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Late Preterm Delivery in Women With Preterm Prelabour Rupture of Membranes

Jenny J.Y. Lim, MHSc,1 Victoria M. Allen, MD, MSc,1,2 Heather M. Scott, MD,1,2 Alexander C. Allen, MD CM14
1 2 3 4

Faculty of Medicine, Dalhousie University, Halifax NS Department of Obstetrics and Gynaecology, Dalhousie University, Halifax NS Department of Pediatrics, Dalhousie University, Halifax NS Perinatal Epidemiology Research Unit, Dalhousie University, Halifax NS

Abstract
Objective: To estimate maternal and neonatal outcomes in women with preterm prelabour rupture of membranes (PPROM) who delivered at 34+0 to 36+6 weeks gestation, particularly in those who had an obstetrically indicated delivery. Methods: We conducted a population-based study of late preterm singleton births complicated by PPROM, using data from the Nova Scotia Atlee Perinatal Database from 1988 to 2006. The study cohort was categorized by type of labour (spontaneous, induced, no labour), and each groups characteristics prior to delivery, and their outcomes were compared after accounting for potential confounding variables. Results: From a total population of 164 384 pregnancies, 2618 deliveries were identified as having PPROM. Among these, 2180 (83.3%) delivered between 34+0 and 36+6 weeks gestation. Adjusted analyses showed no differences in risk between those women entering labour spontaneously (n = 1296) and those with obstetrically indicated delivery (labour induction or Caesarean section without labour, n = 698). Additional adjusted analyses evaluating only women with obstetrically indicated delivery showed that rates of chorioamnionitis (OR 0.27; 95% CI 0.08 to 0.93), composite perinatal morbidity/mortality (OR 0.39; 95% CI 0.25 to 0.62), neonatal depression at birth (OR 0.22; 95% CI 0.06 to 0.86), and respiratory distress syndrome (OR 0.17; 95% CI 0.06 to 0.47) were significantly lower in those delivering at 36 weeks (n = 458) than in those delivering at 34 to 35 weeks (n = 240). Conclusions: This large population-based study suggests that in pregnancies complicated by PPROM rates of adverse maternal and perinatal outcomes at 36 weeks gestational age are at least comparable to those in pregnancies delivering at 34 to 35 weeks, and these rates may be further reduced by delivery after 36 completed weeks if spontaneous labour has not occurred.

Rsum
Objectif: Estimer les issues maternelles et nonatales chez les femmes prsentant une rupture prmature des membranes prterme (RPMP) qui ont accouch entre 34+0 et 36+6 semaines de gestation, particulirement chez celles qui ont connu un accouchement indiqu pour des raisons obsttricales. Mthodes: Nous avons men une tude en population gnrale portant sur les grossesses monoftales se trouvant la fin de la priode considre prterme et compliques par la RPMP, au moyen de donnes issues de la Nova Scotia Atlee Perinatal Database pour la priode allant de 1988 2006. Ltude de cohorte a t catgorise en fonction du type de travail (spontan, dclench, absence de travail); de plus, les caractristiques de chacun des groupes avant laccouchement et leurs issues ont t compares, la suite de la neutralisation des variables confusionnelles potentielles. Rsultats: Sur une population totale de 164 384 grossesses, 2 618 grossesses ont t identifies comme prsentant une RPMP; 2180 de ces grossesses (83,3 %) se sont soldes en un accouchement se droulant entre 34+0 et 36+6 semaines de gestation. Les analyses corriges nont indiqu aucune diffrence en matire de risque entre les femmes connaissant un travail spontan (n = 1 296) et les femmes connaissant un accouchement indiqu pour des raisons obsttricales (dclenchement du travail ou csarienne sans travail, n = 698). Des analyses corriges supplmentaires nvaluant que les femmes ayant connu un accouchement indiqu pour des raisons obsttricales ont indiqu que les taux de chorioamnionite (RC, 0,27; IC 95 %, 0,08 0,93), de morbidit/mortalit prinatales composites (RC, 0,39; IC 95 %, 0,25 0,62), de dpression nonatale la naissance (RC, 0,22; IC 95 %, 0,06 0,86) et de syndrome de dtresse respiratoire (RC, 0,17; IC 95 %, 0,06 0,47) taient considrablement plus faibles chez les femmes accouchant 36 semaines (n = 458) que chez les femmes accouchant 34-35 semaines (n = 240). Conclusions: Cette importante tude en population gnrale laisse entendre que, chez les grossesses compliques par la RPMP, les taux e dissues indsirables maternelles et prinatales la 36 semaine de gestation sont tout le moins comparables ceux des grossesses se soldant en un accouchement 34-35 semaines; de plus, ces taux peuvent tre abaisss davantage par un accouchement survenant la suite de 36 semaines compltes, lorsquun travail spontan ne sest pas manifest.

