Term PreLabour Rupture of Membranes ( TermPROM )

1. Term PreLabour Rupture of Membranes (TermPROM) Max Brinsmead PhD FRANZCOG September 2012

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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