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Management of premature rupture of the fetal membranes at term

Official reprint from UpToDate www.uptodate.com 2013 UpToDate

Management of premature rupture of the fetal membranes at term Author William E Scorza, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jul 2013. | This topic last updated: Aug 1, 2013. INTRODUCTION Premature rupture of the membranes (PROM) refers to rupture of the fetal membranes prior to the onset of regular uterine contractions. It may occur at term (37 weeks of gestation) or preterm (<37 weeks of gestation); the latter is designated preterm PROM (PPROM). Midtrimester PROM typically refers to PPROM at 16 to 26 weeks of gestation; this is an arbitrary definition, which varies slightly among investigators. The frequencies of term, preterm, and midtrimester PROM are approximately 8, 3, and less than 1 percent of pregnancies, respectively. Management of PROM depends upon several factors, most importantly the gestational age at occurrence and the maternal-fetal clinical condition. The management of PROM at term will be reviewed here. Issues regarding midtrimester PROM and management of PPROM are discussed separately. (See "Midtrimester preterm premature rupture of membranes" and "Preterm premature rupture of membranes".) INITIAL EVALUATION Women with term premature rupture of the membranes (PROM) should be evaluated by a clinician. Whether the patient should be evaluated immediately or can remain at home for a few hours to see if labor begins has not been studied. In the absence of high quality data supporting the safety of delaying evaluation, we feel the most prudent approach is prompt assessment to confirm membrane rupture, exclude the presence of infection or a nonreassuring fetal heart rate pattern, determine fetal position, evaluate maternal and fetal well-being, and discuss options for further management. The diagnosis of PROM is based upon a characteristic history (ie, leaking fluid per vagina) and speculum examination (ie, visualization of fluid flowing from the cervical os), supplemented by diagnostic testing of fluid in the posterior fornix, if the diagnosis is uncertain. The clinical manifestations and diagnosis of PROM are the same across gestation and are discussed in detail separately. Digital cervicovaginal examination should be avoided, as it has been associated with an increased risk of intrauterine infection. (See "Preterm premature rupture of membranes", section on 'Diagnosis'.) Gestational age is determined according to the usual parameters (last menstrual period and/or ultrasound biometry). (See "Prenatal assessment of gestational age".) Fetal well-being is evaluated with a nonstress test, with or without a biophysical profile. (See "Overview of fetal assessment".) Fetal position is determined by transabdominal physical examination (Leopolds maneuvers) and ultrasound examination, as needed. Maternal evaluation includes assessment for labor, infection (eg, fever, tachycardia, uterine tenderness), and medical and obstetrical complications. Laboratory studies are the same as those for women admitted with spontaneous labor. (See "Management of normal labor and delivery", section on 'Evaluation'.) ACTIVE OR EXPECTANT MANAGEMENT? The key decision in management of uncomplicated term premature rupture of the membranes (PROM) is whether to initiate delivery or take an expectant approach. We
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Section Editor Charles J Lockwood, MD

Deputy Editor Vanessa A Barss, MD

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Management of premature rupture of the fetal membranes at term

