Max Brinsmead MB BS PhD May 2015 T ERM P RE L ABOUR R UPTURE OF M EMBRANES (T ERM PROM)

R ESOURCES  NICE Guidelines “Intrapartum Care” September 2007  RANZCOG Statement July 2010  Cochrane Database “Planned early birth versus expectant management for prelabour rupture of membranes at term” January 2006

D EFINITION, I NCIDENCE & N ATURAL H ISTORY  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

T ERM PROM –T HE D ILEMMA  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

T HE T ERM PROM S TUDY  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

T ERM PROM S TUDY R ESULTS

 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

T ERM PROM S TUDY O UTCOME  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

C OCHRANE R EVIEW  12 trials of 6814 women in 12 studies found that active vs expectant management resulted in...  No significant difference in the rate of Caesarean birth (RR=0.94, CI )  Reduced risk of clinical chorioamnionitis (RR=0.74, CI )  Reduced risk of endometritis (RR=0.30, CI )  No significant difference in the risk of neonatal infection (RR=0.83, CI ) but...  Fewer infants requiring intensive/special care (RR=0.72. CI )

NICE G UIDELINES

RANZCOG G UIDELINES  Much more interventionist/proactive  Conservative management is only sanctioned for:  Those with a stable cephalic presentation  GBS negative  No digital VE or cervical suture  No signs of chorioamnionitis  Commitment to 4 th hourly monitoring for signs of infection in hospital  A very low threshold for antibiotic use (18 hours)  Vaginal prostaglandins are better avoided

S OME P RACTICAL P OINTS  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

D ETECTION OF C HORIOAMNIONITIS  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

I N C ONCLUSION  Management of TermPROM depends on the context within which you are working  When there is poor maternal and fetal monitoring and high risk of chorioamnionitis then active management (early induction of labour) is appropriate  With informed patient consent...  And on a background of very low tolerance for any delay in response to induction of labour...  Conservative management, particularly for a nulliparous with an unfavourable cervix, is attractive  Oral Misoprotol is a very good alternative

A NY Q UESTIONS OR C OMMENTS ? Please leave a note on the Welcome Page to this website