Planned early birth versus expectant management for women with preterm prelabour rupture of membranes prior to 37 weeks' gestation for improving pregnancy outcome

Sarah L Buchanan, Caroline A Crowther, Kate M Levett, Philippa Middleton, Jonathan Morris
Cochrane Database of Systematic Reviews 2010 March 17, (3): CD004735

BACKGROUND: Delivery after preterm prelabour rupture of the membranes (PPROM) may be initiated soon after PPROM or, alternatively, be delayed. It is unclear which strategy is most beneficial for mothers and their babies.

OBJECTIVES: To assess the effect of planned early birth compared with expectant management for pregnancies complicated with PPROM prior to 37 weeks' gestation.

SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 1), MEDLINE (1996 to May 2009), EMBASE (1974 to May 2009), and reference lists of trials and other review articles.

SELECTION CRITERIA: Randomised controlled trials comparing expectant management with early delivery for women with PPROM prior to 37 weeks' gestation. We excluded quasi randomised trials.

DATA COLLECTION AND ANALYSIS: Two review authors independently evaluated trials for inclusion into the review and for methodological quality.

MAIN RESULTS: We included seven trials (690 women) in the review. We identified no difference in the primary outcomes of neonatal sepsis (risk ratio (RR) 1.33, 95% confidence interval (CI) 0.72 to 2.47) or respiratory distress (RR 0.98, 95% CI 0.74 to 1.29). Early delivery increased the incidence of caesarean section (RR 1.51, 95% CI 1.08 to 2.10). There was no difference in the overall perinatal mortality (RR 0.98, 95% CI 0.41 to 2.36), intrauterine deaths (RR 0.26, 95% CI 0.04 to 1.52) or neonatal deaths (RR 1.59, 95% CI 0.61 to 4.16) when comparing early delivery with expectant management. There was no significant difference in measures of neonatal morbidity, including cerebroventricular haemorrhage (RR 1.90 95% CI 0.52 to 6.92), necrotising enterocolitis (RR 0.58, 95% CI 0.08 to 4.08), or duration of neonatal hospitalisation (mean difference (MD) -0.33 days, 95% CI -1.06 to 0.40 days). In assessing maternal outcomes, we found that early delivery increased endometritis (RR 2.32, 95% CI 1.33 to 4.07), but that early delivery had no effect on chorioamnionitis (RR 0.44, 95% CI 0.17 to 1.14). There was a significant reduction of early delivery on the duration of maternal hospital stay (MD -1.13 days, 95% CI -1.75 to -0.51 days).

AUTHORS' CONCLUSIONS: There is insufficient evidence to guide clinical practice on the benefits and harms of immediate delivery compared with expectant management for women with PPROM. To date all of the clinical trials have had methodological weaknesses and have been underpowered to detect meaningful measures of infant and maternal morbidity.

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