Preterm Premature Rupture of Membranes – Inpatient Versus Outpatient Management: an Evidence-Based Review

Abstract

According to current guidelines, inpatient management until birth is considered standard in pregnant women with preterm premature rupture of membranes (PPROM). With the increasing burden on obstetric departments and the growing importance of satisfaction and right to self-determination in pregnant women, outpatient management in PPROM is a possible alternative to inpatient monitoring. The most important criterion for this approach is to ensure the safety of both the mother and the child. Due to the small number of cases (n = 116), two randomised controlled trials (RCTs) comparing inpatient and outpatient management were unable to draw any conclusions. By 2020, eight retrospective comparative studies (cohort/observational studies) yielded the following outcomes: no significant differences in the rate of maternal complications (e.g., chorioamnionitis, premature placental abruption, umbilical cord prolapse) and in neonatal morbidity, significantly prolonged latency period with higher gestational age at birth, higher birth weight of neonates, and significantly shorter length of stay of preterm infants in neonatal intensive care, shorter hospital stay of pregnant women, and lower treatment costs with outpatient management. Concerns regarding this approach are mainly related to unpredictable complications with the need for rapid obstetric interventions, which cannot be performed in time in an outpatient setting. Prerequisites for outpatient management are the compliance of the expectant mother, the adherence to strict selection criteria and the assurance of adequate monitoring at home. Future research should aim at more accurate risk assessment of obstetric complications through studies with higher case numbers and standardisation of outpatient management under evidence-based criteria.

Key words

preterm premature rupture of membranes - inpatient versus outpatient management - latency period - maternal complications - perinatal/neonatal morbidity

