Outpatient Expectant Management of Term PROM Has Mixed Results

The American College of Obstetricians and Gynecologists (ACOG) recommends induction of labor for all women who present with prelabor rupture of membranes (PROM) at term. Some women decline induction, and ACOG notes that a course of expectant management may be acceptable in these cases. Yet there are limited data on how to manage such patients.

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Massachusetts General Hospital has developed a protocol for outpatient expectant management of term PROM. Kelly M. Chacón, MD, clinical fellow in Obstetrics, Gynecology and Reproductive Biology, along with Allison Bryant, MD, MPH and Mark A. Clapp, MD, MPH, both specialists in the Maternal-Fetal Medicine Program at Massachusetts General Hospital, recently studied women who declined induction and were managed expectantly versus those who were initially admitted.

In the American Journal of Perinatology, they report on outcomes that reflect resource utilization and the patient experience: time from PROM to delivery, and time from admission to delivery.

The Protocol

Developed in 2012, the protocol allows 24 hours of outpatient expectant management for women with term PROM who decline induction of labor and meet the following criteria:

• Negative for group B streptococcus (GBS) on rectovaginal culture
• Negative for HIV and hepatitis B and C virus
• Vertex presentation
• PROM less than 24 hours before the time of presentation
• Clear amniotic fluid
• Reactive nonstress test upon presentation

Women were ineligible for outpatient management if they had unknown GBS results, vaginal bleeding, history of cesarean delivery, hypertensive disease (chronic or gestational), diabetes (pregestational or gestational) or a serious medical condition at the discretion of the admitting provider.

Study Details

The researchers retrospectively studied 369 pregnant women with singleton fetuses who presented to Mass General with term PROM between July 2016 and June 2017 and declined induction.

166 of the women met the protocol's eligibility criteria, of whom 105 were admitted and 61 were discharged for outpatient expectant management.

Results

• Median time from PROM to delivery — 29 hours for women who were expectantly managed vs. 17 hours for admitted patients (P < .001)
• Still pregnant 24 hours after PROM — 68% vs. 21% (P < .001)
• Median time from admission to delivery — 13.9 hours vs. 12.6 hours (P = NS)
• Delivered within 24 hours of admission — 95% vs. 83% (P = .004)

When nulliparas were analyzed separately, the only important difference from the overall cohort was that median time from admission to delivery was significantly shorter among the group managed as outpatients (14 vs. 15.7 hours; P = .006).

Multivariable Analyses

Compared with women who were admitted, women who elected outpatient expectant management had:

• Seven hours longer average time from PROM to delivery (P < .001)
• Eight times higher odds of remaining pregnant 24 hours after PROM (P < .001)
• Five hours shorter average time from admission to delivery (P < .001)
• 90% lower odds that time from admission to delivery would be >24 hours (P = .003)

Patient Counseling

Key messages for women considering outpatient management are that:

• Only 30% of women who chose outpatient expectant management delivered within 24 hours of PROM, which could increase the risk of chorioamnionitis
• On average, women who chose outpatient expectant management spent five fewer hours in the hospital before delivery
• Nearly 85% of women who chose expectant management still required some form of augmentation of labor

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Learn more about the Maternal-Fetal Medicine Program

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