PROM 37 Weeks and Beyond: Induction or Watchful Waiting?
BACKGROUND AND PURPOSE:
Prelabour rupture of the membranes (PROM) can either be managed expectantly (no planned intervention within 24 hours) or planned early birth (either immediate intervention or intervention within 24 hours through some form of induction of labor or by C-section)
This study by Middleton et al. (Cochrane Database of Systematic Reviews, 2017) sought to determine the best course of action following PROM ≥ 37 weeks
Systematic Review and Meta-Analysis
23 trials, including 8,615 women and their infants were included
Trials included oxytocin, vaginal prostaglandin E2, and sublingual, oral, or vaginal misoprostol
Trials that assessed Caulophyllum and acupuncture were also included
Early birth was associated with:
Lower risk of maternal infectious morbidity defined as chorioamnionitis and/or endometritis (risk ratio 0.49; 95% CI 0.33 to 0.72)
Lower chance of definite or probable early-onset neonatal sepsis (risk ratio 0.73; 95% CI 0.58 to 0.92)
There were no significant differences between the two groups regarding
Serious maternal morbidity or mortality
Definite early-onset neonatal sepsis
Early birth was associated with:
Lower risk of chorioamnionitis (risk ratio 0.55; 95% CI 0.37 to 0.82)
Postpartum septicemia (risk ratio 0.26; 95% CI 0.07 to 0.96)
Neonates less likely to receive antibiotics (risk ratio 0.61; 95% CI 0.44 to 0.84)
Higher risk of induction (risk ratio 3.41; 95% CI 2.87 to 4.06; 12 trials)
Shorter time from PROM to birth (mean difference -10.10 hours; 95% CI -12.15 to -8.06)
Lower neonatal birthweights (mean difference -79.25 g; 95% CI -124.96 to -33.55; five trials, 1,043 infants)
Shorter hospitalization time (mean difference -0.79 days; 95% CI -1.20 to -0.38)
Lower risk of NICU admission (risk ratio 0.75; 95% CI 0.66 to 0.85)
If admitted, stay was shorter (risk ratio 0.72; 95% CI 0.61 to 0.85)
More positive views of care from the patient perspective based on visual analogue scale and questionnaires in 2 studies
Following PROM at 37 weeks, planned early birth with induction decreases the risk of maternal and fetal infection compared to expectant management without increasing the risk of C-section
No subgroup differences were found between initial mode of induction for planned early birth
The authors report results overall reflect low quality evidence, i.e., the true effect may be substantially different from the estimate of the effect
Majority of studies had serious design flaws
Outcome estimates were imprecise
The strength of this study is the large number of women and infants included for analysis
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