J Obstet Gynaecol Can 2010;32(6):555560

Key Words: Prelabour rupture of membranes, preterm birth Competing Interests: None declared. Received on October 16, 2009 Accepted on January 27, 2010

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INTRODUCTION

urrently available evidence supports the induction of labour when prelabour rupture of the membranes (PROM) occurs at term ( 37 weeks gestation), to decrease the risk for maternal infections.1,2 Although several studies have demonstrated increased neonatal mortality and morbidity and increased need for re-hospitalization in the first year of life in all infants born at late preterm gestational ages compared with term infants,36 delivery by 37 weeks gestation of pregnancies complicated by preterm PROM (< 37 weeks, PPROM) is universally recommended to reduce the maternal and neonatal morbidity associated with intrauterine infection.7 Optimal timing of delivery prior to 37 weeks in pregnancies complicated by PPROM is less clear812; there is evidence supporting expectant management for PPROM at less than 34 weeks,13,14 but there is no consensus on the optimal management of pregnancies with PPROM and no spontaneous labour by 34 to 36 weeks.8 Increasingly, evidence suggests that pregnancies complicated by PPROM that reach late preterm gestational ages may show improved outcomes with induction of labour, but these studies are limited by their design, small numbers of subjects, and the variable use of antepartum and intrapartum antibiotics and antenatal corticosteroids to accelerate fetal lung maturity.10,15,16 The current study was designed to assess maternal and neonatal outcomes in pregnancies complicated by PPROM that reached at least 34 weeks gestation and delivered before term to better inform obstetrical care providers of the management options for women who do not begin labour spontaneously at late preterm gestational ages.

