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October 1 2001 • Volume 36 • Number 19

Obstetrics

Managing PROM patients at term
Induction, Expectant Management Equally Safe

Sherry Boschert
San Francisco Bureau

SAN FRANCISCO — It's equally safe to immediately induce labor in a healthy pregnant woman with premature rupture of membranes at term or to manage her expectantly, ideally for no more than 24 hours, Dr. Stephanie E. Mann said.

The cumulative data in the medical literature show that immediate labor induction will not increase the risk for C-section in nulliparous women with premature rupture of membranes (PROM). In addition, the onset of labor within 24 hours of membrane rupture is not associated with increased risk of neonatal infection if the woman is not already infected with group B streptococcus, Dr. Mann said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Expectant management also will not increase the risk for endometritis. Still, it may be safer to keep these patients hospitalized, because some data suggest that sending them home doubles the risk for neonatal death, added Dr. Mann, director of obstetrics at San Francisco General Hospital.

Some data suggest that women are happier with immediate induction than with several days of expectant management. Given the equivalent safety profiles and the shorter hospital stays with induction compared with expectant management, hospitals and insurance companies are bound to favor induction, she noted. After 37 weeks' gestation the fetal membranes rupture before the onset of labor in about 8% of pregnancies. Spontaneous labor occurs in 85% of women within 24 hours and in 95% of women within 72 hours.

Six studies comparing immediate induction with expectant management showed no difference in the incidence of neonatal sepsis. One of these studies—the 1996 Term PROM trial with 5,042 women—reported neonatal sepsis in 2%-3% of study participants, a finding that spawned half a dozen subanalyses.

One such analysis of 133 of the women found a twofold increased risk for sepsis if more than 24 hours elapsed between PROM and the onset of labor. Risk was also increased in women who had more than seven digital exams. “It takes a significant number of exams to really increase your risk of neonatal sepsis,” Dr. Mann said.

Infectious morbidity may be more influenced by the interval between vaginal examination and delivery rather than between rupture of membranes and delivery. “It would seem that the clock starts ticking after a vaginal exam,” she added.

A separate subanalysis of the Term PROM data found that maternal group B streptococcal colonization tripled the rate of neonatal infection. Expectant management or immediate induction with prostaglandin gel increased the risk of neonatal infection even further. Immediate induction with oxytocin produced the lowest risk of neonatal infection.

A metaanalysis of three randomized controlled trials found less risk for chorioamnionitis with induction compared with expectant management, but six prospective nonrandomized trials and the literature as a whole suggest no difference in chorioamnionitis risk, Dr. Mann said.

Six randomized controlled trials found no difference in C-section rates in women managed expectantly or immediately induced and found that parity did not influence the risk for C-section. In the Term PROM trial, 9%-10% of women underwent C-section delivery.

The suggestion of an increased risk for neonatal death with expectant management came from a secondary analysis of data on 1,670 women in the Term PROM trial. Four neonates died in the expectant management group, compared with no deaths in the immediate induction group, but the Term PROM trial was not powered to detect a difference in mortality.