Multifetal Gestation and PPROM

Question 1

Definition of PPROM

Answer 1

Preterm Premature Rupture of Membrane → prior to 37 wks, prrior to onset of contractions/labor, amniotic sac ruptures and contents leak into vagina

Question 2

what are the risk factors for PPROM?

Answer 2

prior history, smoker, age < 18 or > 40, low BMI/poor nutrition, low SES, antepartum bleeding

Question 3

what do you need to distinguish PPROM from since it may have similar signs?

Answer 3

urinary incontinence

Question 4

How will a woman with PPROM present?

Answer 4

c/o large gush or trickle of fluid, continuous small leak, increased vaginal discharge, bleeding, pain, fever/chills

Question 5

What tests can you do to diagnose PPROM?

Answer 5

valsalva test 
low amniotic fluid on US 
Fern Test (diagnostic) 
Nitrazine (check for increase in pH) 
AmniSure (\$\$)

Question 6

what is the information you need to include when admiting a patient?

Answer 6

ADC VAN DIMAL

admit, diagnosis, condition, vitals, activity, nursing, diet, I and O, meds, allergies, labs

Question 7

What are factors that influence how you manage PPROM?

Answer 7

gestational age, +/- infection, +/- labor, fetal well being, NICU availability

Question 8

Patient presents with PPROM, what is your first step?

Answer 8

admit to inpatient immediately

Question 9

What would indicated immediate delivery is needed in patient with PPROM?

Answer 9

nonreassuring fetal monitoring, cord prolapse, labor, heavy bleeding, over infection

Question 10

what is commonly associated with PPROM?

Answer 10

abruptio placentae

Question 11

In PPROM, what can you initiate in a patient to mature fetal lungs?

Answer 11

betamethasone (steroid)

Question 12

what meds to you initially give in patient with PPROM?

Answer 12

betamethasone, magnesium sulfat (<32 wks fetal neuroprotection), latency antibiotics

Question 13

Latency antibiotics used prophylactically in PPRom cover what?

Answer 13

Chlamydia trachomatis, Group B strep, Ureaplasmas

Question 14

What are two combinations used in PPROM for prophylaxis?

Answer 14

ampicillin + azthromycin IV

amoxicillin + erythromycin PO

Question 15

Why are latency antibiotics benefitial in PPROM?

Answer 15

increases time between rupture and spontaneous labor

reduces frequency of maternal/fetal infection

Question 16

How long should you prophylactically give antibiotics with PPROM?

Answer 16

7 days → 2 days IV and 5 days PO

Question 17

Management for PPROM is present >34 weeks

Answer 17

deliver

Question 18

Management of PPROM present at 24-33 weeks

Answer 18

inpatient until delivery

labor/infection/fetal distress → deliver

Question 19

Labs and imaging to perform on PPROM

Answer 19

GBS (prior to starting abx.) and OB US

Question 20

What is Virchow’s Triad?

Answer 20

stasis, vessel wall injury, hypercoagulable state

Question 21

What can you give women at increased risk for PPROM in future pregnancies?

Answer 21

17-hydroxyprogesterone caproate supplementation

Question 22

For PPROM, if serial sonographic in future pregnancies indicates shortened cervix in 16-24 weeks what can you do?

Answer 22

cerclage

Question 23

What are neonates at risk for in multifetal pregnancies?

Answer 23

lower birthweight, shorter GA, IUGR, NICU, handicap, risk of CP, risk of NND

Question 24

Dizygotic twins form when

Answer 24

two separate eggs are fertilized

Question 25

What are risk factors for dizygotic twins?

Answer 25

race, age, parity, assisted reproduction techniques

Question 26

Monozygotic/chorionic twins form with

Answer 26

splitting of single fertilized egg

Question 27

Do MoMo twins share a placenta?

Answer 27

yes

Question 28

Egg splits at: day 2-3 day 3-8 day 8-13 day 13-15

Answer 28

DiDi MoDi MoMo conjoined twins

Question 29

How should you adjust the nutrition in multifetal pregnancy?

Answer 29

additional 600 calories/day | weight gain 35-45 lbs

Question 30

what does the twin peak on US indicate?

Answer 30

two separate placenta

Question 31

separate placenta, same or opposite gender

Answer 31

dizygotic

Question 32

"thick" membrane, "twin peak" sign, same or opposite gender

Answer 32

dichorionic

Question 33

"thin" membrane, lack of twin peak sign, same gender

Answer 33

monochorionic

Question 34

no dividing membrane visualized, same gender

Answer 34

monoamniotic

Question 35

Complications from multifetal gestations

Answer 35

preterm labor, gestational diabetes, preeclampsia, IUGR, fetal anomalies, twin-to-twin transfusion, postpartum hemorrhage

Question 36

what is the definition of preterm labor?

Answer 36

average delivery 36 weeks gestation

Question 37

15% of monochorionic gestations are at risk for

Answer 37

twin twin transfusion syndrome (TTTS)

Question 38

what occurs in TTTS?

Answer 38

vascular anastomoses in the placenta → fluid is shunted from one twin to the other

Question 39

when can you detect TTTS on US?

Answer 39

develop between 16-26 weeks

Question 40

Treatment for TTTS

Answer 40

serial amnioreduction or laser ablation

Question 41

Donor twin vs Recipient twin in TTTS

Answer 41

Donor → growth restricted, oligohydramnios/anhydramnios, poor renal perfusion/absent bladder on US, anemic/volume depleted, better outcome Recipient → large, polycythemic, polyhydramnios, volume overload/cardiac issues, hydrops, worse outcome

Question 42

death of co-twin in first trimester is often referred to as

Answer 42

"vanishing twin"

Question 43

what percent of babies can be delivered vaginally is vertex/vertex?

Answer 43

80%

Question 44

if twin A is nonvertex, how should you deliver it?

Answer 44

C-section

Question 45

what birthweight makes a fetus candidate for breech extraction?

Answer 45

> 1500 gm (EFW > 1800 gm and > 32 weeks)

Question 46

When should you deliver uncomplicated well dated twins electively?

Answer 46

38 weeks

Question 47

when should you deliver uncomplicated well dated triplets electively?

Answer 47

35-36 weeks