Term PROM

Question 1

Define PROM at term.

Answer 1

Confirmed rupture of membranes prior to the onset of labour, at ≥37 weeks gestation

Question 2

What is the incidence of PROM.

Answer 2

8%

Question 3

What is the management of term PROM?

Answer 3

• Clinical Hx /exam / obs / bloods - check for signs of chorioamnionitis
• CTG
• Confirm gestation
• Confirm presentation
• Vaginal swab for GBS carriage
• Induction WITHIN 24 hours with syntocin (consider PGE if unfavourable)
• Continuous CTG in labour
• No need for routine antibiotics, if PROM <24hours
• If GBS - needs immediate IOL and GBS antibiotic prophylaxis
• If meconium / suspected chorioamnionitis for immediate IOL

Question 4

What is the evidence for expectant versus early (<24hours) induction?

Answer 4

Cochrane 2017

Planned early induction <24 hours is associated with:

• reduction in maternal chorioamnionitis and endometritis (roughly 50%; RR 0.49); Absolute risk: 11–>6%
• Reduction in suspected and confirmed neonatal sepsis (roughly 25%, RR 0.73)
• Reduced neonatal antibiotic use, admission to SCBU/NICU, hospital stay
• No increase in caesarean section
• Improved maternal satisfaction

Question 5

Compare Amnisure and Actim PROM for PROM detection.

Answer 5

• Amnisure 100% sensitive and specific
• Actim PROM marginally less
• Both POC tests, with quick results (<10mins)
• Both are not affected by semen and trace blood
• Can have false positives 15-30% in threatened preterm labour

Question 6

Compare Amnisure and Actim PROM for PROM detection.

Answer 6

• Amnisure 100% sensitive and specific in RCT
• Actim PROM marginally less
• Both POC tests, with quick results (<10mins)
• Can have false positives 15-30% in threatened preterm labour
• false-positive test results may occur in the presence of blood or semen, alkaline antiseptics, certain lubricants, trichomonas, or bacterial vaginosis.

Question 7

What are the early and late risks of PROM?

Answer 7

early

• Cord prolapse
• Cord compression
• abruption

Late

• Neonatal infection –> chronic lung disease, cerebral palsy, death
• Chorioamnionitis and/or maternal sepsis

Question 8

What are the early and late risks of PROM?

Answer 8

early

• Cord prolapse
• Cord compression
• abruption

Late

• Neonatal infection –> chronic lung disease, cerebral palsy, death
• Chorioamnionitis and/or maternal sepsis

Question 9

Is there any evidence to guide induction method?

Answer 9

Cochrane 2017

• Subgroup analyses
• Syntocin and SL misoprostol were associated with lower rates of infection
• Lower rates of caesarean section using SL misoprostol

Question 10

What are risks/causes for PROM?

Answer 10

• Over distension of the uterus (e.g. polyhydramnios, multiple pregnancy)
• Disruption in membranes function
• Infection
• Smoking
• Frequent digital examinations
• Coitus

Question 11

TERMPROM trial findings.

Answer 11

Multicentre randomised control trial (1996)
Rationale: >60% women labour within 24hours, 95% women labour within 72 hours, IOL assumed to lead to increased CS rate

Inclusion: Prelabour rupture of membranes, >37wks, cephalic, no contraindication to vaginal birth
Randomised to:
IOL oxytocin vs expectant, then IOL after 4 days
IOL PGE vs expectant, then IOL PGE after 4 days

1st outcome: neonatal infection
2nd outcome: CS delivery

• IOL group had significant reduction in:
  clinical chorioamnionitis, need for ABx in labour, or postpartum fever >38
• No significant effect on neonatal infection
• no significant difference on CS rate
• IOL with oxytocin had fewer VE, went into active labour sooner, had shorter labours and shorter time from PROM to delivery than in the PGE or expectant management groups

Question 12

Women declining induction, what criteria are required for conservative management?

Answer 12

• Fixed cephalic presentation.
• Negative Group B streptococcus (GBS) status and no prior history of a baby with EOGBS infection.
• No signs of infection (maternal tachycardia, fever, uterine tenderness).
• Normal CTG and fetal movements.
• Clear amniotic fluid
• Adequate resource/staffing to provide support as an outpatient or inpatient.
• Commitment to regular assessment of maternal temperature, vaginal loss and fetal movements. (4-
hourly temperature check during waking hours is recommended).
• Access to reliable transport.
• Clearly documented plan for review

Question 13

What percentage of women will labour at 24hrs? 48hrs? 96 hrs?

Answer 13

24 = 70%
48 = 85%
96 = 95%