Obs + Gynae Flashcards
How does renal plasma flow change in pregnancy?
Increases
Increases during early trimesters, decreases towards end of third trimester
How does total plasma volume change in pregnancy?
Increases: 30-50%
Changes in heart in pregnancy?
Increased cardiac output
Increased stroke volume
Increased heart rate
Changes in oncotic/osmotic pressure in pregnancy
Decreased serum albumin concentration
Decreased serum colloid osmotic pressure
Changes in clotting system in pregnancy
Increased coagulation factors
Increased fibrinogen
Changes in kidneys in pregnancy
Increased renal blood flow
Increased GFR
Changes in lungs in pregnancy
Increased tidal volume
Increased minute ventilation
Changes in GI system in pregnancy
Nausea + vomiting
Delayed gastric emptying
Prolonged small bowel transit time
Gastrointestinal reflux
Normal physiological changes seen on blood tests in pregnancy
Slight anaemia
Slightly lowered platelets
Increased ALP
Decreased albumin, AST + ALT
Increased GFR
–> decreased Urea + Creatinine –> if Ur + Cr are even slightly raised, this can indicate serious renal disease
Causes of antepartum haemorrhage
Placental abruption
Placenta praevia
Vasa praevia
Uterine rupture
Unexplained
What is vasa praevia
Foetal vessels run in membranes below the presenting foetal part, unsupported by placental tissue or umbilical cord
How does vasa praevia present?
PV bleeding (dark red)
After rupture of foetal membranes
Shock consistent with external loss
Painless bleeding
Rapid foetal distress
Risk factors for vasa praevia
Low-lying placenta
Multiple pregnancy
IVF pregnancy
Bilobed (succenturiate lobed) placentas
Management of vasa praevia
ABCDE assessment + resuscitation
Caesarean section
Monitor during pregnancy
Elective caesarean at 34-36 weeks
What is placenta praevia?
When the placenta is inserted wholly, or in part, into the lower segment of the uterus
What is major placenta praevia?
Grade III or IV
Placenta lies over the cervical os
Why is major placenta praevia concerning?
Cervical effacement and dilatation would result in catastrophic bleeding
What is minor placenta praevia?
Grade I or II
Placenta lies in lower segment, close to, or encroaching on the cervical OS
Risk factor for placenta praevia
Previous Caesarean section
Increased age
Maternal smoking
IVF
Presentation of placenta praevia haemorrhage
Painless, red PV bleeding
Profuse bleeding (shock consistent with external loss)
Often smaller previous APHs
Foetus may have abnormal lie
Management of placenta praevia
ABCDE assessment + resuscitation
Caesarean section
Monitor during pregnancy
Elective caesarean at 38 weeks
Presentation of placental abruption
Painful PV bleeding
PV loss does not correlate with shock (some women have no external loss)
Uterus = tender + firm (woody hard)
Pain is constant, with exacerbations
Foetal distress
May present in labour
Risk factor for placental abruption
ABRUPTION
Abruption previously
Blood pressure e.g. hypertension or pre-eclampsia
Ruptured membranes (premature or prolonged)
Uterine injury
Polyhydramnios
Twins/multiple gestation
Infection in the uterus
Older age (>35)
Narcotic use (cocaine, amphetamines, and smoking)
Placenta accreta
Placental villi are attached to the myometrium
Placenta increta
Villi invaded into >50% of the myometrium
Placenta percreta
Villi pass through whole myometrium up to the serosa
May involve other viscera e.g. bladder or bowel
Risk factors for abnormal placentation
Uterine surgery e.g. CS or myomectomy
Repeated surgical termination of pregnancy
IVF
Maternal age >35
Management of placenta accreta post delivery
Heavy bleeding:
- Blood replacement
- Balloon tamponade e.g. Rusch
- Hysterectomy
Minimal bleeding:
- Leave placenta in situ + monitor
Threatened miscarriage
Bleeding +/- abdominal pain
Closed cervix
Foetus alive
Before 24 weeks (usually 6-9 weeks)
Management of threatened misscarriage
Anti-D if >12 weeks or heavy bleeding, or pain on RhD-ve women
Sonography
Missed miscarriage
Cervical os closed
Foetus no longer alive
No symptoms have occurred - may have some light vaginal bleeding
Pregnancy symptoms may decrease
USS findings of missed miscarriage
Foetal pole >7mm
No foetal heart activity
Mean gestation sac diameter >25mm with no foetal pole or yolk sac
Management of missed miscarriage
Expectant/medical/surgical
Inevitable miscarriage
Bleeding +/- pain
Open cervical os
May have foetus with possible heartbeat
Management of inevitable miscarriage
Expectant/medical/surgical
Use of Anti-D in miscarriages
Given if >12 weeks, or heavy bleeding or pain in Rh-D -ve women
Presentation of incomplete miscarriage
Bleeding +/- pain with passage of large clots or tissue
Possible open cervical os - products of conception may be seen in dilated cervical os
Not all products of conception have been expelled
Presentation of complete miscarriage
Bleeding and pain cease
Closed cervix
USS: empty uterus, endometrial thickness <15 mm
Expectant management of miscarriage
Used if not bleeding heavily
Very effective in incomplete miscarriages
Less effective in women with intact sac
Repeat TVS at 2 weeks to ensure complete miscarriage
Surgical evacuation offered at later date
Medical management of miscarriage
Prostaglandin analogues (misoprostol) often given vaginally
How long might bleeding continue after medical management of miscarriage?
