Term PreLabour Rupture of Membranes (TermPROM) for undergraduates Max Brinsmead MB BS PhD May 2015

Definition, Incidence & Natural History Rupture of membranes after 37 completed weeks of gestation and before the onset of labour Occurs in 8% of pregnancies In the absence of any intervention... 70% of patients will labour within 24 hours 85% will labour within 48 hours 95% will labour within 96 hours

TermPROM –The Dilemma Historically a risk of ascending infection and chorioamnionitis So induction of labour by Syntocinon infusion became the management of choice But some ended in failed induction, especially in nullipara with an unripe cervix So two questions arose: Is it safe to wait for spontaneous ripening? Or can vaginal Prostaglandins be used? These questions answered by the TermPROM trial

The TermPROM Study A multicentre RCT of 5041 women with TermPROM randomly assigned to: Immediate oxytocin infusion Immediate vaginal prostaglandin E2 gel Observation for up to 4 days Primary outcome was the rate of neonatal infection Secondary outcomes included measures of maternal infection, Caesarean section and satisfaction with care Subgroup analysis compared care in hospital with at home and those with Gp B Streptococcus colonization

TermPROM Study Results More women satisfied with active management Higher rates of infection with vaginal prostaglandins but it did not reach statistical significance. In pooled results with other studies this does reach statistical significance A trend towards higher risk of infection with home vs hospital care (RR for nullips requiring antibiotics 1.52 CI 1.04 – 2.24) An association with Gp B Strep colonization and infection Early oxytocin infusion is the most cost effective management

TermPROM Study Outcome Different outcomes for different stakeholders Some saw it as a vindication for conservative management because the primary outcomes were not statistically different in the 3 main study groups Others saw it as the opportunity to use Prostaglandins Certainly it introduced an element of informed patient CHOICE Most saw the trial as vindication for the long-established plan of management i.e. Wait up to 24 hours to see if labour begins Commence Syntocinon at a time that is convenient to all

Some Practical Points The diagnosis is best made by history, speculum examination and, for a few patients: Observation over time Tests for AF e.g. pH strips/sticks or Amnisure (expensive) There is no role for ultrasound If, at the end of the day, you can’t decide if the forewaters are ruptured they probably haven’t Digital examination is to be avoided if you plan to offer a conservative approach Always check during Syntocinon infusion to confirm ruptured forewaters

Detection of Chorioamnionitis Requires a high index of suspicion and concern about... Any low grade fever Fetal (or maternal) tachycardia Discolouration of the liquor Uterine tenderness Decreased fetal movements Be aware that studies suggest that labour in the presence of chorioamnionitis can be DYSFUNCTIONAL And with reduced sensitivity to Syntocinon

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