Physiology of Labor: Premature Membrane Rupture

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Physiology of Labor
Article · February 2015
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Ann. N.Y. Acad. Sci. ISSN 0077-8923
A N N A L S O F T H E N E W Y O R K A C A D E M Y O F SC I E N C E S
Issue: Women’s Health and Disease
Management of premature prelabor rupture
of the membranes
Helena Strevens,1 Kirsten Allen,2 and Jim G. Thornton2
1
Department Obstetrics and Gynecology, University Hospital, Lund, Sweden. 2 Department of Obstetrics and Gynaecology,
Nottingham City Hospital NHS Trust, Nottingham, UK
Address for correspondence: Jim G. Thornton, M.D., F.R.C.O.G., Department of Obstetrics and Gynaecology, University of
Nottingham, Nottingham City Hospital NHS Trust, Hucknall Road, Nottingham, UK. [email protected]
Premature prelabor rupture of the fetal membranes affects about 3% of pregnancies. The cause is usually infection,
especially at earlier gestations. The prognosis and the risks of delivery are both much worse at earlier gestations.
Before viable pregnancy, termination may be offered. Once the fetus is viable, steroids to mature the fetal lungs and
antibiotics to reduce infection are the mainstays of treatment. Delivery is recommended in the presence of signs of
clear-cut infection at early gestational ages. At later ones, balancing the risks of infection from conservative treatment
against the risk of prematurity from delivery is difficult. Published trials to date have not given clear guidance, but a
number are ongoing.
Keywords: prematurity; infection; rupture of membranes
Introduction
The etiology, complications, and management of
premature prelabor rupture of the fetal membranes
all vary with the gestational age at which the rupture
occurs. At previable gestational ages, the prognosis,
with or without treatment, is relatively poor, with
a high risk of delivery before fetal survival is possible and a high risk of pulmonary hypoplasia and
other deformities even if the pregnancy continues.
At later gestational ages, management consists of
antibiotics, steroids to advance lung maturity, and
induction if the risks of intrauterine infection are
higher than the risks of prematurity. Although the
risk of delivery falls with advancing gestational age,
the risk of chorioamnionitis goes in the opposite
direction, so calculating this balance of risks is not
straightforward.
We begin with a description of the etiology, epidemiology, and diagnosis. Various treatments that
have been considered are then discussed, namely
amnioinfusion, techniques to close amniotic leakage, cervical cerclage, tocolysis, antibiotics, maternal
steroids, and timed delivery.
Finally, summary evidence relating to management of premature rupture of membranes (ROMs)
will be presented for four gestational age bands,
namely for less than 16 weeks, for 16–24 weeks, for
24–36 weeks, and for more than 36 weeks. These are
relatively arbitrarily chosen gestational age bands,
and it should be recognized that both prognosis and
management at the borders may vary.
Etiology and natural history
Local infection in the fetal membranes underlying
the cervix is believed to be an important mechanism of membrane rupture. In some cases, primary infection causes membrane weakening and
local prostaglandin release. In other cases, uterine
distension, cervical weakness, or cone biopsy1 are
the primary cause of cervical shortening, and bacteria pass through the cervix as a secondary mechanism. There is fairly strong evidence that infection
plays a larger role at lower gestational ages.2 Despite
occasional suggestions that collagen abnormalities
similar to the various types of Ehlers Danlos might
be associated with premature ROM3,4 no definite
associations with any specific genetic collagen weaknesses has been confirmed.
Without treatment, miscarriage or premature labor typically ensues within a few weeks of the rupture occurring. Depending on the gestational age,
doi: 10.1111/j.1749-6632.2010.05654.x
c 2010 New York Academy of Sciences.
Ann. N.Y. Acad. Sci. 1205 (2010) 123–129 123
Strevens et al .
Premature membrane rupture
the baby may die or face all the complications of
prematurity. Infection in the amniotic sac also becomes increasingly likely with time from rupture, as
a result of spread up the genital tract. Such infection
adds to the fetal complications, in particular increasing the risk of cerebral palsy.5 Placental abruption
is also more common in association with premature ROMs, although this may partly be an artifact
of misdiagnosis of cases of abruption—if retained
blood separates into organized clot and plasma, and
the latter leaks through the cervix it may be misdiagnosed as amniotic fluid. Even in the absence
of infection the harmful fetal effects of premature
ROM include postural deformities and pulmonary
hypoplasia as a direct result of lack of amniotic
fluid.