3 weeks after medical uterine evacuation
Surgical management of miscarriage
Evacuation of retained products of conception if there is excessive or persistent bleeding, or surgical management requested
Suction curettage used
Complications of surgical management of miscarriage
Infection
Haemorrhage
Uterine perforation
Retained products
Intrauterine adhesions
Cervical tears
Intraabdominal trauma
How can uterine and cervical trauma caused by surgical management of miscarriage be reduced?
Giving prostaglandin (misopristol or gemeprost) before the procedure
What is the 1st stage of labour divided into?
Latent phase
Active phase
How is the latent phase of labour defined?
Period taken for cervix to completely efface and dilate up to 3cm
How is the active phase of labour defined?
3cm-10cm full dilatation
Expected rate of cervical dilatation in the active phase
1cm/hour
When would failure to progress be considered in active phase of stage 1 of labour
<2cm dilatation in 2hour
Slowing in progress in parous women
Causes of poor progress in 1st stage of labour
Power - inefficient uterine activity (commonest)
Passenger - malpositions, malpresentation, or large baby
Passage - inadequate pelvis
Combination
Management of poor progress in 1st stage of labour
Membrane sweep
Prostaglandin pessary (as inpatient)
Amniotomy (artificial rupture of membranes) and reassess in 2 hours
Amniotomy + oxytocin infusion and reassess in2 hours (especially in nulliparous women)
Lower segment CS (if foetal distress)
What is Stage 2 of labour?
From full dilatation to delivery of the foetus
How long does Stage 2 normally last?
1 hour of active pushing
Should last no longer than 3h in nulliparous women, 2h in multiparous women
Causes of delay in Stage 2 of labour
Brow presentation
Face presentation
Compound/shoulder presentation
Transverse lie
Occiput posterior/Occiput Transverse position
Disproportion
Management of delay in Stage 2 of labour
Instrumental delivery e.g. ventouse, forceps
Surgical delivery
Risk factors for ovarian cancer
Nulliparity
Early menarche and/or late menopause (increased ovulations)
BRCA gene mutations
HNPCC (Lynch II syndrome)
Age
Obesity
Smoking
Recurrent use of clomifene
Factors that decrease the risk of ovarian cancer
COCP
Pregnancy
Breastfeeding
Presentation of ovarian cancer
Vague, common symptoms
Abdominal discomfort/distension (bloating, but persistent)
Early satiety
Loss of appetite
Pelvic pain
Increased girth/ascites
Urinary symptoms
Change in bowel habits
Abnormal vaginal bleeding
Detection of pelvic mass
Blood tests for ovarian cancer
FBC, U+E, LFTs (albumin)
Tumour markers
Examination findings for ovarian cancer
Pelvic/abdominal mass
Ascites
Omental mass (common site for metastasis) –> ommental cake
Pleural effusion
Supraclavicular lymph nodes
Tumour markers in ovarian cancer
- CA125 increased in 80% epithelial cancers
- CEA (carcinoembryonic antigen): raised in CRC, normal in ovarian cancer
- CA19.9: may be raised in mucinous tumours (also pancreas + breast)
- Others (for rarer tumours): AFP, hCG, LDH, inhibin, oestradiol
Imaging for ovarian cancer
Abdominal/pelvic USS
CXR
CT abdomen/pelvis
Potential findings on USS for ovarian cancer
Presence of pelvic mass
Ascites
Potential findings on CXR for ovarian cancer
Pleural effusion or lung metastases (for staging and properative assessment)
Potential findings on CT abdo/pelvis for ovarian cancer
Omental caking
Peritoneal implants
Liver metastases
Para-aortic lymph nodes
Stage I of ovarian cancer
Limited to ovaries
Ia = one ovary
Ib = two ovaries
Ic =ruptured capsule, tumour on ovarian surface, or positive peritoneal washings/ascites
Stage II of ovarian cancer
Limited to pelvis
IIa = uterus or tubes
IIb = other pelvic structures
IIc = positive peritoneal washing/ascites
Stage III of ovarian cancer
Limited to abdomen (including regional lymph node mets)
IIIa =- microscopic metastases
IIIb = macroscopic mets <2cm
IIIc = macroscopic mets >2cm
Stage IV of ovarian cancer
Distant mets outside abdominal cavity
5 types of epithelial cell ovarian cancers
Serous tumours (most common)
Endometroid carcinomas
Clear cell tumours
Mucinous tumours
Undifferentiated tumours
What might cause hip or groin pain with an ovarian mass?