METHODS

We derived patient data for this study from the Nova Scotia Atlee Perinatal Database, a population-based, clinically-oriented database containing information about demographics, procedures, interventions, morbidity, and mortality for all pregnancies and births occurring in Nova Scotia hospitals and to Nova Scotia residents since 1988. (Deliveries to Nova Scotia residents that occur outside the province are included, and deliveries to residents of other provinces that occur in Nova Scotia hospitals are excluded from provincial populationbased analyses.) Health records personnel collect pregnancy information from standardized patient care records, and the data are promptly entered into the database. Data checks and edits are routinely made at the time of data collection by qualified health records personnel, and validation and abstraction studies confirm the quality of the data in the database.17,18 All pregnancies from 1988 to 2006 were eligible for inclusion in the study. Pregnancies with PROM, defined by a positive test for ferning in vaginal fluid, were identified in the database. Gestational ages at the time of PROM and at delivery were determined based on clinical assessment and ultrasound data.
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The study cohort comprised singleton pregnancies with a cephalic presentation and PROM that resulted in late preterm delivery, occurring between 34 weeks and < 37 weeks. Pregnancies complicated by major congenital anomalies in the infant were excluded. Eligible pregnancies with PROM were divided into groups with spontaneous onset of labour and with obstetrically indicated delivery. Obstetrically indicated delivery was defined as delivery following the induction of labour (including cervical ripening, oxytocin administration before the onset of labour, and/or artificial amniotomy before the onset of labour) or delivery by Caesarean section without labour. Maternal and perinatal summary characteristics included maternal age, parity, pre-delivery weight, smoking at delivery, pregnancy complications such as gestational or pre-existing hypertension or diabetes, administration of antenatal corticosteroids to accelerate fetal lung maturity, antepartum administration of antibiotics, duration of membrane rupture, previous Caesarean section, method of delivery, gestational age at delivery, birth weight, and year of delivery. The primary outcomes of interest were composite maternal morbidity, composite fetal or neonatal mortality, and neonatal morbidity. Composite maternal morbidity included intrapartum complications (defined as umbilical cord prolapse, placental abruption, chorioamnionitis, intrapartum hemorrhage), postpartum hemorrhage, or postpartum infectious complications (defined as postpartum fever, wound infection, or endometritis). Composite fetal or neonatal mortality and neonatal morbidity included fetal or neonatal death, delay in initiating and maintaining respirations (defined as requiring resuscitation by mask or endotracheal tube for 3 minutes), depression at birth (defined as delay in initiating and maintaining sustained respirations, 5-minute Apgar score 3), or neonatal seizures due to hypoxicischemic encephalopathy (Sarnat Score > Stage 1),19 neonatal sepsis (i.e., neonatal pneumonia or positive blood cultures with identified organism), and outcomes associated with preterm birth (defined as moderate or severe respiratory distress syndrome, grade 3 or 4 intraventricular hemorrhage, acute necrotizing enterocolitis, hypoglycemia, polycythemia, or thrombocytopenia). Specific components of the composite outcomes and maternal postpartum length of stay, neonatal length of hospital stay, and days in the neonatal intensive care unit were also evaluated. To provide an understanding of the differences in outcomes after spontaneous onset of labour, induction of labour, and delivery by Caesarean section without labour at late preterm gestational ages, rates of maternal and neonataloutcomes associated with PPROM and late preterm delivery in women entering labour spontaneously at 34+0 to 36+6 weeks (Group 1) were first compared with those in women undergoing indicated delivery at 34+0 to 36+6 weeks (Group 2). To provide an understanding of differences in outcomes among only those pregnancies undergoing induction of labour or delivery by Caesarean section without labour at late preterm gestational

Late Preterm Delivery in Women With Preterm Prelabour Rupture of Membranes

Table 1. Summary characteristics of spontaneous labour (Group 1) and obstetrically indicated delivery (Group 2) with PPROM at 34+0 to 36+6 weeks gestation, 1988 to 2006
Characteristics Mean maternal age, years (SD) Nulliparous (%) Mean pre-delivery weight, kg (SD) Smoking at delivery (%) Gestational diabetes or hypertension (%) Pre-existing medical condition (%) Previous Caesarean section (%) Antenatal corticosteroids (%) Antepartum antibiotics (%) Median latency period, hr (25%, 75%) Caesarean section in current pregnancy (%) Mean gestational age at delivery, wks (SD) Mean birth weight, grams (SD) SD: standard deviation Spontaneous labour n = 1482 28.4 (5.5) 927 (62.6) 78.5 (16.0) 437 (30.9) 4 (0.3) 134 (9.0) 95 (6.4) 148 (10.0) 155 (10.5) 21 (12,46) 96 (6.5) 35.3 (0.8) 2645 (462) Indicated delivery n = 698 28.6 (5.1) 333 (47.7) 79.6 (17.8) 430 (35.1) 7 (1.0) 71 (10.2) 93 (13.3) 80 (11.5) 113 (16.2) 35 (22,64) 131 (18.8) 35.6 (0.7) 2753 (416) P 0.20 < 0.001 0.004 0.13 0.88 0.40 < 0.001 0.29 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001

