PPROM & Chorio-amnionitis

Question 1

What are the causes of premature rupture of membranes in pregnancy?

Answer 1

1- idiopathic weakness of fetal membranes
2- bacterial endotoxin or TNF-a -> release of fetal fibronectin (fFN) -> increased PGE2 & degradation of collagen
3- cervical incompetence
4- trauma: ECV, amniocentesis, cerclage
5- abruptio placenta
6- polyhydramnios
7- multi-fetal pregnancy
8- fetal malpresentation
9- preterm labour

Question 2

What are the predisposing factors for PPROM?

Answer 2

1- low BMI < 19
2- heavy maternal smoking
3- frequent sexual activities
4- recurrent vaginal infections/UTI
5- past history of PPROM/PTL
6- cervical conization
7- low socio-economic status

Question 3

What are the signs of premature rupture of membranes in pregnancy?

Answer 3

1- low fundal height
2- uterus is lax
3- easily palpable fetal parts
4- sterile speculum examination

Question 4

What investigations should be done for PPROM?

Answer 4

1- CBC + urine culture + HVS for C&S
2- ultrasound examination + NST
3- fetal fibronectin >50mg/ml
4- test for IGFBP-1 by Actim PROM & PAMG-1 by AmniSure ROM
5- test for Phosphatidylglycerol (>35w)
6- amniotic fluid index: normally 5 - 25cm
- oligohydramnios <5cm
- polyhydramnios >25cm

Question 5

What are the maternal complications of PROM?

Answer 5

• chorioamnionitis -> puerperal sepsis & subinvolution -> atonic postpartum hemorrhage
• abruptio placenta -> APH
• oligohydramnios -> malpresentation
• complications of the cause

Question 6

What are the fetal complications of PROM?

Answer 6

• neonatal sepsis -> perinatal M&M
• maternal fetal transmission of HIV
• cord compression/prolapse -> fetal distress
• prematurity -> RDS + intracranial hemorrhage + CP + NE
• severe oligohydramnios -> pulmonary hypoplasia + fetal deformities

Question 7

How is PROM managed?

Answer 7

management depends on presence of: labour pains, signs of infections, fetal distress
- if present -> terminate pregnancy no matter the GA
- if not present
-> if GA is < 34 weeks: complete bed rest + corticosteroids + MgSO4 + erythromycin 250mg/6h for 10 days
-> if GA is > 34 weeks: wait 24-48hrs for spontaneous labour pain + give corticosteroids, MgSO4, & Erythromycin -> if labour doesnt occur: induce labour

Question 8

How should vaginal delivery be managed in case of PROM?

Answer 8

1st Stage of Labour
- sedation & analgesia
- asepsis precautions
- strict monitoring

2nd Stage of Labour
- avoid prolongation

3rd Stage of Labour
- guard against postpartum hemorrhage
- guard against puerperal sepsis

Question 9

When is C section indicated in case of PROM?

Answer 9

• maternal sepsis (chorioamnionitis + SIRS)
• fetal distress
• malpresentation
• failed induction

Question 10

What are the predisposing factors for chorioamnionitis?

Answer 10

• PPROM - PROM
• vaginal cervical cerclage
• invasive procedures: amniocentesis, foetoscopy
• immuno-suppression: DM, steroid therapy

Question 11

What are the organisms that may cause chorioamnionitis & what are their routes of infection?

Answer 11

• Mixed infection: G. vaginalis, Fusobacterium, Mycoplasma hominis, & U. Urealyticum
• gonorrhea & chlamydia trachomatis
• GBS, Listeria, Bacteroids
  ascending or trans-placental

Question 12

What is the clinical picture of chorioamnionitis?

Answer 12

• fever, malaise
• lower abdominal pain
• abnormal vaginal discharge &/or bleeding
• reduced fetal movements

Signs of maternal sepsis (infection + SIRS)
2 are diagnostic:
- hyperthermia >38C or hypothermia <36C
- tachypnea >20 breaths/min
- tachycardia >90bpm
- leucocytosis >12000 or leucopenia <4000

Question 13

What will be found on physical examination of a patient with suspected chorioamnionitis?

Answer 13

• period of amenorrhea
• Leopold’s grips -> easily palpable fetal parts, tender uterus
• fetal tachycardia
• sterile speculum examination -> fluid pooling in vagina or leaking from cervical os

Question 14

What investigations are done for diagnosis of chorioamnionitis?

Answer 14

1- CBC + urine analysis + HVS for C&S
2- vaginal + perianal + anal swabs -> GBS
3- ultrasound examination + NST
4- fetal fibronectin >50ng/ml
5- test for IGFBP-1 by Actim PROM & PAMG-1 by AmniSure ROM
6- test for phosphatidylglycerol (>35w)

Question 15

What are the indications for conservative treatment of chorioamnionitis?

Answer 15

• gestational age < 34 weeks
• mother is not in active labour
• no evidence of sepsis
• fetus is alive + not distressed + no CFMF

Question 16

What are the indications for termination of pregnancy in chorioamnionitis?

Answer 16

• gestational age > 34 weeks
• mother is in active labour
• evidence or suspicion of sepsis (+ SIRS)
• fetus is dead or distressed or lethal CFMF

Question 17

How is a lady with chorioamnionitis treated conservatively?

Answer 17

1- hospitalization & sedation to avoid anxiety

2- maternal follow up
- daily observation of vaginal discharges, vital signs, abdominal pain or tenderness
- antibiotics: erythromycin 250mg/6hr for 10 days
- if +ive GBS: Benzyl Penicillin, Cefazolin, or Clindamycin
- corticosteroids 24-34 weeks
- MgSO4 24-30 weeks
- remove cerclage before 24hrs from PROM

3- fetal follow up
- non-stress test
- BPP weekly
- notify NICU

Question 18

What drugs are contraindicated incase of chorioamnionitis?

Answer 18

• amoxicillin-clavulanate -> neonatal necrotizing enterocolitis
• never give tocolysis

Question 19

How is induction of labour done in case of chorioamnionitis?

Answer 19

• PG (prostin-E2) -> augmentation of labour by oxytocin infusion
• C section -> if there are indications

Question 20

How is septic shock managed in chorioamnionitis?

Answer 20

Lactate >2mmol -> ICU

1- resuscitation (20ml/kg crystalloids + packed RBCs + FFP) -> maintain CVP >10cm/h2O
2- Vasopressors (epinephrine) + Inotropes (Doputamine) -> maintain MAP > 65mmHg
3- assisted ventilation -> O2 saturation > 96%
4- steroids + diuretics (if urinary output <30ml/h)
5- broad spectrum antibiotics within 1st hour -> ampicillin + gentamicin + metronidazole
6- septic focus -> hysterectomy in toto