Resealed rupture of membranes
Despite all the above complications, the fetal prognosis, even in the second trimester is not absolutely
hopeless, since occasionally the hole in the membranes reseals, amniotic fluid reforms and the pregnancy proceeds normally to term.6,7
have concluded that this drug reduces the risk of
premature delivery. However, none of the studies reported the effect on premature membrane rupture
separately. Reports of apparent benefits of progesterone on preterm birth are still treated with caution by many experts, because the methodologically
highest quality studies showed no benefit and the
long-term safety of such hormonal treatment remains unproven.20 This is why many large trials are
ongoing.
Prophylactic antibiotics given early in pregnancy,
either routinely21 or selectively to treat ureaplasma
ureolyticum,22 or asymptomatic bacteriuria,23 do
not in general prevent preterm birth. Antibiotics
to treat bacterial vaginosis in pregnancy may possibly reduce preterm birth when started before 20
weeks’ gestation, but there is no evidence that they
reduce preterm rupture of membranes.24 One large
and methodologically good-quality trial as judged
by the Cochrane reviewers25 has suggested that a
screening programe for vaginal infection reduces
preterm birth, but preterm membrane rupture was
not reported.26
Epidemiology and prevention
Diagnosis
Premature ROMs occurs in about 3% of pregnancies.8 It is more common in women who have
had a previous preterm birth, either with or without ruptured membranes9,10 and can be predicted
in ongoing pregnancies with cervical length assessment and fetal fibronectin measurement in
cervical fluid.11 Many other factors such as low
socioeconomic status, cigarette smoking, previous
cervical cone biopsy,1 amniocentesis, and multiple
pregnancy are associated with an increased risk of
premature labor, and probably also with premature
ROMs.
Unfortunately, apart from prophylactic cerclage
in women at high risk of premature birth, there is
no evidence that any other preventive treatment is
effective. Prophylactic cerclage in women at high
risk of preterm labor shows a nonsignificant trend
toward reducing the risk of premature ROMs, relative risk (RR) 0.31 [95% confidence interval (CI)
0.08–1.28].12 This reduction is plausible since prophylactic cerclage also reduces the overall chance of
premature birth.
Many randomized trials and almost as many systematic reviews13–19 have measured the effect of progesterone on the risk of preterm birth, and some
Tests of membrane rupture
The diagnosis of membrane rupture is not straightforward. Patients may mistake a leakage of urine,
a profuse vaginal discharge, or a leakage of separated serum from a retro-placental clot for amniotic fluid. Conversely, they may fail to report a slow
leakage of amniotic fluid that they misdiagnose as
a vaginal discharge or as urine. A sterile speculum
examination in which fluid containing vernix or
meconium is seen coming through the cervix is diagnostic. If fluid is seen pooling in the posterior
fornix, a simple test for a neutral pH (“amnistix”
or nitrazine yellow that changes to blue/purple) is
suggestive that it is amniotic, since normal urine
and vaginal discharge have an acid pH. However
false positives and false negatives can occur with this
test. Various other immunoassays for proteins specific to amniotic fluid have been developed. These
include alpha-feto protein, and placental alpha
microglobulin-1 (PASMG-1) AmniSure,27 but their
test accuracy remains uncertain. An ultrasound assessment of the amniotic fluid volume provides
supportive evidence but again is not diagnostic.
Absent or reduced fluid may result from fetal renal
problems or severe growth restriction, and the fluid
124
c 2010 New York Academy of Sciences.
Ann. N.Y. Acad. Sci. 1205 (2010) 123–129 Strevens et al .
volume may be near-normal if the leakage is only
partial.
Tests of fetal lung maturity
Amniocentesis and measurement of the level of surfactant by the lecithin:sphyngomyelin (L:S) ratio has
been recommended to test fetal lung maturity and
guide the timing of delivery. However, it is rarely
used for this indication in modern practice, partly
because trials of timed delivery have not reported
results stratified into those with or without positive
fetal lung maturity tests.
Tests of infection
High vaginal and endo-cervical swabs for culture
and sensitivity to antibiotics should be taken at the
same time as a speculum examination is performed
to make the diagnosis. However, these are often not
revealing because the vagina is rarely a sterile location even in the absence of clinical infection. In the
United States, transabdominal amniocentesis is occasionally performed to diagnose amnionitis.28 The
amniotic fluid is normally sterile so the presence of
microorganisms is likely to be a sign of clinically
important infection and an indication for delivery.
Such a policy is rarely followed in Europe where obstetricians are fearful that the very act of needling the
amniotic sack may introduce or spread infection, or
directly provoke preterm labor, and it is argued that
in the presence of infection delivery tends to occur
fairly soon anyway.
