PROM, PPROM, Preterm labour Flashcards
(46 cards)
1
Q
what is PROM
A
Prelabor rupture of membranes is the draining of amniotic fluid due to rupture of membranes occurring before the onset of labor.
2
Q
when can PROM occur
A
at term (≥ 37 weeks)
3
Q
when does PPROM occur
A
28- 37 weeks
3
Q
what is PPROM
A
preterm prelabor rupture of membranes is defined draining of amniotic fluid due to rupture of membranes occurring before the onset of labor.
4
Q
what is the pathophysiology for PPROM and PROM (3)
A
- The amniotic membrane integrity is strengthened by collagen synthesis and weakened by metalloproteinases
- as a term is approaching, the activity of metalloproteinases becomes more pronounced in preparation for the labor
- There is major imbalance between metalloproteinase inhibitors and metalloproteinases activity before the onset of the labor, favoring metalloproteinases activity- resulting in in breakdown of collagen fibers, compromising the integrity of the membrane
4
Q
PROM occurs in % of pregnancy
A
3-15%
5
Q
PROM causes what
A
30–40% of preterm labor worldwide.
5
Q
what should you ask in history for PPROM and PROM (9)
A
- Contractions
- Fetal movement
- Time of possiblerupture
- Amount of fluid
- Color and odor of fluid
- Vaginal bleeding
- Pain
- Recent sexual encounters
- Recent trauma and recent physical activity
- Signs of UTI
6
Q
what are risk factors for PROM/ PPROM (9)
A
- Previous PROM or PPROM
- Ascending infection (UTI)
- Nutrition deficiencies
- Smoking
- Multiple gestation
- Polyhydramnios
- Incompetent cervix
- Antepartum bleeding ( mostly 2nd and 3rd trimester)
- Genetic predisposition
6
Q
what is the clinical presentation for PROM and PPROM (5)
A
- A sudden ‘gush of fluid’ leaking from the vagina
- Cramping
- Recurrent dampness or constant leaking
- Contractions
- Back pain
7
Q
what investigations can you do for PROM and PPROM (4)0
A
- USS
- which will show oligohydramnios (low liquor volume) by lowering Amniotic fluid index ( normal 5-25 cm) - FBC, culture and sensitivity , U& E’s, creatinine for septic screening to rule out infectious causes of PROM ( high leukocytes count)
- Nitrazine test
- involvesputting a drop of fluid obtained from the vagina onto paper strips containing Nitrazine dye.
- The strips change color depending on the pH of the fluid.
- The strips will turn blue if the pH is greater than 6.0. A blue strip means it’s more likely the membranes have ruptured
- normal vaginal Ph is 4.5-5.5
- pH of liquor is 7-7.75 - Fern test
- take a sample of fluid, put it on a slide and allow it to dry then look at it under a microscope where you see liquor looking like ferns
7
Q
what should you avoid doing on exam for PROM and PPROM and why
A
Avoid digital vaginal examination ( especially if PPROM) because it can introduce organisms into cervical canal, increases the incidence of chorioamnionitis, post-partum endometritis and neonatal infection
7
Q
what exam do you do in PROM and PPROM (3)
A
- STERILE SPECULUM EXAMINATION
- To Visualize amniotic fluid passing from the cervical canal and pooling in the vagina.
- To exclude any signs of cervicitis, umbilical cord prolapse, vaginal bleeding or fetal prolapse
- To take cervical swab
- To perform Nitrazine and Fern tests. - Obstetric exam
- Check vital signs
- temp
- pulse
- BP
7
Q
what is the general management for PPROM (4)
A
- Send investigations: urine dipstick, urine culture if available, FBC
- If in labour administer Benzyl Penicillin 2 MU q6h IV
- Steroids: dexamethasone 6 mg IM BD x 4 doses
- If not in labor can send to ANW
8
Q
what causes a false positive in a fern test (2)
A
- well estrogenized cervical mucous
- contaminated equipment.
9
Q
what causes a false negative in a fern test (2)
A
- intermittent leaking and thus inadequate amount of amniotic fluid for slide
- heavy contamination with vaginal discharge or blood.
