TERM PRELABOUR RUPTURE OF MEMBRANES (TERMPROM)
Jan 03, 2016
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?