Amni Sure Rapid Reliable NonInvasive Test for ROM

Amni. Sure® Rapid, Reliable, Non-Invasive Test for ROM 17 Th June

(P)PROM is a Major Diagnostic Challenge Premature Rupture of Membranes (PROM) 9. 5% of UK pregnant population in 2011 -20121 Increased risk of infection with latency [maternal & neonatal]2 Preterm Premature Rupture of Membranes (p. PROM) 3% of pregnant population (NHS)1 18 -20% perinatal deaths 3 -8 30% of all preterm births 3 -8 In light of the challenging financial circumstances surrounding the NHS a highly accurate and quick method of diagnosing (P)PROM is needed. 1. Sanchez-Ramos L et al. Obstet. Gynecol 2009; 114: 631 -40. 2. Schaaf JM et al. BJOG 2011; 118: 1196 -204. 3. Mc. Pheeters ML et al. Am J Obstet Gynecol 2005; 192: 1325 -9. 4. Ness A et al. Am J Obstet Gynecol 2007; 197: 426. e 1– 426. e 7 5. Alfirevic Z et al. Ultrasound Obstet Gynecol 2007; 29: 47– 50

What is Amni. Sure? Global leading rupture of membrane bedside test. 99% accuracy at all gestations. Simple vaginal swab test. Detects PAMG-1, only found in amniotic fluid. Can be used with/without speculum.

CLINICAL EVIDENCE RELEVANT METRICS - AMNISURE® ROM TEST Over 25 publications supporting very high accuracy. Only test to maintain same level of accuracy in ‘known’ and ‘unknown’ cases. Only test to have 100% accuracy with Gold Standard Test – Amnio-Infusion. Range of publications below – includes lowest and highest accuracy. Study Cousins 1 Park 2 Grizzell 3 Silva 4 Kwek 5 Hosli 6 Albayrak 7 Year 2005 2007 2008 2009 2010 2011 N 203 183 46 63 100 199 167 SN 98. 9% 98. 7% 100. 0% 92. 7% 94. 4% 94. 3% SP 100. 0% 87. 5% 100. 0% 98. 6% 97. 5% PPV 100. 0% 98. 1% 100. 0% 96. 2% 97. 6% NPV 99. 1% 91. 3% 100. 0% 95. 2% 97. 9% 93. 9% Accuracy 99. 5% 97. 3% 100. 0% 97. 5% 95. 8% 1. Cousins LM, Smok DP, Lovett SM, Poeltler DM. Amnisure placental a microglobulin-1 rapid immunoassay versus standard diagnostic methods for detection of rupture of membranes. Am J Perinatol 2005; 22: 317 – 320. 2. Lee SE, Park JS, Norwitz ER, Kim KW, Park HS, Jun JK. Measurement of placental a-microglobulin-1 in cervicovaginal discharge to diagnose rupture of membranes. Obstet Gynecol 2007; 109: 634– 640. 3. Grizzell et al. Wesley Medical Center | Data found in Amni. Sure ROM Test Package Insert (FDA Cleared). Amni. Sure International, LLC. 2011 4. Silva E, Martinez JC. Diagnosing ROM: a comparison of the gold standard, indigo carmine amnioinfusion, to the rapid immunoassay, the Amni. Sure ROM test. J Perinat Med 2009; 37(S 1): 956. 5. Tagore S, Kwek K. Comparative analysis of insulin-like growth factor binding protein-1 (IGFBP-1), placental alpha microglobulin-1 (PAMG-1) and nitrazine test to diagnose premature rupture of membranes in pregnancy. J Perinat Med 2010; 38: 1 -4. 6. Birkenmaier A, Ries JJ Kuhle J, Burki N, Lapaire N, & Hosli I. Placental a-microglobulin-1 to detect uncertain rupture of membranes in a European cohort of pregnancies. Arch Gynecol Obstet, April 2011 7. Albayrak M, Ozdemir I, Koc O, Ankarali H, & Oren O. Comparison of the diagnostic efficacy of the two rapid bedside immunoassays and combined clinical conventional diagnosis in prelabour rupture of membranes. European Journal of Obstetrics & Gynecology and Reproductive Biology, June 2011. 8. Abdelazim IA, Makhlouf HH. Placental alpha microglobulin-1 (Amni. Sure(®) test) for detection of premature rupture of fetal membranes. Arch Gynecol Obstet. 2011 Oct 30. [Epub ahead of print] 9. Marcellin L, Anselem O, Guibourdenche J, De la Calle A, Deput-Rampon C, Cabrol D, Tsatsaris V. Comparison of two bedside tests performed on cervicovaginal fluid to diagnose premature rupture of membranes. J Gynecol Obstet Biol Reprod (Paris). 2011 Nov; 40(7): 651 -6. Epub 2011 Oct 17. . 4