suggest prompt delivery for women with term PROM. Labor is induced, unless there are contraindications to labor or vaginal delivery, in which case cesarean delivery is performed. Our approach is based on the increased risk of infection with expectant management, as well as a general preference for expedited delivery among outpatients. Other factors to consider are the risks of cord prolapse, cord compression, or abruption with expectant management, as well as the cost and length of hospitalization while waiting for labor to begin [1]. Women who choose induction need to be aware of the possibility of long labor, failure to progress, and cesarean delivery. For a patient who declines induction, we work with her to set a time limit for expectant management if she does not go into labor. Development of infection or other complications would be an indication for delivery by the most appropriate method for the clinical situation. A 2006 systematic review of 12 randomized/quasi-randomized trials of women with PROM at 37 weeks of gestation compared pregnancy outcome of planned intervention versus expectant management and provides support for our approach [2]. Compared with expectant management, planned intervention resulted in: Fewer maternal infections (chorioamnionitis: 6.8 versus 9.8 percent, RR 0.74, 95% CI 0.56-0.97, endometritis 2.3 versus 8.3 percent, RR 0.30, 95% CI 0.12-0.74). For every 50 women who undergo intervention, 1 case of chorioamnionitis would be avoided. Fewer neonatal intensive care unit admissions (12.6 versus 17.0 percent, RR 0.73, 95% CI 0.58-0.91), and a possible trend in reduction of neonatal infection (2.3 versus 2.9 percent, RR 0.83, 95% CI 0.611.12) No increase in the rate of cesarean delivery, even in patients with unfavorable cervixes (RR 0.97, 95% CI 0.69-1.37) These findings were limited by heterogeneity among studies such that immediate induction included waiting 2 to 12 hours after membrane rupture while expectant management included no induction or induction 24 to 96 hours after membrane rupture [3]. The results were also dominated by one large trial (the term PROM study) from the TermPROM study group, which included over 5000 participants and comprised 70 percent of the total number of participants included in the review [4]. The lack of statistical difference in neonatal infection rates between expectant and active management was likely due to underpowering, given that the other infection-related outcomes were significantly increased in the expectant management group. Even a small increase in risk of neonatal infection is important because, if severe (ie, sepsis), there is a small (<5 percent) risk of death. (See "Treatment and outcome of sepsis in term and late preterm infants", section on 'Outcome'.) Subsequent studies have provided additional support for prompt intervention. In one such study, the rates of chorioamnionitis and endometritis at term significantly increased after 12 and 16 hours, respectively: chorioamnionitis 2.7 percent before 12 hours versus 11.8 percent after 12 hours (multivariate analysis OR 2.3, 95% CI 1.2-4.4) and endometritis 1.0 percent before 16 hours versus 3.6 percent after 16 hours (multivariate analysis OR 2.5, 95% CI 1.1-5.6) [5]. The risk of postpartum hemorrhage increased significantly, as well (7.2 before eight hours versus 21.8 percent after eight hours; OR 2.8, 95% CI 1.1-7.2). In another large study, the rate of neonatal sepsis increased with duration of membrane rupture: 0.3 percent at 0 to 6 hours, 0.5 percent at 6 to 18 hours, 0.8 percent at 18 to 24 hours, and 1.1 percent after 24 hours [6]. Cost analysis An economic analysis using data derived from the term PROM study compared all maternal and neonatal treatment costs associated with oxytocin induction to costs associated with expectant management or induction with prostaglandins (prostaglandin E2 gel) [7]. In all of the economic models, induction with oxytocin was less expensive than the alternatives. MANAGEMENT OF INDUCTION We suggest induction with oxytocin, without preinduction cervical ripening. Meta-analyses of randomized trials have not demonstrated a clear benefit from initial use of any prostaglandin in women with premature rupture of the membranes (PROM), including those with unfavorable cervixes [8-12]. Oxytocin is easier to titrate than prostaglandins, and may be less expensive, depending on the prostaglandin
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preparation. However, a clinician may still choose to use prostaglandins if the cervix is particularly unfavorable and his/her risk benefit assessment for an individual patient favors use of a cervical ripening agent [1]. (See "Principles of labor induction".) Misoprostol is inexpensive, readily available, can be administered intravaginally and is stable at room temperature. For these reasons, it has some advantage over other prostaglandin preparations. At least one randomized trial has demonstrated equivalent efficacy to oxytocin for induction of labor in term PROM [13]. If misoprostol is chosen for ripening or induction, an initial dose of 25 mcg is placed in the posterior fornix and it can be repeated every three to six hours, depending on the maternal and fetal response. Alternatively, 50 mcg can be used, but caution is advised because the incidence of tachysystole is greater [14]. At least one randomized trial has reported dinoprostone to be efficacious in patients with an unfavorable cervix with term PROM [15]. A single dose of dinoprostone was administered vaginally for up to 12 hours followed by oxytocin infusion. The authors reported a significantly greater number of women delivering within 24 hours of induction and fewer failed inductions than when oxytocin was used alone. There is minimal information on the safety of mechanical methods of cervical ripening in PROM [16]. For patients with intact membranes, a systematic review of randomized trials reported a significantly increased risk of maternal infection (eg, chorioamnionitis, endometritis) for "all mechanical methods" and for balloon catheters specifically [17]. Neonatal infection rates were not increased. We suggest avoiding mechanical methods of cervical ripening in PROM, given these findings in a population at lower risk of infection than PROM patients and the generally good response to oxytocin induction in PROM patients. (See "Techniques for ripening the unfavorable cervix prior to induction", section on 'Mechanical methods'.) EXPECTANT MANAGEMENT After weighing the risks and benefits of induction versus expectant management (see 'Active or expectant management?' above), women with otherwise uncomplicated pregnancies who are averse to intervention may reasonably choose to undergo a trial of expectant management. These women should have no contraindications to labor and vaginal delivery, no evidence of clinical chorioamnionitis or other medical or obstetrical complications, and reassuring fetal testing. Duration of expectant management Women with term premature rupture of the membranes (PROM) who are followed expectantly go into spontaneous labor and deliver within 24, 48, and 72 hours of PROM in 70, 85, and 95 percent of cases, respectively [4,18]. There are no strong data on which to base a recommendation for the maximum duration of expectant management in the absence of pregnancy complications. In the term PROM study, labor was induced if complications developed or spontaneous labor had not started by 96 hours post membrane rupture [4], and the risk of chorioamnionitis appeared to increase significantly after 24 hours [19]. Meconium stained amniotic fluid Women with meconium stained amniotic fluid were excluded from the term PROM study [4]. Meconium stained amniotic fluid has been associated with an increased risk of clinical chorioamnionitis and positive amniotic fluid cultures, nonreassuring intrapartum fetal heart rate patterns, and meconium aspiration syndrome [19-21]. However, there is no evidence that immediate induction of labor will reduce the risk of these complications, thus meconium stained amniotic fluid is not a strong contraindication to expectant management if antepartum fetal assessment is otherwise reassuring. In some cases, meconium-like staining is actually pigment associated with decidual hemorrhage. Although there are no data from randomized trials, induction and continuous fetal monitoring are prudent when meconium is thick. Expectant management in hospital or at home? We suggest hospitalizing women with PROM. When the TermPROM study group compared outcomes of expectant management at home with expectant management in the hospital, women who were sent home were more likely to develop clinical chorioamnionitis (10.1 versus 6.4 percent; P = 0.006) and their neonates were more likely to be diagnosed with infection (3.1 versus 1.7 percent; P = 0.06) [22]. Multiple logistic regression analyses found that women managed at home compared with in hospital had a higher risk of neonatal infection (OR 1.97, 95% CI 1.00-3.90) and nulliparas managed at home were at increased risk of needing antibiotics before delivery (OR 1.52 95% CI 1.04-2.24). Another risk of home management is the possibility of rapid labor and delivery [23]. For patients who ask for home expectant management, one author proposed the following selection criteria to enhance safety [24]:
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Management of premature rupture of the fetal membranes at term

