LAUSR

BACKGROUND After preterm premature rupture of membranes <24 weeks' gestation, pregnant women may choose pregnancy continuation (expectant management) or termination, either via dilation and evacuation or labor induction. Neonatal outcomes after expectant management are well described. By contrast, limited research addresses maternal outcomes associated with expectant management compared to termination. OBJECTIVE To compare maternal morbidity after preterm premature rupture of membranes <24 weeks' gestation in women who choose either expectant management or termination of pregnancy. STUDY DESIGN This retrospective cohort study includes women with preterm premature rupture of membranes between 14 0/7 and 23 6/7 weeks' gestation with singleton or twin pregnancies at three institutions from 2011-2018. We excluded pregnancies complicated by fetal anomalies, rupture of membranes immediately after obstetric procedures (chorionic villus sampling, amniocentesis, cerclage placement, fetal reduction), spontaneous delivery <24 hours after membrane rupture, and contraindications to expectant management. Our primary outcome was the difference in composite maternal morbidity between women electing expectant management versus pregnancy termination. We defined composite maternal morbidity as including at least one of the following: chorioamnionitis, endometritis, sepsis, unplanned operative procedure after delivery (dilation and curettage, laparoscopy, laparotomy), injury requiring repair, unplanned hysterectomy, unplanned hysterotomy (excluding cesarean delivery), uterine rupture, hemorrhage >1000cc, transfusion, maternal intensive care unit admission, acute renal insufficiency, venous thromboembolism, pulmonary embolism, and readmission within six weeks. We compared demographic and antenatal characteristics of women electing expectant management versus pregnancy termination and used logistic regression to quantify the association between initial management decision and composite maternal morbidity. RESULTS We identified 350 pregnancies complicated by preterm premature rupture of membranes <24 weeks' gestation and 208 were eligible for the study. Of the 208, 108 (51.9%) selected expectant management and 100 (48.1%) selected termination of pregnancy as initial management. Among women selecting termination of pregnancy, 67.0% underwent induction and 33.0% D&E. Compared to termination, women pursuing expectant management had 4.1 times the odds of developing chorioamnionitis (38.0% vs 13.0%, 95% CI 2.03-8.26) and 2.44 times the odds of postpartum hemorrhage (23.1% vs 11.0%, 95% CI 1.13-5.26). Intensive care unit admissions and unplanned hysterectomy only occurred following expectant management (2.8% vs 0.0% and 0.9% vs 0.0%). Of women who pursued expectant management, 36.2% delivered via cesarean with 56.4% non-low transverse uterine incisions. Composite maternal morbidity was higher in the expectantly managed group at 60.2% compared to 33.0% in the termination group. After adjusting for gestational age at rupture, site, race/ethnicity, gestational age at entry to prenatal care, preterm premature rupture of membranes in a prior pregnancy, twin gestation, smoking, cerclage, and cervical exam at time of presentation, expectant management was associated with 3.47 times the odds of composite maternal morbidity (95% CI 1.52-7.93) corresponding to an adjusted relative risk of 1.91 (95% CI: 1.35-2.73). Among women initially pursuing expectant management, 15.7% avoided morbidity and had a neonate who survived to discharge. CONCLUSION Expectant management of preterm premature rupture of membranes <24 weeks' gestation is associated with significantly increased maternal morbidity when compared to termination of pregnancy.