Why is Amni. Sure much more accurate than comparable tests? – PAMG-1 Placental Alpha Microglobulin-1 is only found in amniotic fluid above 1 ng/ml – Simple relationship between a rupture and presence of PAMG -1. Threshold for PAMG-1 detection, >1 ng/ml PAMG-1 concentration in amniotic fluid, 2, 000 -25, 000 ng/ml Faint Positive Line Hypothetical PAMG-1 concentration in ruptured patient PAMG-1 Concentration (ng/ml) Even after miniscule leakages of amniotic fluid, drastic increases of PAMG-1 are found in vaginal discharge

Patient Presents With Signs and Symptoms of Premature Rupture of Membranes (PROM) Patient presents with signs and symptoms of rupture of membranes (PROM) Complete Speculum Examination Obvious Leakage – Admit or Discharge Patient Unsure Following Speculum Admit patient with clinical judgement • Opportunity to administer corticosteroids, ABx, tocolytics and/or transfer patient Collect and run Amni. Sure ROM Test sample Discharge patient with clinical judgement

AMNISURE® ROM TEST (PAMG-1 TEST) PROCEDURE • Step 1: Vaginal swab, 5 -7 cm deep, no speculum required – Step 2: Rotate swab in vial to dilute sample for 1 min • Step 3: Insert test strip into vial and read results after 5 min sharp 7

AMNISURE® ROM TEST (PAMG-1 TEST) READING THE RESULTS Control Line Test Line Faint or broken lines should always be interpreted as a positive result. If both the control line and test line are visible, the test result is positive. If only the one control line is visible on the test strip, the test result is negative. If no lines are visible, the test result is invalid. 8

Current Methods Currently two methods of diagnosing (P)PROM within NHS Trusts: Speculum and History 47% of the time clinicians are not fully confident of diagnosis following a speculum 1. 30% misdiagnosis rate of these difficult cases. Alternate Rupture of Membrane Tests Actim Prom ROM Plus Amni. Sure 1 Neil PRL, Wallace EM. Is Amni. Sure® useful in the management of women with prelabour rupture of the membranes? Australian and New Zealand Journal of Obstetrics and Gynaecology 2010.

SCOPE OF THE PROBLEM PROM DIAGNOSIS AND MANAGEMENT *Appropriate management hinges on correct diagnosis* 25 -30% Estimated percent of pregnancies presenting w/suspicion of p/PROM 1 47% of the time clinicians will be uncertain about the diagnosis based on physical examination alone 2 30% 1 Nisell H, Hagskog K, Westgren M. Assessment of fetal fibronectin in cervical secretion in cases of equivocal rupture of the membranes at term. Acta Obstet Gynecol Scand. 1996 Feb; 75(2): 132 -4. 2 Neil PRL, Wallace EM. Is Amni. Sure® useful in the management of women with prelabour rupture of the membranes? Australian and New Zealand Journal of Obstetrics and Gynaecology 2010. Admitted without a rupture or discharged with a rupture. 10