Cephalic presentation No intrauterine infection Reassuring fetal heart rate tracing Deepest amniotic fluid pocket on ultrasound >2 cm Initial inpatient observation for 72 hours with antibiotic prophylaxis Reliable patient Assistance at home Dependable transportation Home located within 20 minutes of the hospital Ability to check pulse and temperature every six hours, with parameters for notifying their clinician (eg, pulse >100, temperature 100 Fahrenheit [37.8 Celsius]) Daily fetal kick counts Nonstress test and leukocyte count twice weekly Weekly ultrasound examination Antibiotic prophylaxis Meta-analysis of randomized trials supports the use of antibiotic prophylaxis in preterm PROM (PPROM) to reduce the frequency of maternal and fetal infection and delay the onset of preterm labor (ie, prolong latency). (See "Preterm premature rupture of membranes", section on 'Antibiotic therapy'.) Prolonging latency is not a goal in term PROM, but minimizing maternal-fetal infection remains important. There is sparse evidence on the effects of antibiotic prophylaxis with term PROM. A 2002 meta-analysis included only two trials involving a total of 838 women [25]. Compared to placebo or no treatment, use of prophylactic antibiotics (ampicillin and gentamicin or clindamycin and cefuroxime) resulted in a statistically significant reduction in endometritis (RR 0.09, 95% CI 0.01-0.73), but no significant reduction in chorioamnionitis or neonatal mortality or morbidity (eg, infection, pneumonia, meningitis, mechanical ventilation). A subsequent randomized trial of antibiotic prophylaxis (ampicillin and gentamicin) versus no antibiotic prophylaxis also reported that antibiotics decreased chorioamnionitis, but did not lead to a significant reduction in neonatal infection rates [26]. No patient who delivered within 12 hours of ruptured membranes developed any signs of infection. Although appropriate use of intrapartum antibiotics has substantially reduced maternal and neonatal infectious complications, inappropriate or overuse of antibiotics at this time can substantially alter beneficial neonatal flora. Deviated microbial colonization in early infancy has been strongly associated with childhood asthma, allergy and wheezing [27]. These data are not sufficient to make a strong recommendation for or against use of prophylactic antibiotics or choice of antibiotics in expectantly managed patients at term. Our approach to minimizing the risk of infection is prompt induction of labor and use of group B streptococcus (GBS) prophylaxis when indicated rather than expectant management with or without the use of broad spectrum antibiotic prophylaxis (see 'Group B streptococcus colonization' below). Group B streptococcus colonization A positive screening culture for GBS does not necessarily preclude expectant management; there is no consensus on the safety of expectant management in these women [1]. We agree with Centers for Disease Control (CDC) guidelines that maternal prophylaxis against early onset neonatal GBS disease should be administered for 48 hours after PROM and intrapartum to women with positive GBS cultures. (See "Chemoprophylaxis for the prevention of neonatal group B streptococcal disease", section on 'Indications for antibiotic prophylaxis' and "Chemoprophylaxis for the prevention of neonatal group B streptococcal disease", section on 'Preterm premature rupture of membranes'.) In a secondary analysis, the term PROM study evaluated the effect of induction of labor on neonatal infection in mothers with PROM who were GBS positive [28]. Induction with oxytocin was associated with a lower rate of neonatal infection than expectant management (2.5 percent versus >8 percent). However, prenatal GBS culture and chemoprophylaxis were performed at the discretion of the provider, which limits the generalizability of these results. Maternal and fetal monitoring There are no standards for maternal-fetal monitoring in expectantly managed term PROM and no data from randomized trials on which to base recommendations. There is
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Management of premature rupture of the fetal membranes at term

