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RCPSC > Obstetrics - Prematurity > Flashcards

Obstetrics - Prematurity Flashcards

1
Q

Incidence of PPROM

A

3% of all pregnancies

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2
Q

Primary investigations for PPROM

A

Nitrazine, ferning test, AFI (if fluid not visible)

93% sensitivity

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3
Q

Second line investigation for PPROM

A

PAMG-1

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4
Q

GBS swab should be done for PPROM if not done within last

A

5 weeks

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5
Q

risk of recurrence of PPROM

A

10-32%

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6
Q

Risk of PTL in future pregnancy after PPROM

A

34-46%

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7
Q

subclinical infection in ___% of PPROM

A

50%

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8
Q

___% of PPROM proceed to PTL

A

70%

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9
Q

50% of PPROM deliver within

A

one week

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10
Q

PPROM relationship with PTB

A

PPROM causes 1/3 of all PTL

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11
Q

PTB incidence

A

8% of all births

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12
Q

___% of PPROM will have pooling of amniotic fluid in vaginal vault

A

60%

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13
Q

FN rate for pooling of fluid (PPROM)

A

12%

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14
Q

pH required for nitrazine + in PPROM

A

7.0-7.3

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15
Q

Gold standard for equivocal PPROM

A

amnio + carmine dye infusion
(not routinely performed)

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16
Q

pH of vagina

A

3.8 - 4.2

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17
Q

Initial assessment of maternal wellbeing in PPROM

A

HR, BP, Temp
Symptoms
Bloods (WBC)

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18
Q

Initial assessment of fetus in PPROM

A

EFM
USS

  • presentation,
  • biometry,
  • placental location,
  • AFI/DVP,
  • Cx length,
  • BPP if >28/40
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19
Q

Contraindications to expectant management in PPROM

A

1) active labour
2) evidence of infection
3) abruption
4) cord prolapse
5) abnormal CTG or USS

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20
Q

antibiotic options in PPROM

A

1)
a macrolide (erythromycin, azithromycin, or clarithromycin) alone or associated with GBS coverage for 2 days (if GBS status is unknown or positive), or
2)
a combination of ampicillin/amoxicillin and a macrolide independently of GBS status.

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21
Q

PPROM Erythromycin dose (oral)

A

250mg PO QDS x 10/7

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22
Q

PPROM Erytromycin dose (IV/PO)

A

250mg IV QDS x 2/7, then 333mg PO TDS x 5/7

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23
Q

PPROM Azithromycin dose

A

1g PO single dose

(or 500mg PO stat, then 250mg PO daily x 4/7)

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24
Q

PPROM Clarithromycin dose

A

500mg PO BD x 7/7

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25
Q

PPROM GBS coverage

A

Ampicillin 2g IV QDS x 2/7
or
Amoxicillin 500mg PO TDS x 5/7
or
PenG 5 MU IV, then 2.5–3.0 MU every 4 h for 2 d

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26
Q

steroids in PPROM associated with reduction in which fetal outcomes

A

significantly lower incidence of:
- perinatal intraventricular hemorrhage
- respiratory distress syndrome

27
Q

steroids in PPROM associated with no change in which fetal outcomes

A

no differences in:
- necrotizing enterocolitis,
- neonatal sepsis,
- Apgar score <7 at 5 minutes
- chorioamnionitis

28
Q

Patients with prior previable PPROM - risk of PTB in subsequent pregnancy

A

had a 46% risk of preterm birth <37 weeks in subsequent pregnancy,

(23% occurring <28 weeks,
and 17% occurring <24 weeks)

29
Q

PPROM - management in subsequent pregnancy

A

serial USS Cx after 14 weeks

consider progesterone supplementation and cerclage, if clinically indicated.

