Offer Epidural at Second Pain-Med Request in Preterm PROM


SAN FRANCISCO β€” Women with preterm premature rupture of membranes who request pain medication twice within a 3-hour time period for regular painful contractions should be offered epidural analgesia, inasmuch as they are highly likely to deliver with the ensuing 24 hours, a study of more than 1,600 patients has shown.

A retrospective review of 1,608 women with premature rupture of membranes (PROM) and 74 women with preterm PROM (PPROM) showed that the majority of the PPROM group delivered within 24 hours of their second request for analgesia, yet they were significantly less likely to receive an epidural, compared with women in the PROM group, reported Melanie Chichester, R.N., and colleagues in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Because digital examination is precluded in women with PPROM, onset of labor is difficult to determine and timely administration of epidural analgesia can be challenging, Ms. Chichester said.

For this reason, she and colleagues at Christiana Care Health Systems in Newark, Del., sought to assess whether contractions sufficient to cause a second maternal request for analgesia within a 3-hour time period could be substituted for contractions with cervical change as a maker of labor onset.

The investigators reviewed all admissions to their institution with confirmed PROM and PPROM from January 2004 through June 2005.

For analytical purposes, women with rupture of membranes after 24 weeks' and before 34 weeks' gestation were categorized as having PPROM and those with rupture of membranes at week 34 or later were classified as having PROM.

Among women with PPROM, the median time to delivery was 6.62 hours from the time of second request for analgesia, Ms. Chichester said.

Additionally, in the PPROM population, a total of 82% of the women delivered within 24 hours and 96% delivered within 48 hours of their second request for analgesia.

Compared with 79% of the PROM group who received an epidural following their second request for pain medication, only 42% of the PPROM group received an epidural, she said.

Although the study is limited by its retrospective design and small sample size, the findings suggest β€œit is incumbent upon the obstetrician to offer the same level of pain management to the laboring woman with PPROM as to any other parturient,” said Ms. Chichester.

For the relatively small percentage of women who do not deliver in the subsequent 48 hours, the epidural may be discontinued or active management of labor may be considered, depending on presence or absence of signs of infection, she said.

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