Management of preterm pre‐labor rupture of membranes between 24 and 34 weeks: A before‐and‐after study of the implementation and modifications of an outpatient management protocol

INTRODUCTION: In preterm pre-labor rupture of membranes (PPROM) before 34 weeks, expectant management is preferred in the absence of infection to reduce neonatal morbidity. Outpatient management (OM) has emerged as a potential alternative to prolonged hospitalization, but selection criteria remain ill-defined. Our objective was to evaluate latency between PPROM and delivery, and obstetric and neonatal outcomes before and after the implementation of an OM protocol and its subsequent extensions. MATERIAL AND METHODS: We included all women with PPROM before 34 weeks admitted between January 1, 2011, and December 31, 2021. Two periods were compared: Period A (January 2011-April 2013), when all patients were hospitalized until delivery, and Period B (May 2013-December 2021), when eligible patients were offered OM. Period B was subdivided into three phases (B1-B3) reflecting progressive expansion of eligibility criteria-from stable singleton pregnancies with cephalic presentation and normal amniotic fluid (B1), to inclusion of twins and shorter stabilization periods (B2), and finally cases with oligohydramnios or non-cephalic presentations (B3). The primary outcome was latency period (days between PPROM and delivery). Secondary outcomes included obstetric and neonatal complications. Comparisons were made between Periods A and B and across OM subperiods. RESULTS: A total of 539 patients were included: 145 in Period A and 394 in Period B, of whom 126 (32%) received OM. Mean gestational age at PPROM was similar between periods (28.9 ± 3.1 vs. 28.9 ± 3.3 weeks; p = 0.94), as were latency (median 7 [3-17] days vs. 8 [2-21]; p = 0.66) and gestational age at delivery (30.8 ± 3.3 vs. 30.9 ± 3.8 weeks; p = 0.62). Early neonatal bacterial infection was significantly lower in Period B (24.2% vs. 34.5%; p = 0.01). OM use increased steadily from B1 to B3 without prolonging latency or worsening outcomes. CONCLUSION: Following OM protocol implementation, one-third of eligible women with PPROM before 34 weeks were managed at home. Outpatient care, even with broadened eligibility, appeared safe, did not increase maternal or neonatal morbidity, and may reduce early neonatal infections without extending latency.