Professional Documents
Culture Documents
M I N A R S I N
E R I N A T O L O G Y
39 (2015) 495500
www.elsevier.com/locate/semperi
article info
abstra ct
Keywords:
Induction of labor
births and confers serious maternal risks, including intra-amniotic infection, and an
membranes
Preterm delivery
an accurate determination of gestational age and causal factors, as well as the balancing of
maternal and fetal risks. In this review of the existing literature on induction of labor in
Introduction
Preterm premature rupture of membranes (PPROM) dened as
rupture of membranes prior to the 37th week of gestation
complicates approximately 3% of all pregnancies and 2533% of
all preterm births.1 In over 50% of patients diagnosed with
PPROM, delivery occurs within a week of membrane rupture.2
Latency of pregnancy following rupture of membranes is inversely associated with the gestational age at the time of membrane
rupture.3 Intra-amniotic infection (1360%) and placental abruption (412%) are often associated with PPROM. These complications occur more frequently at earlier gestational age of rupture.2
As the gestational age at diagnosis decreases, the severity
and frequency of associated neonatal complications
increases. Respiratory distress syndrome is the most common serious complication observed in the neonate born after
n
Corresponding author.
E-mail address: admackeen@geisinger.edu (A.D. Mackeen).
http://dx.doi.org/10.1053/j.semperi.2015.07.015
0146-0005/& 2015 Elsevier Inc. All rights reserved.
496
SE
M I N A R S I N
E R I N A T O L O G Y
Management
Causes of PPROM are numerous and subsequent management is heavily inuenced by the pathophysiologic culprit,
when it is known or suspected (Fig). Infection is commonly
linked to PPROM with amniotic uid cultures noted to be
positive in 2535% of samples.2,1012 Clinically diagnosed
intra-amniotic infection is a contraindication to expectant
management of pregnancy and warrants expedited delivery,
reserving cesarean delivery for the typical obstetrical
indications.
Initial evaluation of the patient with PPROM should include
an assessment of intra-amniotic infection (e.g., presence of
fever, uterine tenderness, purulent lochia and maternal, or
fetal tachycardia), evaluation for active labor, fetal position,
and fetal well-being are necessary for determining an
39 (2015) 495500
E M I N A R S I N
E R I N A T O L O G Y
39 (2015) 495500
497
Fig. Management of preterm premature rupture of membranes (PPROM). GBS: group B streptococcus; MFM: maternal-fetal
medicine. (Adapted from Mercer BM.)2
In a multicenter trial sponsored by the National Institute of
Child Health and Human Development MaternalFetal Medicine Units, patients who received broad-spectrum antibiotics
for 7 days had twice the latency period as those who received
placebo.18 Signicant decreases were also appreciated in intraamniotic infection, respiratory distress syndrome (RDS),
necrotizing enterocolitis, and bronchopulmonary dysplasia.
Antenatal corticosteroids given prior to 34 weeks have been
demonstrated to reduce the risk of RDS, intraventricular
hemorrhage, and perinatal death.19 A meta-analysis reviewing the use of antenatal corticosteroids in the patient with
early PPROM corroborated these ndings and added that no
signicant differences were noted in maternal or fetal
infection.20
Tocolysis in PPROM is a contentious subject, as the data is
insufcient to make a distinct recommendation either for or
against use. The concern for intra-amniotic infection keeps
many practitioners from using tocolytics in the management
498
SE
M I N A R S I N
E R I N A T O L O G Y
Labor induction
The preferred method for labor induction in the patient with
PPROM remains controversial. The current available literature
addressing this subset of patients is sparse. Common current
practices are guided by studies that were aimed at determining the optimal timing of delivery.14,23 These trials did
demonstrate the benet of labor induction in late PPROM as
compared to expectant management, but optimal method of
induction was not a focus.
Contemporary labor induction practices with PPROM have
been guided by studies of term PROM as well as provider
experience. According to the American Congress of Obstetricians and Gynecologists, recent data in large randomized
trials suggest that for women with premature rupture of
membranes at term, labor should be induced at the time of
presentation, generally with oxytocin, to reduce the risk of
chorioamnionitis.24,25 While this study did suggest improved
outcomes with high-dose oxytocin use, its comparator was
low-dose oxytocin rather than a separate induction agent.25
This calls into question the possible use of alternative
methods for labor induction in not only term PROM, but in
PPROM as well.
The American Congress of Obstetricians and Gynecologists
also reports in the practice bulletin on labor induction that
intravaginal PGE2 appears to be safe and effective in the
setting of PROM.24,26 A 1977 study of 100 patients with term
PROM found that oral PGE2 was safe and effective and
conferred a shorter latency from PROM to delivery.27 Since
this trial, multiple studies have reported conicting data that
consistently support the use of prostaglandins as safe and
effective in the patient with PROM, but differ with regard to
prostaglandins superiority to oxytocin.2833 Butt et al.28 report
in their well-designed randomized controlled trial of 108
women with term PROM that although the time spent in
active labor as well as maternal and neonatal outcomes were
39 (2015) 495500
E M I N A R S I N
E R I N A T O L O G Y
39 (2015) 495500
14.
15.
16.
17.
re fe r en ces
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
499
500
32.
33.
34.
35.
36.
SE
M I N A R S I N
E R I N A T O L O G Y
39 (2015) 495500
37. Krammer J, Williams MC, Sawai SK, OBrien WF. Preinduction cervical ripening: a randomized comparison of
two methods. Obstet Gynecol. 1995;85(4):614618.
38. Kazzi G, Bottoms S, Rosen M. Efcacy and safety of laminaria
digitata for preinduction ripening of the cervix. Obstet Gynecol.
1982;60(4):440443.
39. Wolff K, Swahn ML, Westgren M. Balloon catheter for induction of labor in nulliparous women with prelabor rupture of
the membranes at term. A preliminary report. Gynecol Obstet
Invest. 1998;46(1):14.
40. Mackeen AD, Walker L, Ruhstaller K, Schuster M, Sciscione A.
Foley catheter vs prostaglandin as ripening agent in pregnant
women with premature rupture of membranes. J Am Osteopath
Assoc. 2014;114(9):686692. http://dx.doi.org/10.7556/jaoa.2014.137.
41. ClinicalTrials.org. Evaluation of CRB in PROM patients. https://
www.clinicaltrials.gov/ct2/show/NCT02314728?term=labor+
induction+and+premature+rupture+of+membranes&rank=5.
2015 Accessed 26.04.15.
42. ClinicalTrials.org. FOLCROM trial: Foley catheter in rupture of
membranes. https://www.clinicaltrials.gov/ct2/show/
NCT01973036?term=labor+induction+and+premature+rupture+
of+membranes&rank=4. 2015. Accessed 26.04.15.