ages, rates of maternal and neonatal outcomes associated with PPROM and late preterm delivery in women undergoing indicated delivery at 34+0 to 35+6 weeks (Group 2a) were also compared with those of women undergoing indicated delivery at 36+0 to 36+6 weeks (Group 2b). Statistical analysis was performed by two-tailed, unpaired Student t test, chi-square, and Fisher exact test, using an alpha level of 0.05. Variables were tested for normal distribution. Unadjusted odds ratios and 95% confidence intervals were initially calculated for each outcome, followed by multivariate logistic regression analysis performed in a backward, stepwise fashion (factor retained if it changed the point estimate of the variable representing duration of second stage by 5% or more) to generate adjusted odds ratios for all outcomes, accounting for potential confounding variables (maternal age, parity, smoking, duration of ruptured membranes, pre-existing and pregnancy related medical conditions, previous Caesarean section, use of antepartum antibiotics, use of antenatal corticosteroids, birth weight, gestational age, and year of delivery). Statistical analyses were performed using SAS for Windows version 9.1 (SAS Institute Inc., Cary NC) and EpiInfo (CDC, Atlanta GA). This study received ethics approval from the IWK Health Centre Research Ethics Board.
RESULTS

(32.0%) were obstetrically indicated, with 458 (65.6%) women delivering at 36 weeks gestational age (36+0 to 36+6 weeks). The majority of women (80%) underwent induction of labour for the indication of PPROM without chorioamnionitis; Caesarean section without labour was performed for the indications of previous Caesarean section (31%), failed induction of labour (20%), and non-reassuring fetal status (18%). Maternal and perinatal summary characteristics for women having spontaneous onset of labour and women who had an obstetrically indicated delivery are summarized in Table 1. Women in the obstetrically indicated delivery group (Group 2) were more likely than the spontaneous onset of labour group (Group 1) to have a higher pre-delivery weight (P = 0.004), to have had a previous Caesarean section (P < 0.001), to have a longer duration of ruptured membranes (P < 0.001), to have received antibiotics antepartum (P < 0.001), to deliver at a higher gestational age (P < 0.001), and to have babies with a higher birth weight (P < 0.001). Women in Group 2 were less likely to be nulliparous (P < 0.001). There was no difference in maternal age, rates of smoking at delivery, administration of antenatal corticosteroids, or the presence of pregnancy-related or pre-existing hypertension or diabetes between the two groups. Women undergoing obstetrically indicated delivery were more likely than the spontaneous onset of labour group to undergo Caesarean section in the current pregnancy (19% vs. 7%, P < 0.001). Most of the women in the indicated delivery group underwent Caesarean section because of previous Caesarean section (27%), non-reassuring fetal heart rate (21%), or dystocia (19%), while women entering labour spontaneously had Caesarean section for dystocia (30%),
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From a potential study population of 164 384 women from 1988 to 2006, 2618 women (1.6%) had PPROM and 2180 (83.3%) of these women delivered at late preterm gestational ages (from 34 weeks to < 37 weeks). Among these deliveries, 698

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Table 2. Maternal and perinatal outcomes associated with spontaneous labour (Group 1) and obstetrically indicated delivery (Group 2) with PPROM at 34+0 to 36+6 weeks gestation, 1988 to 2006
Outcome Composite maternal morbidity* Placental abruption Chorioamnionitis Postpartum hemorrhage Postpartum infection* Composite perinatal mortality/morbidity Neonatal sepsis|| Depression at birth# Complications of preterm birth** Respiratory distress syndrome Spontaneous labour n (%) 183 (12.3) 24 (1.6) 29 (2.0) 71 (4.8) 77 (5.2) 232 (15.6) 101 (6.8) 15 (1.0) 139 (9.4) 54 (3.6) Indicated delivery n (%) 81(11.6) 13 (1.9) 11 (1.6) 28 (4.0) 27 (3.9) 82 (11.8) 30 (4.3) 10 (1.4) 46 (6.6) 21 (3.0 Unadjusted OR (95% CI) 0.93 (0.70 to 1.23) 1.15 (0.58 to 2.28) 0.80 (0.40 to 1.62) 0.83 (0.53 to 1.30) 0.73 (0.47 to 1.15) 0.72 (0.55 to 0.94) 0.61 (0.40 to 0.93) 1.42 (0.63 to 3.18) 0.68 (0.48 to 0.96) 0.82 (0.49 to 1.36) Adjusted OR (95% CI) 0.95 (0.70 to 1.29) 1.65 (0.78 to 3.49) 0.65 (0.31 to 1.35) 0.90 (0.57 to 1.42) 0.75 (0.45 to 1.23) 0.87 (0.64 to 1.17) 0.68 (0.44 to 1.05) 2.09 (0.89 to 4.90) 0.77 (0.54 to 1.10) 1.02 (0.61 to 1.73)

