Reply to “Management of prelabour rupture of membranes (PROM) at term”

Amos Grunebaum

doi:10.1515/jpm-2013-0127

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Reply to “Management of prelabour rupture of membranes (PROM) at term”

Amos Grunebaum

Veröffentlicht/Copyright: 4. Juli 2013

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Aus der Zeitschrift Journal of Perinatal Medicine Band 41 Heft 6

Term prelabour rupture of fetal membranes (PROM), also known as term premature rupture of membranes, is defined as the rupture of fetal membranes prior to labour beyond 37 weeks of gestation and happens in about 8% of pregnancies [1]. Term PROM is associated with an increased risk of infections, such as chorioamnionitis and neonatal sepsis, a risk that increases with the length of time between PROM and delivery [5, 6].

The two options of managing term PROM commonly include expectant management and awaiting spontaneous labour versus active management and delivery with induction inducing agents, such as oxytocin or other agents.

In the UK, the National Institute for Health and Care Excellence (NICE) guidelines of term PROM recommend expectant management for 24 h [4], while in the USA, the American College of Obstetricians and Gynecologists (ACOG) advises active management of term PROM to reduce the risk of infectious complications [1].

Ismail and Tahiri [3] believe that “… detection of developing infections could be enhanced by using a combination of investigations (at presentation, 12 and 24 h) as well as current advice to self-monitor temperature and vaginal loss.” However, by the time clinical infection has been detected, the chances are that subclinical infection has been ongoing for some time and there will be a likelihood of a delay in treatment and delivery. There is no evidence that this approach of expectant management and self-monitoring of temperature is safe.

The TERMPROM study by Hannah et al. in 1996 compared expectant management with induction of labour with oxytocin or prostaglandin in 5042 women with term PROM and was the largest prospective randomised study done on term PROM [2]. They showed a similar rate of caesarean deliveries but a significantly increased risk of clinical chorioamnionitis, antibiotic use, longer maternal hospital stay, and postpartum fever in women with expectant management when compared to those with labour induction. They concluded that there was a lower risk of maternal infection with oxytocin induction, and that women view induction of labour more positively than expectant management.

In the technical bulletin on term PROM, ACOG recommended that: “… for women with PROM at term, labour should be induced at the time of presentation, generally with oxytocin infusion, to reduce the risk of chorioamnionitis” (level A recommendation), and “… delivery is recommended when PROM occurs at or beyond 34 weeks of gestation” (level B recommendation). These recommendations are based on the fact that there are presently not enough data supporting the safety of expectant management of term PROM, and that in the absence of a safe expectant management, delivery is in the best interest of mother and newborn.

In conclusion, expectant management of term prelabour PROM delays delivery without evidence that it is safe, and if the patient is admitted to hospital, expectant management unnecessarily increases length of stay.

The right answer to the management of term PROM is not to wait for any signs of infection but instead to recommend to women with term prelabour PROM to proceed with delivery and to actively induce labour in the absence of a contraindication to vaginal delivery. PROM should not be managed at home because of the increased risk of cord prolapse and intrauterine cord compression from oligohydramnios. Neither self-monitoring of temperature or vaginal loss (whatever that means) have been found to be effective or safe in term PROM.

Hannah et al. have shown conclusively that delays in term PROM increases the risk for infections, such as chorioamnionitis, neonatal infection, admission to the neonatal intensive care unit, and that women view active management more positively than expectant management [2]. Therefore, the best and safest approach to term prelabour PROM is to recommend active management and expeditious delivery.

Corresponding author: Amos Grunebaum, Department of Obstetrics, New York Weill Medical College of Cornell University, 525 East 68th Street, Suite J-130, New York 10065, USA, E-mail: amosgrune@yahoo.com

References

[1] ACOG Practice Bulletin. Premature rupture of membranes. Number 80; 2007.Suche in Google Scholar

[2] Hannah ME, Ohlsson A, Farine D, Hewson SA, Hodnett ED, Myhr TL, et al. Induction of labor compared with expectant management for prelabor rupture of the membranes at term. N Engl J Med. 1996;334:1005–10.10.1056/NEJM199604183341601Suche in Google Scholar

[3] Ismail AQT, Lahiri S. Management of prelabour rupture of membranes (PROM) at term. J Perinat Med. 2013;41:647–9.Suche in Google Scholar

[4] NICE. Intrapartum care. Secondary intrapartum care 2009. http://www.nice.org.uk/nicemedia/live/11837/36275/36275.pdf. Accessed XX Month, 20XX.Suche in Google Scholar

[5] Novak-Antolic Z, Pajntar M, Verdenik I. Rupture of the membranes and postpartum infection. Eur J Obstet Gynecol Reprod Biol. 1997;71:141–6.10.1016/S0301-2115(96)02624-3Suche in Google Scholar

[6] Wagner MV, Chin VP, Peters CJ, Drexler B, Newman LA. A comparison of early and delayed induction of labor with spontaneous rupture of membranes at term. Obstet Gynecol. 1989;74:93–7.Suche in Google Scholar

The author stated that there are no conflicts of interest regarding the publication of this article.

Received: 2013-6-5

Accepted: 2013-6-5

Published Online: 2013-07-04

Published in Print: 2013-11-01

Artikel in diesem Heft

https://doi.org/10.1515/jpm-2013-0127