PTL/PROM/PPROM

Question 1

risk factors / indication for swab and treatment for GBS sepsis

Answer 1

labour related - PTL <37 weeks, PPROM, term PROM >18hrs

maternal RF - fever >38, GBS positive, previous infant with GBS

Question 2

management of GBS in

PPROM
term PROM >18hours
chorioamnionitis

Answer 2

intrapartum antibiotic prophylaxis (IAP) - IV benzylpenicillin 4hourly until birth, at least 4 hours prior to delivery

PPROM - erythromycin if not in labour

term PROM >18hrs - IOL + IAP (regardless of swabs)

chorioamnionitis signs - ampicillin + gentamicin + metronidazole, IOL (do not use tocolysis)

Question 3

definition of pre term labour

Answer 3

regular painful contractions associated with dilation +/- effacement at <37/40

Question 4

what is foetal fibronectin

Answer 4

only done to test for PTL - NOT PPROM!

glycoprotein that promotes adhesion between foetal chorion and maternal decidua (ie endometrium during pregnancy)

elevation >50 suggests PTL

useful to know <34/40 so you can do steroid loading

Question 5

causes of PTL

Answer 5

previous PTL (most important RF)

cervical incompetence - past surgery, cone biopsy, short cervix (<25mm)

PPROM

APH

uterine over distension - multiple, polyhydramnios, macrosomia

idiopathic

Question 6

prevention of PTL

Answer 6

reduce modifiable RF

• smoking, drugs, reduce stress, limit excessive activity
• treat UTI and BV

monitor - cervical length

options

• progesterone pessary (preferred)
• cervical cerclage (<15mm CL, high risk)

Question 7

pelvic exam for PTL

Answer 7

inspect - blood, liquor, discharge
sterile speculum - PPROM or PTL, pooling of liquor in speculum, discharge, dilation, membranes, liquor, collect high vaginal swab for fFN and low swab and anal swab for GBS

sterile bimanual - ONLY if cord prolapse suspected
- CI if ROM or praaevia

Question 8

indications to swab for fFN

Answer 8

symptomatic PTL
22-34 weeks gestation
intact membranes
<3cm dilated

Question 9

management for threatened PTL

Answer 9

admit to maternal ward - ROM, regular painful contraction, cervical dilation

tocolysis if <34 weeks with nifedipine (allow time for steroids to work)

corticosteroids - 2x betamethasone IM 24hrs apart

MgSO4 <30weeks

Abx - benzylpenicillin

Question 10

risk factors for cord prolapse

Answer 10

IOL - ARM before head is engaged

presentation other than cephalic

Question 11

management of cord prolapse

Answer 11

mum in knee chest position on all 4s
digitally displace cord into vagina
C/S unless fully dilated and VB can occur rapidly

Question 12

definition of PROM

Answer 12

prelabour rupture of membranes at >/=37 weeks and >4hours before onset of labour

Question 13

complications of PROM

Answer 13

cord prolapse
infection - neonatal sepsis chorioamnionitis
placental abruption

Question 14

Ix for PROM

Answer 14

if unsure about ROM use amnicator (blue/purple means ROM, orange means intact)
swabs - low vaginal and anorectal for GBS, MCS, chlamydia and gonorrhoea
urine MCS
FBC, CRP
USS for liquor volume

Question 15

management of PROM

Answer 15

counsel - high risk of infection to mum and baby
recommendation - IOL +/- Abx

IOL - oxytocin
expectant - at home or in hospital, at 18hours need IOL and GBS prophylaxis

Question 16

how do you determine rupture of membranes?

Answer 16

positive cough or valsalva - fluid leaks from os
pooling of liquor in vaginal cavity
amnicator (alkaline/blue suggests ROM)
ferning on microscopy

Question 17

define PPROM

Answer 17

preterm prelabour ROM (<37 weeks)

Question 18

complications of PPROM

Answer 18

PTL
infection 
abruption 
cord prolapse
oligohydramnios
foetal deformities - club foot 
neonatal mortality

Question 19

management of PPROM

Answer 19

if not in labour:
>34 weeks - IOL
<34 weeks - wait

Abx - erythromycin 10 days
steroids - betamethasone if <34 weeks
tocolysis - ONLY for transfer
MgSO4 - if imminent delivery and <30 weeks

ongoing monitoring - temperature, foetal movements, discharge, CTG