Latency, Perinatal and Maternal Outcomes in Conservatively Managed Patients With Preterm Premature Rupture of Membranes at 24-34 Weeks Gestation at Kenyatta National Hospital

Abstract

Background: Preterm premature rupture of membranes (PPROM) complicates 3%-8% of all pregnancies and is associated with 30–40% of preterm births, perinatal and maternal morbidities, and mortality. At 24-34 weeks, PPROM is conservatively managed if there are no indications for immediate delivery. Although latency period, time from PPROM to delivery for conservatively managed PPROM determines the perinatal and maternal outcomes, this has not been evaluated at Kenyatta National Hospital (KNH). Information on latency and associated pregnancy outcomes can inform patient guidance on expectations and likely maternal and perinatal outcomes. Objective: To describe the latency period, perinatal and maternal outcomes in conservatively managed patients with PPROM at 24-34 weeks of gestation at KNH in 2019. Methods: This was a retrospective descriptive cohort study in which records of conservatively managed patients with PPROM at 24-34 weeks at KNH from 1st January to 31st December 2019 were reviewed. Latency was defined as the time from spontaneous rupture of membranes to delivery. The mean (standard deviation) and median (interquartile range) latency period was estimated. Perinatal morbidity was summarized as percentages, while the perinatal mortality rate was calculated as the number of fetal and early neonatal deaths/per 1000 total births following PPROM. We evaluated the association between latency period (of > 72 hours and > 7 days) with adverse perinatal and maternal outcomes. A p-value of < 0.05 was considered statistically significant. Results: Between January 2019 and December 2019, we screened 514 files of which 143 (27.8 %) maternal files (122 singletons and 21 multiple pregnancies) and 165 (95%) neonatal files were eligible. The mean age of participants was 28.4 (± 6.3) years. The mean gestation at PROM and at delivery was 30.1 (± 2.7) and 31.1 (± 2.3) weeks respectively. The overall mean latency was 6.7 (± 8.5) days and 15.1 (± 13.2) ,6.1 (± 6.7) and 3.1 (± 2.4) days at 24 – 28 weeks, 28+1 – 32, and 32+1 – 34 weeks of gestation respectively. The perinatal morbidity rate was 63% (95% Confidence Interval (CI), 55.4% – 70.0%) due to respiratory distress syndrome 38.2% (CI, 31.1% – 45.8%), neonatal jaundice 32.7% (CI, 26.0% – 40.2%), neonatal sepsis 26.7% (CI, 20.5% – 33.9%) and necrotizing enterocolitis 3.6% (CI, 1.7% – 7.7%). The Perinatal Mortality Rate was 194/1000 live births. The incidence of maternal morbidity was 18.9%, due to abruptio placentae 4.9% (CI,0.7%-6.0%), chorioamnionitis 6.3% (CI,3.4%-11.5%), cord prolapse 3.4%(CI,2.4%-9.8%), retained placenta 0.7%(0.1%-3.9%) and postpartum hemorrhage 2.1% (CI, 0.7%-6.0%) the use of steroids and antibiotic were associated with latency of >72hours, while prolonged latency of >7 days was associated with early gestation at PPROM, gestation at birth at 28+1-32 weeks, use of steroids and antibiotics. Prolonged latency of > 72 hours was associated with hyperbilirubinemia and necrotizing enterocolitis, however latency of > 7 days was not associated with any adverse perinatal and maternal outcomes. Conclusion: The mean latency of pregnant women who had PPROM at 24-34 weeks, was 6.7 days, and was highest at 24-28 weeks’ gestation. Perinatal morbidity and mortality was high. Maternal morbidity was 18.9% with leading morbidity being chorioamnionitis. There was no maternal death. Prolonged latency was associated with necrotizing enterocolitis(NEC) and hyperbilirubinemia and was not associated with any adverse maternal outcomes. Recommendations: When not contraindicated, conservative management of PPROM at 24-34 weeks is safe can be offered to eligible women to prolong latency. Interventions that can increase latency and improve neonatal survival should be assessed and instituted. These study findings can be used to generate statements for future references.