Maternal morbidity and neonatal survival after periviable PPROM: the impact of latency duration

Abstract

Abstract Background Periviable preterm premature rupture of membranes (PPROM) is a rare (< 1%), critical obstetric complication associated with profound maternal and neonatal morbidity. Management involves a delicate trade-off between optimizing neonatal survival via pregnancy prolongation and mitigating maternal risks like chorioamnionitis, sepsis, and placental abruption. While expectant management is the standard to reach viability, research has predominantly focused on neonatal outcomes. Consequently, the potential for progressive, daily accumulation of maternal risk during latency remains insufficiently characterized. This study aims to identify maternal morbidity and risk factors, specifically evaluating the impact of latency duration on both safety and survival to provide objective data for clinical counseling and shared decision-making. Methods This retrospective cohort study analyzed 212 cases of PPROM diagnosed before 24 + 6 weeks’ gestation. Patients were classified by initial management into expectant management ( n = 84) or termination of pregnancy ( n = 128) groups. The primary outcome was composite maternal morbidity (CMM). To address confounding by indication, propensity-score matching was performed within the sub-23-week subcohort. Maternal complication accrual over the latency interval was evaluated using a competing-risks framework. Factors associated with neonatal survival to discharge were analyzed using Firth-penalized multivariable logistic regression to account for small-sample bias. Results In the propensity-score-matched cohort, expectant management was independently associated with a significant increase in CMM (matched OR 3.22; 95% CI 1.31–7.92; p = 0.011). Overall CMM rates were 32.1% in the expectant group and 11.7% in the termination group. Maternal temperature > 37 °C at admission was the strongest independent predictor of maternal morbidity across the entire cohort (OR 4.37; 95% CI 1.59–11.99; p = 0.005). Within the expectant management arm, each additional day of latency was not associated with a progressive increase in daily maternal risk ( p = 0.299). Conversely, each day of pregnancy prolongation was significantly associated with an increased probability of neonatal survival to discharge (adjusted OR 1.058 per day; 95% CI 1.027–1.102; p < 0.001). Among live-born infants managed expectantly, the survival-to-discharge rate was 63.6%. Conclusion Expectant management of periviable PPROM is associated with a more than three-fold increase in maternal morbidity compared to termination; however, this risk does not escalate progressively with each additional day of latency. In contrast, every day of pregnancy prolongation significantly enhances the probability of neonatal survival to discharge. These findings indicate that in the absence of acute maternal complications and under vigilant clinical supervision, expectant management represents a rational and viable strategy to optimize neonatal outcomes without a compounding daily risk profile for the mother.