30
Q

PPROM - expectant management - each additional day adds % to neonatal survival

A

Expectant management improves neonatal survival by approximately 2% for each additional day of in utero maturation, with the optimal benefit between 24 and 27 weeks

31
Q

decision for in utero transfer at borderline viability should factor in:

A
  • gestational age
  • estimated fetal weight
  • parental preference
32
Q

current definition of borderline viability

A

prior to 25+6
(usually 22+0 to 25+6)

Period of ambiguity is greatest prior to and including 24+6

33
Q

neonates at 23+0 to 24+6 constitute about ___% of admissions to NICU

A

2%

34
Q

2015 Canadian neonatal network: survival for 23 and 24wkers till discharge

A

53% of 23 wkers
75% of 24 wkers

35
Q

benefits of delivery in a level 3 center

A
  • reduction in mortality
  • reduction in severe IVH
  • reduction in other causes of neonatal mortalitu
  • improvement of maternal decision making
  • may aid in prolonging pregnancy
36
Q

Ontario recommends transfer at borderline viability in cases in which:

A
  • family opted for active management
  • family would like to explore options
  • if referring centre is not comfortable with counselling around issues at the gestation
37
Q

most accurate method of dating

A

CRL after 7 weeks

38
Q

corticosteroids in the periviable cohort has shown to:

A
  • increased survival to 1 year of life
  • increased C/S
  • lower rates of mortality
  • lower rates of neurodevelopment impairment
39
Q

MgSO4 for neuroprotection should be given till what gestational age

A

31+6

40
Q

MgSO4 recommended if full intervention intended as early as ____

A

23 weeks, in cases of imminent delivery

41
Q

caesarean delivery in the extreme preterm population should be reserved for

A

maternal or obstetric indications when active neonatal management is planned

42
Q

when delayed cord clamping, what ambient temperature of OR

A

21C

43
Q

who should be offered an elective cerclage and when

A

12-14 weeks, for

  • history of 3 or more second trimester losses or extreme premature deliveries
  • no other cause than potential cervical insufficiency is identified
44
Q

who should be offered an abdominal cerclage

A

women with a classic history of cervical insufficiency in whom prior vaginal cervical cerclage has been unsuccessful
or
women who have undergone trachelectomy

45
Q

who should be offered an emergency cerclage

A

cx <4cm without contractions, before 24/40

46
Q

who should be offered serial cervical length assessment by USS

A

if cerclage is not considered or justified, but wHx of 1-2 prior mid-trimester losses or extreme premature deliveries

47
Q

who should be CONSIDERED for cerclage in singleton pregnancies

A
  • hx of spont PTB or possible cx insufficiency
    IF
  • cx =<25mm <24/40
48
Q

emergency or rescue cerclage should be considered in twins when

A

> 1cm dilation prior to viability

49
Q

cervical insufficiency prevalence

A

in up to 1% of obstetric populations

50
Q

cervical insufficiency in recurrent mid-trimester loss

A

8%

51
Q

up to ___% acute cervical insufficiency associated with intra-amniotic infection

A

80%

52
Q

microbial invasion of the amniotic cavity has been reported to occur in ___% of women with cervical insufficiency and exposed fetal membranes

A

50%

53
Q

which cerclage allows for higher placement (closer to inner os)

A

shirodkar

54
Q

risk of cervical laceration at insertion of cerclage

A

11-14%

55
Q

elective removal of cerclage at what gestation

A

36-38/40

56
Q

cerclage with PPROM - when to remove

A

within 48h

57
Q

administration of _____ prior to cerclage high reduce protruding membranes

A

indomethacin

related to fetal urine production and through tocolytic value

58
Q

conservative observation management of cx insufficiency

A

1) urine MCS and BV cultures
2) serial TV USS every 7-14 days from 16/40
3) reduce physical activity, prolonged periods of standing, frequent or repetitive lifting
4) encourage smoking cessation

59
Q

significantly shortened cx length in twins

A

<15mm - may benefit from cerclage

60
Q

emergency cerclage prolongs pregnancy by

A

4-9 wks avg

61
Q

who should be offered vaginal progesterone for prevention of PTB

A
  1. previous spont PTB
    And/or
  2. cx length <25mm at 16-24 weeks
62
Q

recommend dose PV progesterone

A
  • 200mg OD for singleton
  • 400mg OD for twins
63
Q

how long can progesterone continue

ie. For PTB prevention

A

upto 34-36 weeks

64
Q

when should progesterone therapy by initited

A

16-24 weeks

RCPSC (17 decks)

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