Compression of the obturator nerve
What three factors does the risk of malignnacy index (RMI) take into account for ovarian masses?
Menopausal status
Ultrasound findings
CA125 level
Causes of raised CA125
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
Ovarian cancer, breast cancer, metastatic lung cancer, endometrial cancer (not vulval)
Ascites
Menstruation
Ovarian torsion
Surgical management of ovarian cancer
Total abdominal hysterectomy
Bilateral salpingo-oophrectomy
Infracolic omentectomy
Lymph node sampling (pelvic + para-aortic)
Peritoneal biopsies
Pelvic washings
Sampling of ascites
Medical management of ovarian cancer
Adjunct to surgical management
Chemotherapy: carboplatin + paclitaxel
Monitor response using CA-125 levels
Intraperitoneal chemotherapy
What is stress incontinence
Loss of urine associated with a rise in intrabdominal pressure e.g. coughing or sneezing
Due to weakness of pelvic floor and sphincter muscles
Risk factors for stress incontinence
Increasing age
Traumatic vaginal delivery
Obesity
Previous pelvic surgery
What is urge inctontinence?
Caused by overactivity of the detrusor muscle of the bladder (overactive bladder)
What is mixed incontinence?
A combination of urge incontinence and stress incontinence
Risk factors for urge incontinence
Increased age
Obesity
Smoking
Family history
Diabetes mellitus
When might overflow incontinence occur?
When there is chronic urinary retention due to an obstruction of outflow of urine
Occurs without the urge to pass urine
More common in men
Causes of overflow incontinence in women
Anticholinergic medications
Fibroids
Pelvic tumours
Neuro conditions e.g. MS, diabetic neuropathy, spinal cord injuries
Modifiable lifestyle factors that may contribute to incontinence symptoms
Caffeine consumption
Alcohol consumption
Medications
BMI
Modified Oxford grading system for strength of pelvic muscle contractions on bimanual examination
0 - no contraction
1: faint contraction
2: weak contraction
3: moderate contraction with some resistance
4: good contraction with resistance
5: strong contraction, a firm squeeze, and drawing inwards
Investigations for incontinence
Bladder diary - fluid intake, urination and incontinence
Urine dipstick testing - rule out UTI or DM
Post-void residual bladder volume
Urodynamic testing (urge incontince if not responding or other features)
Management of stress incontinence
Avoidance of caffeine, diuretics and overfilling bladeder
Avoid excessive or restricted fluid intake
Weight loss
Supervised pelvic floor exercises (3 months)
Surgery
Duloxetine (where surgery is less preferred)
Surgical management options for stress incontinence
Tension-free vaginal tape
Autologous sling procedures (uses fascia instead of tape)
Colposuspension
Intramural urethral bulking
Management of urge incontinence
Bladder retraining for at least 6 weeks (first line)
Anticholinergic medication e.g. oxybutynin, tolterodine, solifenacin
Mirabegron as alternative medication
Invasive procedures
Anticholinergic side effects
Dry mouth
Dry eyes
Urinary retention
Constipation
Postural hypotension
Cognitive decline, memory problems, and worsening of dementia
When is mirabegron contraindicated for an overactive bladder/incontinence
In uncontrolled hypertension
Invasive management options for urge incontinence
Botox bladder injections
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion
What is red degeneration of a fibroid
Ischaemia, infarction and necrosis of fibroid due to disrupted blood supply - common in 2nd and 3rd trimester of pregnancy due to fibroid rapidly outgrowing blood supply, uterus changing shape and therefore arteries kinking
Classical patient of red degeneration of fibroid
Pregnant women - often 2nd and 3rd trimester
History of fibroids - or history of heavy periods and difficulty concieving etc
Severe abdominal pain and low-grade fever, tachycardia, vomiting
Management of red degeneration of fibroid
