A systematic review of intentional delivery in women with preterm prelabor rupture of membranes

We read with great interest the meta-analysis performed by Hartling and colleagues [1]. We want to underscore the scope of their results, and then we would like to ask the authors two questions.

This work compared data from two opposing management approaches to women with preterm prelabor rupture of membranes (PPROM). In expectant management, which is the classical approach, a gain in maturity is favored by trying to prolong pregnancy at the risk of chorioamnionitis. Inversely, in intentional delivery, chorioamnionitis appears to be the complication to be avoided.

In the study by Hartling et al., a significant diminution of the clinical chorioamnionitis level, observed in the intentional delivery group, allowed childbirth outside the context of infection, which is the research goal of intentional delivery. On the other hand, the authors did not find differences between the two groups in the investigated complications related to prematurity. Expectant management had no benefit in terms of respiratory distress syndrome, necrotizing enterocolitis or intraventricular hemorrhage. This absence of neonatal difference may be due to a lack of power of the study, but also to very weak divergence observed between the two groups in terms of gestational age at birth. It is possible to think that considering these results, expectant management does not give enough time to achieve a gain in maturity but prolongs pregnancy enough to allow the occurrence of a complication on the maternal side.

We would like to know the opinion of these authors about these two aspects. It appears to us that the study of periventricular leukomalacia is an important element on the neurological state of these infants. Effectively, damage at the level of the white matter appears to be a stage between antenatal infection/inflammation and the occurrence of cerebral palsy. Was this information available in the studies regrouped by the meta-analysis? Finally, we would also like to know the reasons that prompted the authors on their choice of gestational age window. The choice of the lower limit at 30 weeks of gestation did not allow the inclusion, in this meta-analysis, of the work of Nelson et al. [2] who were the first to undertake a randomized clinical trial on this subject. At the other extreme, the choice of the upper limit close to term included in the analysis infants with a weak risk of major neonatal morbidities. We have just completed a randomized clinical trial in Europe investigating intentional delivery versus expectant management of PPROM between 28 and 32 weeks of gestation (MICADO Study) and the selection of the targeted gestational age window at PPROM seems to be a crucial point.

Professor Jean-Charles Pasquier

Department of Obstetrics & Gynaecology

Faculté de Médecine

Université de Sherbrooke

3001, 12e avenue Nord

Sherbrooke, QC, Canada J1H 5N4

Tel: [phone] ext. 13875

E-mail: [email protected]