Management
Clinical chorioamnionitis
Some years ago, the suggestion gained currency that,
if delivery was imminent, antibiotics should be deferred until after cord clamping, even in the presence of clinical chorioamnionitis, on the grounds
that fetal swabs would allow bacterial sensitivity to
be measured more accurately. However, the only
trial of this policy, which compared predelivery administration of antibiotics with delaying administration until after delivery, in the presence of clinical
chorioamnionitis29 showed such overwhelming fetal benefit from predelivery administration that it
was suspended.
Antibiotic trials in premature ROMs subsequent
to the Gibbs trial have confined themselves to patients without clear evidence of chorioamnionitis
and have shown less clear-cut benefits. Nevertheless,
the lesson of the Gibbs trial should not be forgotten.
Premature membrane rupture
In the presence of signs of chorioamnionitis, antibiotic administration should not be deferred even if
delivery is imminent.
In the absence of signs of infection, the largest
and best designed trial (ORACLE 1),30 which was
performed on patients with preterm labor with
ruptured membranes, failed to demonstrate any
substantive fetal benefit from antibiotics overall.
However, in those who were given erythromycin
there was a reduction in preterm labor and respiratory distress. Even in this group, the trend toward
reduced perinatal mortality did not reach conventional levels of significance.
Choice of antibiotics
The results of the ORACLE trial clearly indicate that
erythromycin is preferable to coamoxiclav as the antibiotic of choice with premature ROMs and no clear
signs of infection. Co-amoxiclav was associated with
an increased fetal risk of necrotising enterocolitis.
Steroids to provoke fetal lung maturity
There is overwhelming randomized trial evidence
that for deliveries predicted to deliver before 34
weeks, the administration of corticosteroids to the
mother reduces both the risk of neonatal respiratory distress syndrome and perinatal mortality.31
Early concerns that steroids might be less effective, or even harmful in the presence of ruptured
membranes have also been shown to be unfounded.
Among women with premature ROMs at first dose,
the latest systematic review shows a reduction in
risk of fetal or neonatal death of RR 0.62 [95% CI
0.46–0.82].
Bedrest
Many authors advocate bed rest, especially when
membrane rupture occurs before viability on the
grounds that this encourages the hole in the membranes to reseal. Such resealing does occasionally
occur,6,7 and in such cases the amniotic fluid reaccumulates and pregnancy proceeds normally to term.
However, there is no evidence that bed rest encourages this process and it carries the inevitable risk of
increasing thromboembolic risks for the mother.
Tocolysis
Most trials of tocolysis for suspected preterm labor
have excluded pregnancies with premature ROMs.
Although the drugs do generally prolong the pregnancy, they have, even with such exclusion, failed
to demonstrate any reduction in substantive fetal
c 2010 New York Academy of Sciences.
Ann. N.Y. Acad. Sci. 1205 (2010) 123–129 125
Strevens et al .
Premature membrane rupture
Figure 1. Neonatal mortality in Sweden, 2001–2002.
adverse outcomes. Some authorities (e.g., NICE)
have therefore concluded that tocolysis has no place
in premature ROMs. However, the lack of evidence
of effectiveness with either intact or ruptured membranes may be a result of lack of power, or an artifact
of the fact that most trials excluded pregnancies at
the highest risk. It is implausible that effective tocolysis never improves fetal outcomes at the limits
of viability. There is evidence that this is the case.
For example, figures for neonatal death in Sweden
between 2001 and 2002 (Fig. 1, courtesy of Professor
I. Ingemarssson, Lund, Sweden) where tocolysis is
widely used whether the membranes are ruptured or
not, and where gestational age is routinely recorded
to the nearest day based on early scan, show a notably sharp decrease in mortality between weeks 24
and 25. One plausible explanation is the effective
use of tocolytics after 24 weeks.
Drugs to reseal the membranes
There have been various attempts over the years
to reseal holes in the membranes with endoscopically administered mixtures of fibrin glue and
platelets.32,33 Results have been somewhat better
after iatrogenic membrane rupture than when the
membranes rupture spontaneously, presumably because infection is less likely to be a causative factor in
the former cases. However there have been no randomized trials, and the practice has not yet entered
regular clinical use.
126
Cervical cerclage
There is no place for the insertion of a cervical suture
of any type after membrane rupture has occurred.
The risk of introducing infection is too great. If a
suture has been inserted previously, it should usually
be removed because of the risks of providing a focus
for infection.
Management by gestational age
Less than 16 weeks’ gestation
At these very early gestational ages the diagnosis
may be difficult. A typical history of ruptured membranes may not be clear-cut, so a detailed ultrasound assessment should be performed. If this reveals severely reduced or absent amniotic fluid, renal
agenesis or urinary outflow obstruction should be
excluded. Once these abnormalities have been excluded, rupture of the membranes remains the most
likely diagnosis. The prognosis at this early gestational age is very poor, with at least half of such patients delivering within 1 week and 85% by 4 weeks.
