- Massachusetts General Hospital has developed a protocol for outpatient expectant management of prelabor rupture of membranes (PROM) at term for women who decline induction
- This retrospective study involved 166 women, of whom 105 were admitted and 61 were discharged for outpatient expectant management
- Women who chose expectant management over admission for labor induction experienced significantly longer times from PROM to delivery (by seven hours on average)
- However, delivery within 24 hours of admission was significantly more likely in women initially discharged for outpatient expectant management
- Even after outpatient expectant management, approximately 85% of women still required augmentation of labor
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.
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.
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.
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.
- 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).
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)
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
Learn more about the Maternal-Fetal Medicine Program
Refer a patient to the Obstetrics program at Mass General