Previable PROM in twins: A systematic review and meta-analysis
Marwan Odeh1,2, Maya Frank Wolf1,2, Forsan Kenaan3
1Raya Strauss Wing of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.
Background:
Previable prelabor rupture of membranes (PROM) in twin pregnancies is a rare but high-risk condition associated with substantial neonatal mortality and maternal morbidity. Management options include expectant management and selective reduction, though guidance is limited and based primarily on singleton data. Emerging reports suggest selective reduction may improve outcomes for the unaffected co-twin by prolonging latency and reducing maternal complications.
Objectives:
To evaluate maternal, obstetric, and neonatal outcomes in twin pregnancies complicated by previable PROM before 24 weeks of gestation, and to compare outcomes following expectant management and selective reduction.
Search Strategy:
A comprehensive literature search was conducted in Medline, Embase, and Web of Science for studies published between January 1990 and September 2024.
Selection Criteria:
Eligible studies included case reports, case series, and cohort studies, reporting outcomes of twin pregnancies with previable prelabor rupture of membranes (PPROM) managed either expectantly or by selective reduction of the affected twin.
Data Collection And Analysis:
Data on maternal, obstetric, and neonatal outcomes were extracted and pooled for analysis. Subgroup analyses were performed based on management strategy: selective reduction versus expectant management.
Main Results:
A total of 45 studies were included, comprising 286 twin pregnancies with previable PROM. Selective reduction was performed in 16.4% (n = 47) of the pregnancies. Across the entire cohort, no infant was discharged home alive in 32.0% of the pregnancies, one infant in 51.6%, and two infants in only 16.4%. Clinical chorioamnionitis occurred in 33.5%, maternal sepsis in 7.8%, septic shock in 1.6%, and hysterectomy in 0.8%. Compared to expectant management, selective reduction was associated with longer latency (15.0 ± 8.4 vs. 8.3 ± 5.7 weeks), higher gestational age at delivery (31.6 ± 7.7 vs. 24.4 ± 4.4 weeks), and higher birth weight (2663.6 ± 703.9 vs. 1251.3 ± 773.0 g) of the co-twin, all P < 0.001. Following selective reduction compared to expectant management, the discharge home of one live infant was more common (66.0% vs. 33.8%, P < 0.001), yet the discharge of two infants was not possible (0.0% vs. 25.7%, P < 0.001). Following selective reduction, clinical chorioamnionitis and neonatal death were lower (19.1% vs. 40.3%, P = 0.008 and 3.6% vs. 17.1%, P = 0.033, respectively).
Conclusions:
Twin pregnancies with PPROM are associated with high maternal and neonatal risks. Selective reduction may improve outcomes for the unaffected twin and reduce maternal morbidity. These findings underscore the need for individualized, multidisciplinary counseling and highlight the critical gaps in evidence guiding management in this rare clinical scenario.