Supportive
Rest, fluids, analgesia
Commonest causes of PID
Neisseria gonorrhoeae –> tends to produce more severe PID
Chlamydia trachomatis
Mycoplasma genitalium
Risk factors for PID
No barrier contraception
Multiple sexual partners
Younger age
Existing STIs
Previous PID
Intrauterine device
Symptoms of PID
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding e.g. intermenstrual or postcoital
Pain during sex (dyspareunia)
Fever
Dysuria
Examination findings in PID
Pelvic tenderness
Cervical excitation (motion tenderness)
Inflamed cervix
Purulent discharge
Investigations in PID
NAAT swabs - gonorrhoea, chlamydia, mycoplasma genitalium if available
HIV + syphylis test
High vaginal swab - bacterial vaginosis, candidiasis, trichomoniasis
Look for pus cells on swab from vagina or endocervix, under microscope (absence useful in excluding)
Pregnancy test - rule out ectopic
Inflammatory markers - raised
Management of PID
Referral to GUM
Contact tracing
Start antibiotics before swab results obtained: doxycycline, metronidazole, IM ceftriaxone
Leave in recently inserted coil. If no response within 72 hours, remove coil + prescribe any other necessary emergency contraceptives
Complications of PID
Sepsis
Abscess
Infertility
Chronic pevlis pain
Ectopic pregnany
Fitz-Hugh-Curtis syndrome
What is Fitz-Hugh-Curtis syndrome
Complication of PID
Caused by inflammation and infection of the liver capsule –> adhesions between liver and peritoneum
RUQ pain (can be referred to right shoulder)
Adhesiolysis required
USS measurements for assessing foetal size
Estimated foetal weight
Foetal abdominal circumference
Antibiotic usage in UTI in pregnancy
Nitrofurantoin (avoid in third trimester)
Amoxicillin
Cefalexin
Nitrofurantoin in pregnancy
Avoided in 3rd trimester due to risk of haemolytic anaemia
Trimethoprim in pregnancy
Avoided in 1st trimester
Folate antagonist –> neural tube defects
Sulfonamides in pregnancy
Avoided in 3rd trimester as are associated with kernicterus (brain damage due to high levels of billirubin)
Tetracyclines in pregnancy
Avoided as cause permanent staining of baby’s teeth, and problems with skeletal development
Intramural fibroids
Within myometrium
As they grow, they change the shape and distort the uterus
Subserosal fibroids
Just below outer layer of uterus
Grow outwards and can become very large, filling abdominal cavity
Submucosal fibroids
Just below endometrium
Can be resected hysteropically
Presentation of fibroids
Often asymptomatic
Menorrhagia
Prolonged menstruation (>7 days)
Abdominal pain, worse during menstruation
Bloating/feeling full in abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia
Reduced fertility
Palpable pelvic mass, or enlarged firm non-tender uterus
Investigations of fibroids
Hyteroscopy for submucosal fibroids with heavy menstrual bleeding
Pelvic ultrasound for larger fibroids
MRI scanning may be considered before surgical options
Management of fibroids <3 cm
Same as for heavy menstrual bleeding
Mirena coil
Symptomatic management - NSAIDS + tranexamic acid
COCP
Cyclical oral progestogens
Management of heavy menstrual bleeding
If no identigied pathology, fibroids <3cm diameter or suspected/diagnosed adenomyosis –>
1st line = LNG-IUS
If declines or not suitable:
- Non-hormonal = tranexamic acid, NSAIDs
- Hormonal = COCP, cyclical oral progestogens
Surgical management for smaller fibroids with HMB
Endometrial ablation
Resection of submucosal fibroids during hysteroscopy
Hysterectomy
Management of fibroids >3cm
Symptomatic - NSAIDs, tranexamic acid
Mirena coil - depends on size + shape
COCP
Cyclical oral progestogens
Surgical management of larger fibroids
Uterine artery embolisation
Myomectomy (preserves ferility)
Hysterectomy
GnRH agonists prior to surgery to shrink fibroid
Symptoms of endometriosis
Cyclical abdominal or pelvic pain
Deep dyspareunia
Dysmennorhoea
Infertility/subfertility
Cyclical bleeding from other sites