Publication History

Received: 17 February 2021

Accepted after revision: 19 May 2021

Article published online:
29 September 2021

• References/Literatur

• 1 Goldenberg RL, Culhane JF, Iams JD. et al. Epidemiology and causes of preterm birth. Lancet 2008; 371: 75-84
• 2 Mercer BM. Preterm premature rupture of the membranes: current approaches to evaluation and management. Obstet Gynecol Clin North Am 2005; 32: 411-428
• 3 Mercer BM. Preterm premature rupture of the membranes. Obstet Gynecol 2003; 101: 178-193
• 4 Kuba K, Bernstein PS. ACOG practice bulletin no. 188: prelabor rupture of membranes. Obstet Gynecol 2018; 131: 1163-1164
• 5 Kenyon S, Boulvain M, Neilson JP. Antibiotics for preterm rupture of membranes. Cochrane Database Syst Rev 2013; (12) CD001058
• 6 Major CA, de Veciana M, Lewis DF. et al. Preterm premature rupture of membranes and abruptio placentae: is there an association between these pregnancy complications?. Am J Obstet Gynecol 1995; 172: 672-676
• 7 Melamed N, Hadar E, Ben-Haroush A. et al. Factors affecting the duration of the latency period in preterm premature rupture of membranes. J Matern Fetal Neonatal Med 2009; 22: 1051-1056
• 8 Bendix J, Hegaard H, Bergholt T. et al. Expectant management of PPROM and major complications before planned delivery: A retrospective cohort study. J Obstet Gynaecol 2015; 35: 570-577
• 9 Ekin A, Gezer C, Taner CE. et al. Risk factors and perinatal outcomes associated with latency in preterm premature rupture of membranes between 24 and 34 weeks of gestation. Arch Gynecol Obstet 2014; 290: 449-455
• 10 Goya M, Bernabeu A, García N. et al. Premature rupture of membranes before 34 weeks managed expectantly: maternal and perinatal outcomes in singletons. J Matern Fetal Neonatal Med 2013; 26: 290-293
• 11 Mehra S, Amon E, Hopkins S. et al. Transvaginal cervical length and amniotic fluid index: can it predict delivery latency following preterm premature rupture of membranes?. Am J Obstet Gynecol 2015; 212: 400.e1-400.e9
• 12 Test G, Levy A, Wiznitzer A. et al. Factors affecting the latency period in patients with preterm premature rupture of membranes. Arch Gynecol Obstet 2011; 283: 707-710
• 13 Rizzo G, Capponi A, Angelini E. et al. The value of transvaginal ultrasonographic examination of the uterine cervix in predicting preterm delivery in patients with preterm premature rupture of membranes. Ultrasound Obstet Gynecol 1998; 11: 23-29
• 14 Tsoi E, Fuchs I, Henrich W. et al. Sonographic measurement of cervical length in preterm prelabor amniorrhexis. Ultrasound Obstet Gynecol 2004; 24: 550-553
• 15 Phupong V, Kulmala L. Factors associated with latency period in preterm prelabor rupture of membranes. J Matern Fetal Neonatal Med 2016; 29: 2650-2653
• 16 Peaceman AM, Yinglei L, Rouse DJ. et al. Length of latency with preterm premature rupture of membranes before 32 weeksʼ gestation. Am J Perinatol 2015; 32: 57
• 17 Manuck TA, Maclean CC, Silver RM. et al. Preterm premature rupture of membranes: does the duration of latency influence perinatal outcomes?. Am J Obstet Gynecol 2009; 201: 414.e1-414.e6
• 18 Mercer BM, Miodovnik M, Thurnau GR. et al. Antibiotic therapy for reduction of infant morbidity after preterm premature rupture of the membranes: a randomized controlled trial. JAMA 1997; 278: 989-995
• 19 Bond DM, Middleton P, Levett KM. et al. Planned early birth versus expectant management for women with preterm prelabour rupture of membranes prior to 37 weeksʼ gestation for improving pregnancy outcome. Cochrane Database Syst Rev 2017; (03) CD004735
• 20 AWMF-Leitlinie 015/025. Prävention und Therapie der Frühgeburt. 2019. Accessed February 16, 2021 at: https://www.awmf.org/uploads/tx_szleitlinien/015-025l_S2k_Praevention-Therapie_Fruehgeburt_2020-02.pdf
• 21 Thomson A. Care of women presenting with suspected preterm prelabour rupture of membranes from 24 + 0 weeks of gestation. BJOG 2019; 126: e152-e166
• 22 Schmitz T, Sentilhes L, Lorthe E. et al. Preterm premature rupture of membranes: CNGOF Guidelines for clinical practice – Short version. Gynecol Obstet Fertil Senol 2018; 46: 998-1003
• 23 Rath W, Schlembach D. Ambulante Betreuung hypertensiver Schwangerer. Frauenarzt 2020; 61: 678-682
• 24 Morton J, Peabody C, Newdorp J. et al. Premature rupture of membranes: A clinical study. Am J Obstet Gynecol 1942; 43: 422-436
• 25 Calkins L. Premature spontaneous rupture of the membranes. Am J Obstet Gynecol 1952; 64: 871-877
• 26 Taylor ES, Morgan RL, Bruns PD. et al. Spontaneous premature rupture of the fetal membranes. Am J Obstet Gynecol 1961; 82: 1341-1348
• 27 Eastman NJ, Hellman LM. Williams Obstetrics. The clinical course of labor, chapter 16. New York: Appleton-Century Crofts, Inc.; 1966: 396-409
• 28 Cunningham FG, McDonald PC, Gant NF. Williams Obstetrics. Preterm and postterm pregnancy and inappropriate fetal growth, chapter 38. Norwalk, Connecticut: Appleton and Lange; 1989: 741-753
