(447) Timing of delivery of preterm membrane rupture at 34 weeks and beyond: A cost-effectiveness analysis

To examine outcomes and the cost-effectiveness of immediate delivery at 34 weeks’ gestation versus expectant management to 35, 36, and 37 weeks in the setting of preterm premature rupture of membranes (PPROM).

Study Design:

A decision-analytic model was built using TreeAge software to compare outcomes of immediate delivery versus expectant management to 35, 36, and 37 weeks in a theoretical cohort of 35,913 pregnant people with PPROM at 34 weeks. Clinical outcomes included stillbirth, neonatal death, neurodevelopmental disorder, maternal mortality, healthy neonate, maternal sepsis leading to ICU admission, neonatal sepsis, NICU admission, costs and quality adjusted life years (QALYs). Probabilities, costs, and utilities were derived from literature.

Results:

In our cohort, expectant management resulted in fewer neonatal deaths, neurodevelopmental disorders, and NICU admissions, in addition to increasing the number of healthy neonates delivered across all expectant management weeks (Table 1). Conversely, expectant management was found to increase the number of cases of stillbirth, maternal mortality, maternal sepsis, and neonatal sepsis. Each increasing week of expectant management yielded additional QALYs but was associated with increased costs. In this comparison, the optimal outcome and most cost-effective was expectant management to 37 weeks. One-way sensitivity analysis for the cost of antepartum care revealed that when the cost of antepartum admission exceeded $54,267 then management up to 36 weeks became cost-effective as compared to waiting until 37 weeks. One-way sensitivity analysis for the cost of NICU stay demonstrated that at 16 times the NICU cost, expectant management to 36 weeks becomes dominated by 37 weeks.

Conclusion:

Management of PPROM at 34-36 weeks’ gestation remains controversial, with guidelines incorporating both immediate delivery and expectant management. The current model suggests that ongoing expectant management to 37 weeks may improve outcomes and be a cost-effective strategy.