*Adjusted for duration of membrane rupture, previous Caesarean section, year of delivery Adjusted for duration of membrane rupture, gestational age at delivery, year of delivery Adjusted for duration of membrane rupture, year of delivery Adjusted for nulliparity Adjusted for maternal age, duration of membrane rupture, previous Caesarean section, gestational age at delivery, year of delivery || Adjusted for year of delivery #Adjusted for pre-existing medical conditions, gestational age at delivery **Adjusted for previous Caesarean section, pre-existing medical conditions, gestational age at delivery Adjusted for gestational age at delivery

non-reassuring fetal heart rate (26%), and previous Caesarean section (15%). Components of the maternal morbidity and perinatal morbidity or mortality outcomes were rare (< 10%). Unadjusted analyses comparing women entering labour spontaneously (Group 1) and women undergoing obstetrically indicated delivery (Group 2) with PPROM delivering at late preterm gestational ages (Table 2) demonstrated a reduced risk for composite perinatal morbidity and mortality, neonatal sepsis, and complications of preterm birth in women with indicated delivery. Adjusted analyses controlling for relevant factors (Table 2) demonstrated no differences in maternal or perinatal outcomes. The numbers of pregnancies complicated by cord prolapse, intrapartum hemorrhage, perinatal mortality, and intraventricular hemorrhage were too small to analyze separately. Pre-delivery weight was not included in the regression analyses because the number of missing values was too large (> 10%). The median length of postpartum stay for mothers was three days for both groups (range 0 to 12 days and 0 to 16 days respectively for spontaneous labour and indicated delivery groups, P = 0.80), while the median neonatal length of stay was five days (range 0 to 103 days) and four days (range 0 to 30) respectively for the spontaneous labour and obstetrically indicated delivery groups (P < 0.001). Median length of stay in NICU was 10 days (range 0 to 279 days) for the spontaneous labour group and seven days (range 0 to 30) for the indicated delivery group (P < 0.001).
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Maternal and perinatal outcomes for those women who had obstetrically indicated delivery and delivered from 34+0 to 35+6 weeks (Group 2a, n = 240) were then compared with those who delivered from 36+0 to 36+6 weeks (Group 2b, n = 458). No differences in maternal age, parity, pre-delivery weight, smoking, pregnancy related conditions, or pre-existing medical conditions were observed between the two groups. Despite the fact that there was no difference in rates of previous Caesarean section (P = 0.6), more women underwent Caesarean section in the group delivering at 34+0 to 35+6 weeks (Group 2a) than at 36+0 to 36+6 weeks (Group 2b) (22.9% vs. 16.6%, P = 0.04). Unadjusted analyses showed decreased risks for composite perinatal morbidity/ mortality, depression at birth, overall complications of preterm birth, and respiratory distress syndrome in particular (Table 3) for women who delivered at 36+0 to 36+6 weeks gestation compared to women who delivered at 34+0 to 35+6 weeks. These differences remained significant after adjusting for relevant factors (Table 3). In addition, the maternal risk of chorioamnionitis was significantly decreased when adjusted for year of delivery (OR 0.27; 95% CI 0.80 to 0.93). Pre- delivery weight and smoking were not included in the regression analyses due to the large number of missing values (> 10%). The median length of postpartum hospital stay for mothers was four days (range 0 to 13) in women delivering at 34+0 to 35+6 weeks and three days (range 0 to 16) in women delivering at 36+0 to 36+6 weeks (P < 0.001), while the median neonatal length of stay was six days