• 29 Carlan SJ, OʼBrien WF, Parsons MT. et al. Preterm premature rupture of membranes: a randomized study of home versus hospital management. Obstet Gynecol 1993; 81: 61-64
• 30 Ryan G, Oskamp M, Seaward P. et al. Randomized controlled trial of inpatient vs. outpatient management of PPROM. Am J Obstet Gynecol 1999; 180: S95
• 31 Abou El Senoun G, Dowswell T, Mousa HA. Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeksʼ gestation. Cochrane Database Syst Rev 2014; (04) CD008053
• 32 Ellestad SC, Swamy GK, Sinclair T. et al. Preterm premature rupture of membrane management-inpatient versus outpatient: A retrospective review. Am J Perinatol 2008; 25: 69-73
• 33 Beckmann M, Gardener G. Hospital versus outpatient care for preterm pre-labour rupture of membranes. Aust N Z J Obstet Gynaecol 2013; 53: 119-124
• 34 Dussaux C, Senat M-V, Bouchghoul H. et al. Preterm premature rupture of membranes: is home care acceptable?. J Matern Fetal Neonatal Med 2018; 31: 2284-2292
• 35 Huret E, Chanavaz-Lacheray I, Grzegorczyk-Martin V. et al. [Home care of premature rupture of membranes prior to 37 weeksʼ gestation]. Gynecol Obstet Fertil 2014; 42: 222-228
• 36 Garabedian C, Bocquet C, Duhamel A. et al. [Preterm rupture of membranes: Is home care a safe management?]. J Gynecol Obstet Biol Reprod (Paris) 2016; 45: 278-284
• 37 Catt E, Chadha R, Tang S. et al. Management of Preterm Premature Rupture of Membranes: A Comparison of Inpatient and Outpatient Care. J Obstet Gynaecol Can 2016; 38: 433-440
• 38 Palmer L, Grabowska K, Burrows J. et al. A retrospective cohort study of hospital versus home care for pregnant women with preterm prelabor rupture of membranes. Int J Gynecol Obstet 2017; 137: 180-184
• 39 Petit C, Deruelle P, Behal H. et al. Preterm premature rupture of membranes: Which criteria contraindicate home care management?. Acta Obstet Gynecol Scand 2018; 97: 1499-1507
• 40 Bouchghoul H, Kayem G, Schmitz T. et al. Outpatient versus inpatient care for preterm premature rupture of membranes before 34 weeks of gestation. Sci Rep 2019; 9: 4280
• 41 Guckert M, Clouqueur E, Drumez E. et al. Is homecare management associated with longer latency in preterm premature rupture of membranes?. Arch Gynecol Obstet 2020; 301: 61-67
• 42 Rath W, Stelzl P, Kehl S. Outpatient Induction of Labor–Are Balloon Catheters an Appropriate Method?. Geburtshilfe Frauenheilkd 2021; 81: 70-80
• 43 Van Den Heuvel JF, Ganzevoort W, De Haan-Jebbink JM. et al. HOspital care versus TELemonitoring in high-risk pregnancy (HOTEL): study protocol for a multicentre non-inferiority randomised controlled trial. BMJ Open 2019; 9: e031700
• 44 (G-BA) Gemeinsamer Bundesausschuss. IQTIG (Institut für Qualitätssicherung und Transparenz im Gesundheitswesen) Qualitätsreport 2019. Accessed February 16, 2021 at: https://iqtig.org/downloads/berichte/2019/IQTIG_Qualitaetsreport-2020_2021-02-11.pdf
• 45 Nelson DM, Stempel LE, Zuspan FP. Association of prolonged, preterm premature rupture of the membranes and abruptio placentae. J Reprod Med 1986; 31: 249-253
• 46 Bartfield MC, Carlan S. The home management of preterm premature ruptured membranes. Clin Obstet Gynecol 1998; 41: 503-514
• 47 Sharp GC, Stock SJ, Norman JE. Fetal assessment methods for improving neonatal and maternal outcomes in preterm prelabour rupture of membranes. Cochrane Database Syst Rev 2014; (10) CD010209
• 48 Lorthe E, Ancel P-Y, Torchin H. et al. Impact of latency duration on the prognosis of preterm infants after preterm premature rupture of membranes at 24 to 32 weeksʼ gestation: a national population-based cohort study. J Pediatr 2017; 182: 47-52.e2
• 49 Ancel PY, Goffinet F. EPIPAGE 2 Writing Group. EPIPAGE 2: a preterm birth cohort in France in 2011. BMC Pediatr 2014; 14: 97
• 50 Ayres AW. Home management of preterm premature rupture of membranes. Int J Gynaecol Obstet 2002; 78: 153-155
• 51 Martin D, Gardner M, Howell K. et al. Outcome and cost analysis of preterm premature rupture of membranes in an outpatient setting. Am J Obstet Gynecol 1996; 174: 463
• 52 Doyle NM, Monga M, Kerr M. et al. Maternal stressors during prolonged antepartum hospitalization following transfer for maternal-fetal indications. Am J Perinatol 2004; 21: 27-30
• 53 Richter MS, Parkes C, Chaw-Kant J. Listening to the voices of hospitalized high-risk antepartum patient. J Obstet Gynecol Neonatal Nurs 2007; 36: 313-318
• 54 Turnbull DA, Wilkinson C, Griffith EC. et al. The psychosocial outcomes of antenatal day care for three medical complications of pregnancy: a randomised controlled trial of 395 women. Aust N Z J Obstet Gynaecol 2006; 46: 510-516
• 55 Ramsey PS, Nuthalapaty FS, Lu G. et al. Contemporary management of preterm premature rupture of membranes (PPROM): a survey of maternal-fetal medicine providers. Am J Obstet Gynecol 2004; 191: 1497-1502