There is a very high risk of pulmonary hypoplasia in
the small fraction of babies who reach viability and
survival to hospital discharge is rare. Most authorities would offer termination of pregnancy in this
situation. If there is any sign of chorioamnionitis
in the mother, pyrexia, abnormal vaginal discharge,
raised white blood cell count, or other acute phase
reactant (e.g., ESR, CRP, etc.), antibiotics should be
given to reduce the risk of serious maternal septic
c 2010 New York Academy of Sciences.
Ann. N.Y. Acad. Sci. 1205 (2010) 123–129 Strevens et al .
complications. In the presence of infection, delivery
usually ensues rapidly, but if it does not, termination
is recommended.
16–24 weeks’ gestation
At these slightly more advanced gestational ages,
the prognosis is still poor, but not hopeless.34 Reported case series survival rates may be as high as
46%.35–37 However, such figures should be interpreted with caution since survival is much better at
the upper end of this gestational age range and it is
unclear from some reports whether ascertainment
was complete and whether poor prognosis cases in
which labor was induced were included.
Amniotic fluid infusion has been advocated as
a possible treatment with the idea that by replacing the missing fluid it might reduce the risk of
pulmonary hypoplasia.38,39 It may well do this,
but it tends to leak away fairly rapidly after infusion so it often has to be repeated, and the transabdominal needling might introduce infection or
stimulate preterm labor. This is why amnioinfusion has not yet entered clinical practice outside
randomized controlled clinical trials.40,41 An ongoing pilot trial of amnioinfusion for ruptured
membranes at 16–24 weeks (http://www.controlledtrials.com/ISRCTN81932589) will soon indicate the
feasibility of such a trial.
24–30 weeks’ gestation
In the absence of clear-cut signs of infection all authorities would manage such pregnancies conservatively, since the risks of delivery clearly outweigh
the risks of observation in utero. Nevertheless, there
is a significant risk of chorioamnionitis with observation and most authorities would advocate the
prophylactic administration of broad-spectrum antibiotics, such as erythromycin. Steroids should be
given to reduce the risk of respiratory distress syndrome. Although bed rest is frequently advocated,
it is not evidence based and carries risks of increasing maternal morbidity. Similarly, the evidence for
tocolysis at these early gestational ages is very weak.
It should be restricted to use in randomized controlled trials, or those few pregnancies at the limit
of viability where the risks of delivery are judged to
clearly outweigh the risks of infection.
30–34 weeks’ gestation
There has been one systematic review of induction
of labor at this gestational age band.42 It suggested
Premature membrane rupture
that a policy of induction reduced chorioamnionitis.
However, it should be interpreted with caution. Two
of the four trials included in the meta-analysis restricted themselves to patients in whom a test of lung
maturity had been performed before entry and none
of the trials administered antibiotics or steroids before entry. Finally, although there was an apparent benefit in terms of reduced chorioamnionitis,
there was no effect on perinatal death, neonatal
sepsis, respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), necrotising enterocolitis (NEC), or neonatal length of stay. The best
policy is probably to treat such patients conservatively, with antibiotic cover until labor, signs
of fetal compromise, or signs of chorioamnionitis
ensue.
If a cervical suture is in place at the time membrane rupture occurs, the choice of removal or not is
difficult. Nonrandomized studies comparing a policy of suture removal with retention have given conflicting results.43,44 However, since infection is relatively common at this gestational age, most authors
recommend that cervical sutures should be removed
when membrane rupture is confirmed, the only exception being when the suture is known to have
been buried, such as the Shirodkar or transabdominal suture.
34–36 weeks’ gestation
At this relatively advanced gestation, many authorities recommend induction on the grounds that there
is little to gain from a slight increase in maturity,
and the risks of infection from delay, which might
increase cerebral palsy, outweigh this. Such calculations might be right but there are no data from
randomized controlled trials to support them. Fortunately, this deficit will soon be remedied by the
Australian PPROMT (Pre-term Pre-labour Rupture
of the Membranes close to Term ISRCTN 44485060)
trial. In this trial, participants with ruptured membranes between 34 ± 0 days and 36 ± 6 days are allocated either to have labor induced immediately or
to be observed until another clinical indication for
induction develops. The primary outcome is neonatal sepsis and the sample size is 1,812 women. In the
meantime both policies of induction or observation
are acceptable.
Conflicts of interest
The authors declare no conflicts of interest.
c 2010 New York Academy of Sciences.
Ann. N.Y. Acad. Sci. 1205 (2010) 123–129 127
Strevens et al .
Premature membrane rupture
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