Late Preterm Delivery in Women With Preterm Prelabour Rupture of Membranes

Table 3. Maternal and perinatal outcomes associated with obstetrically indicated delivery with PPROM at 34+0 to 35+6 weeks gestation (Group 2a) and obstetrically indicated delivery with PPROM at 36+0 to 36+6 weeks gestation (Group 2b), 1988 to 2006
Characteristics Composite maternal morbidity* Placental abruption Chorioamnionitis* Postpartum hemorrhage Postpartum infection Composite perinatal mortality/morbidity Neonatal sepsis Depression at birth Complications of preterm birth|| Respiratory distress syndrome#
*Adjusted for year of delivery No confounding variables retained in the final model Adjusted for nulliparity Adjusted for previous Caesarean section, year of delivery Adjusted for pre-existing medical conditions || Adjusted for antenatal corticosteroid administration, antepartum antibiotic use, previous Caesarean section #Adjusted for antepartum antibiotic use

34+0 to 35+6 weeks n (%) 32 (13.3) 6 (2.5) 7 (2.9) 12 (5.0) 9 (3.8) 45 (18.8) 15 (6.3) 7 (2.9) 28 (11.7) 16 (6.7)

36+0 to 36+6 weeks n (%) 49 (10.7) 7 (1.5) 4 (0.9) 16 (3.5) 18 (3.9) 37 (8.1) 15 (3.3) 3 (0.7) 18 (3.9) 5 (1.1)

Unadjusted OR (95% CI) 0.78 (0.47 to 1.29) 0.61 (0.20 to 1.82) 0.29 (0.07 to 1.13) 0.69 (0.30 to 1.58) 1.05 (0.44 to 2.57) 0.38 (0.23 to 0.62) 0.51 (0.24 to 1.06) 0.22 (0.06 to 0.86) 0.31 (0.16 to 0.60) 0.15 (0.05 to 0.46)

Adjusted OR (95% CI) 0.81 (0.49 to 1.32) 0.61 (0.20 to 1.82) 0.27 (0.08 to 0.93) 0.70 (0.32 to 1.51) 1.13 (0.47 to 2.70) 0.39 (0.24 to 0.62) 0.51 (0.24 to 1.06) 0.22 (0.06 to 0.86) 0.36 (0.19 to 0.68) 0.17 (0.06 to 0.47)

(range 030) and four days (range 024), respectively (P < 0.001). Median length of stay in NICU was nine days (range 0 to 30) and four days (range 0 to 24) respectively for delivery at 34+0 to 35+6 weeks and 36+0 to 36+6 weeks (P < 0.001).
DISCUSSION

preterm gestational ages.1012 The current study evaluated pregnancies complicated by PPROM occurring at 34 to 36 weeks to further evaluate maternal and perinatal outcomes at these gestational ages. The majority of adverse outcomes evaluated in the current study were rare (< 10%), with rates comparable to or lower than previously reported rates associated with PPROM and late preterm birth.10,13,15,20 Interestingly, while no significant differences were demonstrated in women delivering from 34+0 to 36+6 weeks with spontaneous onset of labour or obstetrically indicated delivery, both maternal and perinatal differences were observed when only obstetrically indicated deliveries were evaluated, with adjusted analyses showing improved outcomes in women who delivered at 36+0 to 36+6 weeks, especially for chorioamnionitis, depression at birth, and complications of preterm birth. Conservative management at 34 to 36 weeks has previously been shown to increase the risk of chorioamnionitis and maternal hospital stay, with no significant reduction in neonatal morbidity.15,23 Differences seen in the current study may be explained by the general policy at the time of the study in our tertiary centre (which provides care for approximately one half of the deliveries in Nova Scotia) of expectant management of PPROM in the absence of labour, clinical evidence of intrauterine infection, or non-reassuring fetal status, followed by induction of labour or Caesarean section without labour at 36 weeks (or sooner with documented fetal lung maturity). However, regional centres in Nova Scotia accepting the return from the tertiary centre of high risk patients between
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Preterm prelabour rupture of membranes accounts for approximately one third of preterm births20 and is associated with challenging management decisions regarding timing of delivery at late preterm gestational ages. It is a clinical management issue eliciting a wide variety of responses across Canada.8 While early, late, and postneonatal mortality and neonatal morbidity among unselected infants is known to be lower at term than at late preterm gestational age,3,4,6 the primary motivation for considering obstetrically indicated delivery earlier than term in the presence of PPROM is based on balancing the risks associated with preterm birth with the risks of maternal, fetal, and neonatal infectious morbidity. At term ( 37 weeks), there is evidence supporting the induction of labour to reduce the time interval between PROM and delivery to decrease the risk for maternal infections.1,2 Expectant management and antibiotic administration in women with PPROM at less than 34 weeks gestation may prolong pregnancy and reduce the risks associated with later preterm birth, without the consequent maternal and neonatal morbidity.13,15,21 While some reviews advocate planned delivery following PROM when gestational age reaches 34 weeks,7,14,15,20,22 others document uncertainty in the benefits of indicated delivery for late

