PPROM

Question 1

PPROM (viable)

Scenario 1 - AMA, P0, 26/40, IVF (overseas), w cerclage in-situ

Scenario 2 - 34yo P1, 27/40, Flu A c/b pneumo in ICU w abn dopplers (reversed) + NRCTG + footling breech

Scenario 3 - primip, term, PROM, breech presentation

Scenario 4 - 33yo G2P1, 29/40 PPROM w chorio, LLP/short cervix + previous CS, rural hospital, lives far from hospital

Scenario 5 - 34yo p/w high fever 29/40 on bkg of PPROM earlier

Scenario 6 - 43yo DCDA with demise of 1 twin earlier, PPROM 35/40 malpresentation in PTL

Scenario 7 - 25yo nullip 26/40, PPROM in setting of recent rescue cerclage

Answer 1

• M risk - chorio/abrup/CS/PPH/endome
• F risk - hypo/contractu/cord/PTB
• N risk - RDS/IVH/NEC/FDIU/NND
• confirm - spec - amnisure+HVS
• exclude infection - FBE/UEC/CRP/G&S
• MDI - MFM/Paeds/Ano+/-ID
• admission/observation 48/24
• regular pad checks
• steroid loading x2, 12-36/24
• PO erythromycin for 10 days
• +/- IVC-IVT + antipyretic
• +/- IV Abx +/- triple
• +/- MgSo4 if in labour
• +/- cerclage removal (if true PPROM)
• if chorio -> usually not suitable for in-utero transfer -> expedite delivery -> transfer newborn
• MOD - presentation/fetal wellbeing
• Chorio - more likely GA>Spinal
• emCS - more likely classical

Ongoing OPC mx
- OP F/U - wkly MCS + twice wkly bloods
- Monitor sx
- IOL from 37/40

Postpartum
- debrief/document
- recurrence up to 30%
- screen for vag/urine infection
- cervical surveillance +/- cerclage +/-P4
- exclude uterine anomalies

cord prolapse risk.
- 1% cephalic
- 11% non-cephalic presentation

Question 2

PPROM mx (pre-viable - before 24/40)

Scenario 1 - PPROM 23/40 w cerclage in-situ, twin preg, hx of previous cone bx & previous CS

Scenario 2 - PPROM 23/40 w/o cerclage

Scenario 3 - PPROM twin 24/40 with short cervix

Answer 2

• 10% can reseal (e.g. post amnio)
• 50% del in 1/52, 80% in 4/52
• survival rate <24/40 =5%
• survival <26/40 =60%
• survival 28-30/40 =98%
• paed counselling important to decide
• full resus vs TOP (mife/miso)

Question 3

Postpartum mx of pt suspected of chorioamnionitis

Scenario 1 - 34yo, 29/40, chorio, emCS for NRCTG

Answer 3

• MDI - Obs/Paeds/ID
• Follow local guidelines
• swab plac membrane/cord/plac
• placenta to histology
• inform Paed team re: chorio dx
• nursery + MCS + IV Abx
• continue IV Abx for mother 24-48/24
• chase MCS from BC/plac…
• repeat FBE/UEC/CRP ?improve
• LMWH + mechanical VTE proph
• consider switch PO Abx 5/7
• debrief/documentation
• at risk of endometritis/wound infect
• counsel re: sx to monitor on DC