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Term PROM Management – June 2007

We reviewed  and discussed in detail the studies, as covered in the attached powerpoint presentation, which included the first termPROM study and the secondary analyses of that data regarding predictors of maternal infection, expectant management at home versus in the hospital, and impact of GBS colonization.

The group decision was to continue to offer the option of expectant management at home for up to four days, with the explanation to the patient that there is probably no advantage to waiting more than 48-72 hours (i.e. spontaneous labor is not more likely to start beyond that time frame – see Natural History of Spontaneous Labor, below.

In making this decision we considered the following factors, among others, from the the “Predictors of Maternal Infection” study (Seaward, Hannah et al, 1998)
- the odds ratio for chorio was 1.77 at a latency interval of 24-48 hours compared with < 12 hours
- chorio risk did not increase after 48 hours compared with 24-48 hours.
- several other factors, especially  including number of vaginal exams, but also duration of active phase, meconium and parity were more significant predictors of infection than latency interval,
-  given the quality of the data was biased toward overestimating risk of chorio (see slide on limitations of the studies)

We changed the patient education handout “Information for After the Bag of Waters if Broken” to read:  “There may be a slightly increased risk of infection in your uterus when the bag of waters is broken for more than twenty-four hours and if you are not in labor”.

We also added to the PROM management algorithm that we would offer breast stimulation or castor oil to women as a part of expectant management.

Regarding GBS colonized women with ROM, we discussed that we can’t send them home because we need to start antibiotics, (per CDC guidelines) but we will offer the option of expectant management in the hospital.  (There is no data of sufficient quality to provide any guidance in this area).

The last part of the discussion centered around the question of doing an in-person evaluation at 24-36 hours in women with expectant management at home.  While some members of the group felt that a check-in by phone was adequate, they went with the opinion of the majority that we will do a triage evaluation at 24-36 hours after ROM.

We also discussed that some MDs recommend an AFI in women with SROM before sending them home, but there is no evidence for this.  In the TermPROM study, only ten percent of women managed at home had either an AFI or a biophysical profile.