May also suffer from continuous pain e.g. with adhesions
Urinary symptoms
Bowel symptoms
Possible examination findings in endometriosis
Endometrial tissue visible in vagina on speculum, especially in posterior fornix
Fixed cervix on bimanual
Tenderness in the vagina, cervix, and adnexa
Diagnosis of endometriosis
Gold standard = laparoscopic surgery + biopsy
Pelvic USS may reveal large endometriomas and chocolate cysts, but often unremarkeable
Management of endometriosis
Analgesia e.g. NSAIDs +/- paracetamol
Hormonal management: COCP, POP, Depo-Provera, Nexplanon implant, Mirena coil, GnRH agonists
Surgical management: laparoscopic surgery to excise or ablate tissue, and adhesiolysis. Surgery is only way to improve fertility
Final solution = hysterectomy + bilateral salpingo-oophrectomy.
Risk factors for ectopic pregnancy
Previous ectopic
Previous PID
Previous surgery to fallopian tubes
IUDs
Older age (>35)
Smoking
Age <18 at first sexual intercourse
Black
IVF
Presentation of ectopic pregnancy
Typically 6-8 weeks gestation
Missed period
Constant lower abdominal pain (LIF or RIF)
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness
Dizziness or syncope
Shoulder tip pain (peritonitis)
USS findings for ectopic pregnancy
Transvaginal USS
Gestational sac containing yolk sac or foetal pole seen in a fallopian tube
Sometimes non-sepcific mass in tube
Mass containing empty gestational sac = blob/bagel/tubal ring sign
Mass moves separately to ovary, but looks like corpus luteum
Empty uterus/fluid in uterus (pseudogestational sac)
Management of pregnancy of unknown location
Serum hCG tracked over time - baseline + repeated at 48 hours to monitor (should double in normal pregnancy)
If hCG rises >63% –> repeat USS in 1-2 weeks to confirm intrauterine pregnancy
If rise <63% –> likely ectopic pregnancy
Fall >50% –> likely miscarriage –> urinary pregnancy test in 2 weeks to confirm completeness
Management of ectopic pregnancy
Expectant management
Medical management e.g. methotrexate
Surgical management - salpingectomy or salpingotomy (salpingotomy if risk factors for infertility e.g. csontralateral tube damage)
Criteria for expectant management of ectopic pregnancy
Follow-up must be possible
Unruptured ectopic
Adnexal mass <35 mm
No visible heartbeat
No significant pain
hCG >1000IU/L, <1500IU/L
Criteria for methotrexate management of ectopic pregnancy
Follow-up must be possible
Unruptured ectopic
Adnexal mass <35 mm
No visible heartbeat
No significant pain
hCG <1500 IU/L
Confirmed absence of intrauterine pregnancy on USS
Advised not to get pregnant for 3 months after treatment
Features for diagnosis of PCOS
Two of:
- Anovulation/oligo-ovulation
- Hyperandrogenism
- Polycystic ovaries on USS (string of pearls appearance)/increase ovarian volume
Symptoms of ovarian cysts (uncomplicated)
Pelvic pain
Bloating
Fullness in abdomen
Palpable pelvic mass
Follicular cysts
Commonest type of ovarian cyst
Developing follicle that fails to rupture –> cyst persists
Tend to disappear after a few menstrual cycles
Thin walls + no internal structures
Corpus luteum cysts
Occurs when corpus luteum fails to break down –> fills with fluid
Often seen in early pregnancy
May cause pelvic discomfort, pain, or delayed menstruation
Who does not require further investigation for ovarian cyst
Premenopausal women
Simple cyst <5cm on ultrasound
Women under 40 years with complex ovarian mass require what tumour marks for possible germ cell tumour
Lactate dehydrogenase (LDH)
Alpha-fetoprotein
Human chorionic gonadotropin
Management of simple ovarian cysts <5cm in premenopausal women
Tend to resolve within 3 cycles
No follow-up scan required
Management of simple ovarian cysts 5-7cm in premenopausal women
Routine referral to gynaecology
Yearly ultrasound monitoring
Management of simple ovarian cysts >7cm in premenopausal women
Consider MRI or surgical evaluation as hard to characterise with USS