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32 and 36 weeks, including those with PROM, did not necessarily follow this policy. The current observational study provides information relevant to management options for obstetrically indicated delivery when pregnancies complicated by PPROM reach late preterm gestational ages, but it was limited by a non-randomized study design. The year of delivery was included in the regression analyses to accommodate changes in the clinical management of PPROM. During the study period, the majority of women would have received intrapartum antibiotics for GBS prophylaxis. Amniocentesis would not routinely have been performed for documentation of fetal lung maturity. Vaginal fluid for analyses of fetal lung maturity would have been variably collected after 34 weeks gestation, but this information was not available in the database. The current study incorporated large numbers of patients over a long period of observation to examine maternal, fetal, and neonatal outcomes associated with late preterm birth in pregnancies complicated by PPROM. The findings are applicable to other homogeneous populations with similar health services, especially those with a similar proportion of their population delivering preterm and those with similar rates of adverse maternal and perinatal outcomes with late preterm delivery following PPROM. This retrospective evaluation was limited to the data collected in the database, and thus there may be information on factors relevant to the groups in this study (such as Bishops score, body mass index, Caesarean section by maternal request, and elective induction of labour) that we were unable to include in the comparisons. However, through data re-abstraction (with a high level of agreement for most routine variables) and validation studies, the data in the Nova Scotia Atlee Perinatal Database have been shown to contain reliable information.17,18
CONCLUSION