9
Q
what is the general management for PROM/PPROM (5)
A
- Admit patient to labour ward or antenatal ward
- Monitor uterine activity and fetal heart
- Check maternal PR and temperature every 4 hours
- Assess for labour, chorioamnionitis and placental abruption at least daily
- USS for presentation, anatomy and liquor volume
9
Q
how do you manage PPROM > 34 weeks (3)
A
- If HIV negative, induce or augment if no spontaneous labour in 24 hrs since rupture of membranes
- If HIV positive start immediate induction, if not in labor within 24 hours consider cesarean
- Deliver by cesarean section if previous cesarean section.
10
Q
what are signs of chorioamnionitis (
A
- maternal tachycardia
- maternal fever
- abdominal tenderness
- foul vaginal discharge
- WBC > 16000
10
Q
what is the management for PROM (4)
A
- Start Benzyl Penicillin 2 MU q6h IV if PROM ≥ 18 hours
- FBC, group & save
- Induce/augment labour by 24 hours after PROM
- Caesarean delivery if previous cesarean section
11
Q
how do you manage PPROM of 28-34 weeks (4)
A
- Expectant management
- Minimize mobility; encourage leg exercises and/or anti-embolic measures
- Treat with Steroids and oral antibiotics for latency: Erythromycin 250 mg QID for 7 days and deliver at 34 weeks gestation unless there are signs of chorioamnionitis
- Admission FBC, Repeat FBC weekly or if otherwise indicated
11
Q
what are maternal complications of PROM/PPROM (3)
A
- Infection e.g. endometritis
- Risk of cesarean section
- Thromboembolic events due to being bed ridden
11
Q
how do you manage PPROM of 26-28 weeks (3)
A
- Consultant input strongly recommended
- USS for estimated fetal weight.
- Decision to continue with pregnancy discussed with patient
- Conservative management involving close monitoring for infection, labour or placental abruption; pelvic rest. modified bed rest with bathroom privilege, serial USS, and oral antibiotics for latency.
- Give corticosteroids at 27 weeks if patient reaches that gestation
12
Q
what is the management of chorioamnionitis (2)
A
- Ampicillin 1 g OR Benzyl Penicillin 2 MU IV q6h, plus Gentamicin 240 mg daily IV until 48 hours afebrile.
- If still spiking fevers add metronidazole 500 mg IV every 8 hours until 48 hours afebrile
12
how do you manage PPROM <26 weeks (2)
1. Determine gestation age to provide a realistic appraisal of outcomes
2. Options to be discussed with patient:
- Labour induction with IV oxytocin and/or oral or intravaginal misoprostol
- Conservative management: close monitoring for infection, labour or placental abruption, strict pelvic rest, modified bed rest with bathroom privileges, serial USS, and oral antibiotics for latency.
13
what are fetal complications of PROM/ PPROM (6)
1. Preterm labor
2. Placenta abruption
3. Neonatal sepsis
4. Cerebral palsy secondary to intraventricular hemorrhage
5. Infection
6. respiratory distress syndrome secondary to pulmonary hypoplasia
13
where are WBC's elevated (2)
1. pregnancy
2. up to 7 days after antenatal corticosteroids
14
what is preterm labor
it is the onset of contractions that cause progressive cervical changes at < 37 weeks GA
15
preterm birth complications are the leading cause of what
death among children under 5 years of age
16
you shouldnt use the tocolytic nifedipine with what
magnesium
16
preterm labor complicates how many pregnancies
10-12%
17
what are the fetal side effects of the tocolytic nifedipine (2)
1. sudden fetal death
2. fetal distress
17
how will the patient clinically present in the history and examination in preterm labor(4)
History
- Lower abdominal pain
- Backache
- Early contractions
Examination
- Presence of mild or moderate contractions with cervical dilation and effacement on Vaginal examination
17
what are the risk factors for preterm labor (14)
1. Ascending infection
- UTI
- Cervicitis
- Bacterial vaginosis
- Candida infection
2. Systemic infection
- Febrile illness i.e malaria
3. Uterine distension
- Multiple pregnancy
- Macrosomia
- Polyhydramnios
4. Antepartum hemorrhage
- placenta abruption
5. Uterine malformations
- Bicornuate uterus
- Fibroid uterus
6. Cervical weakness
- previous surgeries
- genetic predisposition
- cervical insufficiency
7. previous preterm delivery
8. smoking and illegal drug use
9. lower socioeconomic status- associated with poor nutrition
10. extremes of age