Management of ovarian cysts in postmenopausal women
Correlate with CA125 result
Refer to gynaecologist (2 week wait if raised CA125)
Simple cysts <5cm –> monitored with 4-6months USS
Surgical intervention if required
Meig’s syndrome
Ovarian fibroma (benign ovarian tumour)
Pleural effusion
Ascites
Removal of tumour results in resolution of effusion + ascites
presents in older women
When is ovarian torsion more likely to occur
Ovarian mass >5cm e.g. cyst or tumour (more likely with benign tumours)
During pregnancy
In younger girls before menarche due to longer infundibulopelvic ligaments
Presentation of ovarian torsion
Pelvic pain:
- Sudden onset
- Severe
- Unilateral
- Constant
- Progressively worsening
Nausea + vomiting
Localised tenderness
Potential palpable mass
Diagnosis of ovarian torsion
Pelvic ultrasound
Ideally transvaginal USS
‘Whirlpool’ sign = free fluid in pelvis and oedema of the ovary
Definitive diagnosis = laparoscopic surgery
Management of ovarian torsion
Emergency –> admit under gynaecology
Laparascopic surgery:
- Detorsion (fixed in place)
- Oophrectomy
Complications of ovarian torsion
Loss of function of ovary (typically other compensates)
Necrotic ovary not removed –> infection –> abscess —> sepsis
Rupture –> peritonitis + adhesions
Small for gestational age vs foetal growth restriction
SGA = baby small for dates, no reason stated why. Baby may be growing appropriately and not at increased risk of complications
FGR = growth slowed due to pathology, with a higher risk of morbidity and mortality, many end up SGA
Placenta-mediated causes of IUGR
Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions
Refers to conditions that affect transfer of nutrients across the placenta
Non-placenta mediated causes of IUGR
Refers to pathology of foetus
Genetic abnormalities
Structural abnormalities
Foetal infection
Errors of metabolism
Risk factors for IUGR
Maternal age <16 or >35
Low BMI
Pre-pregnancy weight >75kg
Low interpregnancy interval (<6 months) or long interval (>120 months)
Risk factors for IUGR
Maternal age <16 or >35
Low BMI/Obesity
Diabetes
Low interpregnancy interval (<6 months) or long interval (>120 months)
Pre-existing maternal disease e.g. renal disease, hypertension
Pregnancy complications e.g. pre-eclampsia
Multiple pregnancy
Smoking
Drug use
Signs of IUGR
SGA
Reduced amniotic fluid volume
Abnormal Doppler studies (‘head sparing’)
Reduced foetal movements
Abnormal CTGs
Monitoring of SGA/IUGR
Women with 3 or more minor/1 or more major risk factors, or with issues measuring symphisis fundal height –> serial growth scans + umbilical artery doppler
Management of IUGR at term
Delivered if beyond 36 weeks
Labour induction or C-section are required
Management of IUGR preterm
Aim to prevent in utero demise or neurological damage, whilst maximising gestation
Abnormal doppler –> reviewed at least 2x weekly
If absent end-diastolic flow –> admit mother, give steroids if pre-34 weeks, daily CTG
Beyond 34 weeks, delivery often performed
Preterm prelabour rupture of membranes (P-PROM)
Amniotic sac has ruptured before onset of labour, and before 37 weeks gestation
Diagnosis of P-PROM
Pooling of amniotic fluid in vagina on speculum examination
If doubt of diagnosis –>
- Insulin-like growth factor-binding protein-1: present in high concentrations in amniotic flud, tested on vaginal fluid
- Placental alpha-microglobin-1 (similar alternative)
Ultrasound may be useful - oligohydramnios
Management of P-PROM
Prophylactic antibiotics to prevent chorioamnionitis: erythromycin 250mg qds for 10 days, or until labour is established
Induction of labour may be offered from 34 weeks
Options for prophylaxis of preterm labour
Vaginal progesterone (gel or pessary) - offered if cervical length <25mm on USS between 16-24GW, with no previous preterm birth/trauma
Cervical cerclage - offered if cervical length <25mm between 16-24GW, with previous premature birth or cervical trauma