consensus that digital vaginal examination and vaginal intercourse should be avoided to reduce the risk of intrauterine infection. Some type of fetal surveillance is reasonable (eg, kick counts, nonstress tests, biophysical profile) to provide the clinician and patient with some assurance of fetal well-being, but none of these tests has good sensitivity for predicting fetal infection, even when performed daily. However, cord prolapse or cord compression may be first suspected because of fetal heart rate decelerations. In the term PROM study, women assigned to expectant management were asked to check their temperature twice daily and report temperatures 37.5 Celsius, monitor and report changes in color or odor of amniotic fluid, and notify their clinician if any complications developed [22]. Other monitoring, such as white blood cell count, was at physician discretion. MANAGEMENT OF THE NEWBORN (See "Clinical features and diagnosis of sepsis in term and late preterm infants", section on 'Maternal and neonatal risk factors'.) SUMMARY AND RECOMMENDATIONS Premature rupture of the membranes (PROM) refers to rupture of the fetal membranes prior to the onset of labor or regular uterine contractions. It occurs in 8 percent of pregnancies at term. (See 'Introduction' above.) The initial evaluation of all pregnancies in which PROM is suspected should include confirmation of membrane rupture, confirmation of gestational age, and assessment of fetal well-being. The need for group B streptococcal chemoprophylaxis should also be determined. (See 'Initial evaluation' above.) We suggest prompt induction of labor in women with term PROM (Grade 2B). Compared to expectant management, induction of labor is associated with a reduction in infection and lower treatment costs, with no increase in cesarean delivery. (See 'Active or expectant management?' above.) We suggest induction with oxytocin (Grade 2B). Oxytocin is as effective as prostaglandins, is easier to titrate, and may be less expensive, depending on the preparation. (See 'Management of induction' above.)

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