Multifetal Gestation and PPROM Flashcards
Definition of PPROM
Preterm Premature Rupture of Membrane → prior to 37 wks, prrior to onset of contractions/labor, amniotic sac ruptures and contents leak into vagina
what are the risk factors for PPROM?
prior history, smoker, age < 18 or > 40, low BMI/poor nutrition, low SES, antepartum bleeding
what do you need to distinguish PPROM from since it may have similar signs?
urinary incontinence
How will a woman with PPROM present?
c/o large gush or trickle of fluid, continuous small leak, increased vaginal discharge, bleeding, pain, fever/chills
What tests can you do to diagnose PPROM?
valsalva test low amniotic fluid on US Fern Test (diagnostic) Nitrazine (check for increase in pH) AmniSure (\$\$)
what is the information you need to include when admiting a patient?
ADC VAN DIMAL
admit, diagnosis, condition, vitals, activity, nursing, diet, I and O, meds, allergies, labs
What are factors that influence how you manage PPROM?
gestational age, +/- infection, +/- labor, fetal well being, NICU availability
Patient presents with PPROM, what is your first step?
admit to inpatient immediately
What would indicated immediate delivery is needed in patient with PPROM?
nonreassuring fetal monitoring, cord prolapse, labor, heavy bleeding, over infection
what is commonly associated with PPROM?
abruptio placentae
In PPROM, what can you initiate in a patient to mature fetal lungs?
betamethasone (steroid)
what meds to you initially give in patient with PPROM?
betamethasone, magnesium sulfat (<32 wks fetal neuroprotection), latency antibiotics
Latency antibiotics used prophylactically in PPRom cover what?
Chlamydia trachomatis, Group B strep, Ureaplasmas
What are two combinations used in PPROM for prophylaxis?
ampicillin + azthromycin IV
amoxicillin + erythromycin PO
Why are latency antibiotics benefitial in PPROM?
increases time between rupture and spontaneous labor
reduces frequency of maternal/fetal infection
How long should you prophylactically give antibiotics with PPROM?
7 days → 2 days IV and 5 days PO
Management for PPROM is present >34 weeks
deliver
Management of PPROM present at 24-33 weeks
inpatient until delivery
labor/infection/fetal distress → deliver
Labs and imaging to perform on PPROM
GBS (prior to starting abx.) and OB US
What is Virchow’s Triad?
stasis, vessel wall injury, hypercoagulable state
What can you give women at increased risk for PPROM in future pregnancies?
17-hydroxyprogesterone caproate supplementation
For PPROM, if serial sonographic in future pregnancies indicates shortened cervix in 16-24 weeks what can you do?
cerclage
What are neonates at risk for in multifetal pregnancies?
lower birthweight, shorter GA, IUGR, NICU, handicap, risk of CP, risk of NND
Dizygotic twins form when
two separate eggs are fertilized
What are risk factors for dizygotic twins?
race, age, parity, assisted reproduction techniques
Monozygotic/chorionic twins form with
splitting of single fertilized egg
Do MoMo twins share a placenta?
yes
Egg splits at: day 2-3
day 3-8
day 8-13
day 13-15
DiDi
MoDi
MoMo
conjoined twins
How should you adjust the nutrition in multifetal pregnancy?
additional 600 calories/day
weight gain 35-45 lbs
what does the twin peak on US indicate?
two separate placenta
separate placenta, same or opposite gender
dizygotic
“thick” membrane, “twin peak” sign, same or opposite gender
dichorionic
“thin” membrane, lack of twin peak sign, same gender
monochorionic
no dividing membrane visualized, same gender
monoamniotic
Complications from multifetal gestations
preterm labor, gestational diabetes, preeclampsia, IUGR, fetal anomalies, twin-to-twin transfusion, postpartum hemorrhage
what is the definition of preterm labor?
average delivery 36 weeks gestation
15% of monochorionic gestations are at risk for
twin twin transfusion syndrome (TTTS)
what occurs in TTTS?
vascular anastomoses in the placenta → fluid is shunted from one twin to the other
when can you detect TTTS on US?
develop between 16-26 weeks
Treatment for TTTS
serial amnioreduction or laser ablation
Donor twin vs Recipient twin in TTTS
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
death of co-twin in first trimester is often referred to as
“vanishing twin”
what percent of babies can be delivered vaginally is vertex/vertex?
80%
if twin A is nonvertex, how should you deliver it?
C-section
what birthweight makes a fetus candidate for breech extraction?
> 1500 gm (EFW > 1800 gm and > 32 weeks)
When should you deliver uncomplicated well dated twins electively?
38 weeks
when should you deliver uncomplicated well dated triplets electively?
35-36 weeks