11. poor or lack of antenatal care
12. PPROM
13. maternal stress
14. previous still birth
17
what is the tocolytic nifedipine contraindicated in
Cardiac disease but
use with caution in
renal disease
18
what investigations do you do for preterm labor (5)
1. Transvaginal ultrasound to check for a short cervical length (<2.5 cm)
2. Sterile Speculum exam
- High vaginal swab
3. Urinalysis
4. MRDT
5. FBC
18
what management do you give to prevent preterm labor (5)
1. Screen and treat asymptomatic bacteriuria/urine microscopy (previous preterm birth)
2. If previous preterm birth and current singleton gestation, then treat with hydroxyprogesterone acetate 250mg IM every week at 16-36 weeks if available
3. Interventions with inconsistent evidence – treatment of asymptomatic bacterial vaginosis, cervical cerclage
4. Offer a choice of either prophylactic vaginal progesterone or prophylactic cervical cerclage to women with:
- A history of spontaneous preterm birth or mid-trimester loss between 16+0 and 34+0 weeks of pregnancy
and
- in whom a transvaginal ultrasound scan has been carried out between 16+0 and 24+0 weeks of pregnancy
that reveals a cervical length of < 25 mm, who have either:
~ had PPROM in a previous pregnancy
~ a history of cervical trauma
5. Discuss the benefits and risks of prophylactic progesterone and cervical cerclage with the woman and take her preferences into account.
19
in established preterm labor how do you manage ( 8)
1. Monitor fetal heart rate and contractions
2. IV line with NS at maintenance rate
3. Send investigations if available: FBC, urinalysis / urine dipsticks, speculum exam to check for abnormal discharge,
4. Do a wet prep/mount fortrichomonas and bacterial vaginosis
5. USS for presentation, AFI, placental location, EFW, EGA
and anatomy
6. Group B streptococcus prophylaxis
- Treat with penicillin IV (erythromycin if allergy to penicillin)
7. Steroids for decreased risk of respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC) and intraventricular haemorrhage (IVH)
- Treat at 28-34 wks gestation unless fetal lung maturity is confirmed
- Betamethasone 12 mg IM every 24 hrs x 2 doses; or
- Dexamethasone 6 mg IM every 12 hrs x 4 doses
7. Tocolytic medications to delay delivery for 48 hrs (for steroids to work) if contractions are present
8. Delivery and neonatal care
- Inform NICU so that neonatologist or paediatrician may attend delivery
- Deliver with intact membranes if possible
- Minimize trauma by easing out the head in second stage of labour
- Forceps may be used to assist delivery; avoid vacuum extraction
- Suction neonatal airway immediately, avoid hypothermia and transfer neonate to NICU as soon as possible
9. Consider Caesarean delivery if breech presentation
10. Consider using Magnesium sulfate for neuroprotection if viable, EGA <32 weeks, and concern for imminent preterm birth (dosage as per preeclampsia protocol; or if IV infusion available, give 4g IV loading dose over 30
minutes, followed by 1 g/hr maintenance)
- If antenatal magnesium sulfate has been started for fetal neuroprotection, tocolysis should be discontinued.
- For planned preterm birth for fetal or maternal indications, magnesium sulfate should be started ideally
within 4 hours before birth.
- Magnesium sulfate should be discontinued at delivery, if delivery is no longer imminent, or when a
maximum of 24 hours of therapy has been administered.
20
what are maternal side effects of the tocolytic salbutamol
heart palpitations
20
what are maternal side effects of the tocolytic nifedipine (7)
1. Flushing
2. headache
3. dizziness
4. nausea
5. transient hypotension
6. transient tachycardia
7. palpitations
21
what are the tocolytic medications (3)
1. nifedipine
2. indomethacin <32 weeks
3. salbutamol
22
what is the tocolytic indomethacin contraindicated in (2)
1. significant renal and hepatic impairment
22
what are maternal side effects of the tocolytic indomethacin (2)
1. nausea
2. heartburn
22
what are the fetal side effects of the tocolytic indomethacin (6)
1. Constriction of ductus
arteriosus
2. pulmonary HTN
3. reversible renal dysfunction with oligohydramnios
4. IVH
5. NEC
6. hyperbilirubinemia
22
what are the fetal side effects of the tocolytic salbutamol
transient fetal tachycardia
23
what is the tocolytic salbutamol contraindicated in (20
1. cardiac disease
2. renal disease
