neonatal composite outcome between the two groups was comparable: 14.6% (36 of 246 women) in the ICP group versus 15.5% (53 of 341 women) in the OCP group (p = 0.76). 

The chorioamnionitis rate was also similar: 12.0% (41 of 246 women) versus 9.8% (24 of 341 women), respectively (p = 0.39).

Intrauterine death, placental abruption, maternal sepsis and endometritis rates between the two groups were the same as well.

But the cord prolapse rate was dramatically higher in the ICP group compared to the OCP group: 4.5% versus 1.5% (p = 0.03).

Propensity score matching among the 66 patients in the effective outpatient care group and the 246 in the inpatient group showed that the risk of neonatal morbidity was similar for the two groups (OR 0.88; 95% CI: 0.35 – 2.25).

The risk of chorioamnionitis was also comparable for the two groups (OR 0.54; 95% CI: 0.15 – 1.95), while the risks of prolapse cord and placental abruption were no longer significantly different.

“There is insufficient evidence to claim that outpatient management should currently be standard care for PPROM,” the authors wrote. “For this purpose, we need more retrospective studies and a large national prospective study.”