GTG - 73 - Care of women presenting with suspected Preterm prelabour rupture of membranes from 24 weeks of gestation. Flashcards
PPROM complications up to what % of pregnancies
3%
A combination of clinical assessment and 1) which blood tests and 2) which other parameter should be used to diagnose chorioamnionitis in women with PPROM.
WCC, CRP AND fetal heart rate.
None of these should be used in isolation.
PPROM is associated with what % of preterm births
30-40%
What is the median latency after PPROM?
7 days - tends to shorten as gestational age at PPROM advances
What is the gold standard for diagnosis of PPROM?
Maternal history followed by sterile speculum examination demonstrating liquor.
If on speculum no amniotic fluid is observed. What tests could clinicians consider?
IGFBP-1 or PAMG-1 test of vaginal fluid.
What is the role of US assessment of amniotic fluid volume in diagnosis of PPROM
It is unclear.
What are the symptoms of clinical chorioamnionitis that women should be advised of and observed for?
Lower abdominal pain, abnormal vaginal discharge, fever, malaise and reduced fetal movements.
Aside from symptoms which other parameters should be observed when clinically assessing for chorioamnionitis?
Pulse, blood pressure, temperature and fetal CTG.
Following administration of steroids when should the WCC return to baseline?
3 days following administration
Following administration of steroids when will the WCC rise?
24hrs after administration.
Which maternal serum marker is most informative for predicting histological chorioamnionitis after PPROM?
CRP
For diagnosing histological chorioamnionitis after PPROM what is the sensitivity and specificity of CRP
sensitivity 68.7% and specificity 77.1%
When caring for a woman with PPROM as an outpatient what does the RCOG advise regarding frequency of reviews
One to two times each week.
bloods tests, observations and FHR monitoring.
How long should antibiotics be given following diagnosis of PPROM?
erythromycin should be given for 10 days or until the woman is in established labour. (whichever is sooner)
From a cochrane review what are the benefits of antibiotics following diagnosis of PPROM?
Reduced chorioamnionitis, prolonged latency and improved neonatal outcomes
From the cochrane review what is the RR reduction in chorioamnionitis with antibiotics in PPROM?
RR 0.66
What are the neonatal outcomes that are improved with use of antibiotics in PPROM?
Reduction in babies born within 48 hours and 7 days.
Neonatal infection
Surfactant use
Oxygen therapy
Abnormal cerebral ultrasound prior to discharge.
Which outcomes did NOT see a significant improvement with antibiotic use in PPROM?
There was no improvement in perinatal mortality or on the health of the children at 7 years of age.
Which group of antibiotics may be used in women who cannot tolerate erythromycin for PPROM
Penicillin
Which antibiotic should be avoided in PPROM
co-amoxiclav - due to the association with neonatal necrotising enterocolitis.
AN steroids with PPROM between 34-35+6?
Given the high number needed to treat and the potential side effects of steroids administration should be evaluated on an individual basis.
What is the RR reduction of cerebral palsy following MgSO4 administration?
0.69
What was the demonstrated effect of tocolysis in PPROM.
An average 73 hours latency of delivery and fewer births within 48 hours, however
Increased risk of 5 min APGAR score less than 7 and an increased need for ventilation support.
For women before 34 weeks tocolysis also increased risk of chorio.
What is the median latency with PPROM between
1) 24 - 28/40?
2) 31+
1) 8-10 days
2) decreases to 5 days
What did a case control study demonstrate with women who have reduced amniotic fluid volumes on USS
They are more likely to give birth within 7 days from membrane rupture.
regarding timing of delivery. What management should be offered in pregnancies complicated by PPROM after 24 weeks and no other contraindications to continuing?
Expectant management until 37 weeks.
On an individual basis with careful consideration of patient preference and ongoing clinical assessment.
Previous guidance recommended expectant management to 34 weeks. Regarding neonatal sepsis/infection, what is the difference between early birth expectant management to 37 weeks.
No difference
Previous guidance recommended expectant management to 34 weeks. What is the difference in RDS incidence with early birth compared to 37 weeks expectant management
Higher incidence of respiratory distress syndrome. RR 1.26
Previous guidance recommended expectant management to 34 weeks. what is the difference is LSCS rate compared to expectant management to 37 weeks
Increased rates of LSCS. RR 1.26
Previous guidance recommended expectant management to 34 weeks. What is the difference in overall perinatal mortality or IUFD? compared to expectant management to 37 weeks
No difference
What are the implications for any future pregnancies.
The risk of PPROM in subsequent pregnancies is increased.
A short inter pregnancy interval is associated with a greater risk.
In future pregnancies who/and in what setting should women with pregnancies affected by PPROM be looked after?
A consultant with interest in pre-term birth and in a dedicated preterm birth clinic.