REFERENCES
1. Hannah ME, Ohlsson A, Farine D, Hewson SA, Hodnett ED, Myhr TL, et al. Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group. N Engl J Med 1996;334:100510. 2. Dare MR, Middleton P, Crowther CA, Flenady VJ, Varatharaju B. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev 2006;CD005302. 3. McIntire DD, Leveno KJ. Neonatal mortality and morbidity rates in late preterm births compared with births at term. Obstet Gynecol 2008;111:3541. 4. Yoder BA, Gordon MC, Barth WH. Late preterm birth: does the changing obstetric paradigm alter the epidemiology of respiratory complications? Obstet Gynecol 2008;111:81422. 5. Stewart DL, Romero JR, Buysman EK, Fernandes AW, Mahdevia PJ. Total healthcare costs in the US of preterm infants with respiratory syncytial virus lower respiratory infection in the first year of life requiring medical attention. Curr Med Res Opin 2009;25:2795804. 6. Tomashek KM, Shapiro-Mendoza CK, Davidoff MJ, Petrini JR. Differences in mortality between late-preterm and term singleton infants in the United States, 19952002. J Pediatr 2007 Nov;151:4506. 7. ACOG Committee on Practice BulletinsObstetrics. ACOG practice bulletin no. 80: premature rupture of membranes. Obstet Gynecol 2007;109:100718. 8. Smith G, Rafuse C, Anand N, Brennan B, Connors G, Crane J, et al. Prevalence, management, and outcomes of preterm prelabour rupture of the membranes of women in Canada. J Obstet Gynaecol Can 2005;27:54753. 9. Engle WA. A recommendation for the definition of late preterm (near-term) and the birth weight-gestational age classification system. Semin Perinatol 2006;30:27. 10. Morris JM, Roberts CL, Crowther CA, Buchanan SL, Henderson-Smart DJ, Salkeld G. Protocol for the immediate delivery versus expectant care of women with preterm prelabour rupture of the membranes close to term (PPROMT) Trial [ISRCTN44485060]. BMC Pregnancy Childbirth 2006;6:9. 11. van der Ham DP, Nijhuis JG, Mol BWJ, van Beek JJ, Opmeer BC, Bijlenga D, et al. Induction of labour versus expectant management in women with preterm prelabour rupture of membranes between 34 and 37 weeks (the PPROMEXIL-trial). BMC Pregnancy Childbirth 2007;7:11. 12. Wood, S. Safety and efficacy study of intentional delivery in women with preterm and prelabour rupture of the membranes. Available at: http://clinicaltrials.gov/ct2/show/NCT00259519. Accessed September 1, 2009. 13. Lieman JM, Brumfield CG, Carlo W, Ramsey PS. Preterm premature rupture of membranes: is there an optimal gestational age for delivery? Obstet Gynecol 2005;105:127. 14. Cox SM, Leveno KJ. Intentional delivery versus expectant management with preterm ruptured membranes at 3034 weeks gestation. Obstet Gynecol 1995;86:8759. 15. Naef RW, Allbert JR, Ross EL, Weber BM, Martin RW, Morrison JC. Premature rupture of membranes at 34 to 37 weeks gestation: aggressive versus conservative management. Am J Obstet Gynecol 1998;178:12630. 16. Neerhof MG, Cravello C, Haney EI, Silver RK. Timing of labor induction after premature rupture of membranes between 32 and 36 weeks gestation. Am J Obstet Gynecol 1999;180:34952. 17. Fair M, Cyr M, Allen AC, Wen SW, Guyon G, MacDonald RC. An assessment of the validity of a computer system probabilistic record linkage of birth and infant death records in Canada. Chronic Dis Can 2000;21:813. 18. Joseph KS, Fahey J. Validation of perinatal data in the Discharge Abstract Database of the Canadian Institute for Health Information. Chronic Dis Can 2009;29:96100. 19. Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study. Arch Neuro 1976;33:696705. 20. Mercer BM. Preterm premature rupture of the membranes: current approaches to evaluation and management. Obstet Gynecol Clin N Am 2005;32:41128. 21. Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of the membranes: a systematic review. Obstet Gynecol 2004;104:10517. 22. Pasquier J-C, Picaud J-C, Rabilloud M, Claris O, Ecochard R, Moret S, et al. Neonatal outcomes after elective delivery management of preterm premature rupture of the membranes before 34 weeks gestation (DOMINOS Study). Eur J Obstet Gynecol Reprod Biol 2009;143:1823. 23. Hartling L, Chari R, Friesen C, Vandermeer B, Lacaze-Masmonteil T. A systematic review of intentional delivery in women with preterm prelabor rupture of membranes. J Matern Fetal Med 2006;19:17787.

Preterm prelabour rupture of membranes with delivery at < 37 weeks gestational age may be associated with significant maternal and perinatal risks. In our population, rates of adverse maternal and perinatal outcomes were rare. This large population-based study suggests that rates of adverse maternal and perinatal outcomes at 36 weeks gestational age in pregnancies complicated by PPROM are at least comparable to those estimated in pregnancies delivering at 34 to 35 weeks, and may be reduced further by delivery after 36 completed weeks if spontaneous labour has not occurred.
ACKNOWLEDGEMENTS

We acknowledge the Reproductive Care Program of Nova Scotia for providing access to the data. Dr Victoria M. Allen is supported by a New Investigator Award of the Canadian Institutes of Health Research.

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