Outcome of prelabor rupture of membranes before or at the limit of viability: systematic review and meta-analysis

Background Counselling of pregnancies complicated by pre- and periviable PROM to reach a shared decision-making is challenging and the current, limited evidence hampers the robustness of the information provided. Objective To elucidate the rate of obstetric and neonatal outcomes following expectant management for premature rupture of membranes (PROM) occurred before or at the limit of viability. Study design Medline, Embase, Cinahl and Web of Science databases were searched electronically up to September 2023. We included both prospective and retrospective studies of singleton pregnancies with PROM before and at the limit of viability (i.e., occurring between 14/0 and 24/6 weeks of gestation). Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for cohort studies. We used meta-analyses of proportions to combine data and reported pooled proportions. In view of the clinical heterogeneity, a random-effect model was used to compute the pooled data analyses. The study was registered with the PROSPERO database (CRD42022368029). Results The pooled proportion of termination of pregnancy (TOP) was 32.3%. After the exclusion of cases of TOP, the rate of spontaneous miscarriage or fetal demise was 20.1%, whereas the live birth rate was 65.9% of the ongoing pregnancies. The mean gestational age at delivery among the liveborn cases was 27.26 weeks and the mean latency between PROM and delivery was 39.40 days in liveborn cases. The pooled proportion of cesarean delivery was 47.9% of the liveborn cases. Oligohydramnios occurred in 47.1% of cases. Chorioamnionitis occurred in 33.4% of cases; endometritis in 7%, placental abruption in 9.2%, postpartum hemorrhage in 5.3%. Hysterectomy was necessary in 1.2% of cases. Maternal sepsis occurred in 1.5% of cases while no maternal deaths were reported in the included studies. When focusing on neonatal outcomes, the mean birthweight was 1022.85 grams in liveborn cases. The admission to NICU rate was 86.3%, RDS complicated 66.5%; pulmonary hypoplasia or dysplasia was diagnosed in 24.0% of cases and persistent pulmonary hypertension in 40.9%. Other neonatal complications included necrotizing enterocolitis in 11.1%, ROP in 27.1%, IVH in 17.5% of the surviving neonates. Neonatal sepsis complicated 30.2% of cases and the overall neonatal mortality was 23.9%. The long-term follow-up at 2-to-4 years was normal in 74.1% of the available cases. Conclusions PROM before or at the limit of viability is associated with a high burden of both obstetric and neonatal complications, with an impaired long-term follow-up at 2-to-4 years in almost 30% of cases, and thus representing a clinical challenge for both counselling and management. These data are useful when first approaching such patients to offer the most comprehensive possible scenario on short- and long-term outcomes of this condition and to help parents for a shared decision-making.