Speculum Case Study – 4, 000 Births 1, 200 Births 565 170 • Mid-Size Trust • Based on NHS Average, a hospital will see 30% SROM cases. • Based on Neil and Wallace (2011) study, 47% of the time clinicians will not be totally confident if the mother has ruptured or not from speculum and history alone. • Based on the average from accepted business cases, 30% of difficult cases will be misdiagnosed i. e. mother is admitted unnecessarily or discharged incorrectly. • Average cost of misdiagnosis is £ 1, 014. 65 – One night admission (£ 658. 00), Medication (£ 27. 85), 4 x 1 hour clinician’s time (£ 328. 80). £ 172, 490. 50 • Multiply this cost by the number of misdiagnosis equals £ 172, 490. 50

Current Tests – Actim Prom detects a protein named IGFBP-1 is not just found in amniotic fluid, it is also found in background vaginal discharge and blood. Leads to high of number of contra-indications producing false results. Over 40 publications have been produced analysing IGFBP-1 and PAMG-1 (Amni. Sure). In 2012 the most recognised (P)PROM publication was produced. A meta-analysis which reviewed all 40 publications – Ramsauer et al. 2012.

Clinical Evidence – Ramsauer et al. 2012 Summary – IGFBP-1 test is acceptable in ‘known’ cases i. e. obvious leakage, but unacceptable in ‘unknown’ cases i. e. when ROM tests are used throughout the NHS. Conclusion – “Comparison with its performance in women for whom membranes status is known, the performance of the IGFBP-1 test decreases significantly when used on patients for whom membrane status is unknown. In this latter clinically relevant population, the PAMG-1 test has higher accuracy than the IGFBP-1 test”.

ROM Plus Accuracy: ROM Plus has an FDA cleared specificity of 75% (58% >36 weeks) and a PPV of 85%. ROM Plus Test 510(k) Substantial Equivalence Determination Decision Summary, 2011. www. accessdata. fda. gov/cdrh_docs/reviews/ K 110605. pdf. FDA Warning: “The ROM Plus test may report positive results in patients with intact membranes (see specificity in the performance section) and therefore decisions to induce labor should not be based solely on the ROM Plus results” ROM Plus Test 510(k) Substantial Equivalence Determination Decision Summary, 2011. www. accessdata. fda. gov/cdrh_docs/reviews/ K 110605. pdf.

Actim Prom vs. Amni. Sure Case Study – 4, 000 Births Actim Prom Amni. Sure 1, 200 SROM Cases 565 Difficult Cases – Actim Prom used. 565 Difficult Cases – Amni. Sure Used Based on Ramsauer et al. 2012 – 75. 8% Accuracy in ‘Unknown’ i. e. difficult cases Based on Ramsauer et al. 2012 – 97. 5% accuracy in ‘Unknown’ i. e. Difficult cases. Of 565 Cases Actim Prom would statistically misdiagnose 136 cases. Of 565 Cases Amni. Sure would statistically misdiagnose 14 cases. Total Unnecessary Costs = £ 137, 992. 40 (136 x £ 1014. 65) Total Unnecessary Costs = £ 14, 205. 10 (14 x £ 1014. 65) Using Amni. Sure, as found by more than 60 NHS Trusts, produces significant cost savings – In the case of a 4, 000 birth hospital savings would be c£ 123, 787. 30

Realistic Benefits using Amni. Sure Efficiency - A mother visits the hospital with relevant signs and symptoms – first complete speculum, if unsure, use Amni. Sure – mother can be accurately diagnosed and therefore treated relevantly within 10 minutes of being seen. Contra-Indications - Only test not contra-indicated by blood, semen, urine and/or infection so can be used in all scenarios. Other tests do not offer the same. Community Programs – Many busier Trusts allow community midwives to use Amni. Sure to prevent mothers unnecessarily being on the unit. Liability – Clinicians can add Amni. Sure sticker to patient’s notes as evidence of taking necessary precautions.

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