Factors Associated with Neonatal Survival in Pregnancies Complicated by Periviable Rupture of Membranes

Abstract Periviable rupture of membranes (ROM) occurs in 0.4% of pregnancies and is associated with substantial maternal and neonatal morbidity. Data to inform prognosis and neonatal outcomes are limited. To assess factors that influence neonatal survival to discharge in expectantly managed pregnancies affected by ROM at less than 25 weeks' gestation. Retrospective case control study of nonanomalous, singleton pregnancies complicated by ROM at less than 25 weeks' gestation and delivered at a tertiary center from 2005 to 2024. The cohort included patients who opted for expectant management at the time of ROM diagnosis and subsequently delivered a liveborn neonate eligible for neonatal resuscitation. Resuscitation was offered at ≥23 weeks' gestation from 2004 to 2019 and ≥22 weeks' gestation from 2020 to 2024. Multiple gestations, termination, fetal demise, or planned comfort care were excluded. Patients were stratified by neonatal survival to discharge, and maternal, obstetric, and neonatal variables were compared between groups. The primary outcome of neonatal survival was analyzed using Chi-square test and secondary outcomes analyzed with Chi-square, student's t-test, and Wilcoxon rank sum where appropriate. Of 121 pregnancies meeting inclusion criteria, 82 (67.8%) delivered a neonate that survived to discharge. Gestational age (GA) at delivery was significantly associated with survivorship (25.3 weeks vs. 24.1 weeks, p = 0.01). GA at ROM, latency, and residual amniotic fluid index did not differ between groups. Survivors were more likely to have received antenatal corticosteroids (100% vs. 95%, p = 0.04). Vaginal delivery was more frequent among survivors (p = 0.01), although cesarean delivery was more common overall (59.5%). Maternal morbidity occurred in 45.9% of cases, most commonly due to infection. In our cohort, overall survival of expectantly managed singleton pregnancies affected by ROM at less than 25 weeks' gestation is 67.8%. Gestational age at delivery was significantly associated with survival. Expectant management is associated with significant risk of both neonatal and maternal morbidity.