TERM PRELABOUR RUPTURE OF MEMBRANES (TERMPROM)

RESOURCES

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

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

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

COCHRANE REVIEW 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 0.82 -1.08)

Reduced risk of clinical chorioamnionitis (RR=0.74, CI 0.56 -0.97)

Reduced risk of endometritis (RR=0.30, CI 0.12-0.74)

No significant difference in the risk of neonatal infection (RR=0.83, CI 0.61-0.12) but...

Fewer infants requiring intensive/special care (RR=0.72. CI 0.57-0.92)

NICE GUIDELINES

RANZCOG GUIDELINES

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 4th hourly monitoring for signs of infection in hospital

A very low threshold for antibiotic use (18 hours)

Vaginal prostaglandins are better avoided

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

IN CONCLUSION 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

ANY QUESTIONS OR COMMENTS?