OBSTETRICS 3: PPROM, Chorioamnionitis, Infections in Pregnancy, Itching in Pregnancy, IOL, Puerperal Pyrexia Flashcards
What is the difference between PROM and PPROM?
PROM = premature rupture of membranes = rupture of membranes occurring prior to onset of labour >37w
PPROM = pre-term premature ROM = ROM prior to onset of labour <37w
How can PPROM present and what are the RFs?
Hx of “popping sensation” or “gush” w/continuous watery fluid draining thereafter
RFs:
- smoking
- lower GU infection
- uterine abnormalities/cervical incompetence
- prev. PPROM
- multiple pregnancy/polyhydramnios
How is PPROM investigated?
DO NOT DO DVE (increased risk of ascending infection)
Dx = Sterile Speculum examination - check for liquor after woman has been lying down for 30mins
- observed = don’t perform diagnostic test, offer care consistent w/PPROM
- not observed = IGFBP-1 or PAMG-1, + maternal history and condition
How is PPROM managed generally?
Admit to antenatal ward for first 48hrs
- monitor for infection
- reduce risk of infection
- prepare for delivery
- decide on timing of delivery
Can be managed at home if low risk of cord prolapse and normal inflammatory markers
What are the 3 main causes of neonatal mortality assoc. with PPROM?
- prematurity
- sepsis
- pulmonary hypoplasia
What does inpatient management of PPROM include in terms of managing infection risk?
BEDSIDE: obs, clinical signs + sx, CTG
BLOODS: WCC, CRP
Erythromycin 250mg QDS - max 10/7 OR until labour established (whichever is sooner)
2nd line = PO penicillin
What does outpatient management of PPROM include in terms of managing infection risk?
2-6x daily temperatures at home
Low threshold for attending hospital
Day care/maternity triage/AN ward 1-2/w
- obs, CTG, WCC, CRP
How should preparation for delivery be managed in PPROM?
Antenatal steroids
- 2 x 12mg doses of betamethasone IM 24h apart OR 4x6mg dexamethasone IM every 12hrs
(single repeat course if <34+0, very high risk of birth within next 48hrs etc.)
- under 24 weeks: discuss antenatal CS w/woman + MDT
- 24-34w = offer AN CS
- >34w = consider AN CS
What are antenatal corticosteroids assoc. with?
GOOD = reduction in neonatal deaths, respiratory distress syndrome, IVH
BAD = increase in neonatal hypoglycaemia, developmental delay, DKA in diabetics so co-administer w/insulin
How is deciding on the time of delivery managed in PPROM?
<34w = expectant mx until 37+0 (unless additional obstetric indications e.g. infection, foetal compromise)
34-37w = discuss IOL or expectant mx
At term (PROM) = first 24h expectant mx or IOL, after 24h = IOL, 4hrly temps, 24h foetal monitoring
If any GBS or meconium - immediate IOL or CS
Monitor neonate for at least 12h after delivery
What is chorioamnionitis?
Intraamniotic infection
Acute inflammation of membranes and chorion of placenta typically due to ascending polymicrobial infection in setting of membrane rupture
What are RFs for chorioamnionitis?
Premature labour
Prolonged labour
Internal monitoring of labour
Multiple vaginal exams
Meconium stained amniotic fluids
GBS, UTI, BC, short cervix
How is chorioamnionitis diagnosed?
Presence of fever + 2 other signs:
- uterine tenderness
- maternal tachycardia
- fetal tachycardia
- foul/purulent amniotic fluid
How is chorioamnionitis managed?
Once evident -> deliver
1st dose of abx to be given as soon as infection is suspected + need to be continued until birth of baby
IPAbx = benzylpeniccilin + gentamicin + metronidazole (no penicillin allergy)
- non severe penicillin allergy = cefotazime + metronidazole
- severe pen allergic = vancomycin + gentamicin + metronidazole
What are complications of chorioamnionitis?
Neurological damage
Premature labour
HIE
Cerebral palsy
Periventricular leukomalacia
What is group B strep?
Gram +ve cocci in chains
Commensal bacterium of vagina + rectum
Most common cause of early onset neonatal infection in neonates <7d old
NOTE: NHS doesn’t routinely offer all pregnant women screening for GBS
- if GBS found in a prev. pregnancy = test at 35-37w GA or 3-5w prior to anticipated delivery date
How should a woman be advised if she is identified as having GBS colonisation/bacteriuria/infection during her current pregnancy?
If she becomes pregnant again:
- new baby will be at increased risk of early-onset group B streptococcal infection
- she should inform her maternity team that she’s had a +ve GBS test in a prev. pregnancy
- her maternity care team will offer her antibiotics in labour
How is GBS managed in pregnancy?
GBS COLONISATION/BACTERIURIA/INFECTION = intrapartum antibiotics (IAP)
GBS UTI = appropriate treatment at time of diagnosis as well as IAP
- SROM at term = IOL + IAP
- >34w = immediate birth by IOL or CS
- <34w = risks PTL > risks of perinatal infection
Not required for women undergoing ELCS in absence of labour and intact membranes - however all women having CS offered abx at time of operation.
If GBS +ve and declines IAP - baby should be monitored closely for 12hrs after birth
What are indications for IAP and what antibiotics are used?
INDICATIONS:
- GBS bacteriuria during current pregnancy
- +ve for GBS in late pregnancy (incidentally by intentional testing)
- prev. baby w/early or late-onset GBS disease
ABX USED:
- benzylpenicillin
- cefotaxime if non-severe pen allergic
- vancomycin if severe pen allergic
METHOD: first dose of abx given as labour starts and continues until birth of baby
What are signs of EOGBS?
- noisy breathing and grunting
- increased RR, WOB
- very sleepy or unresponsive
- constant crying, distressed
- unusually floppy
- don’t feed well
- fever
- change in skin colour or have blotchy skin
- slow or fast HR
NOTE: early onset = <72hrs, late onset = >72hrs
What is the risk of transmission of HIV during pregnancy?
1.5-2% mother to child transmission occurs transplacentally
Vast majority of infections due to maternal foetal transmission during childbirth or postnatally through breastfeeding.
What procedures should be undertaken with caution in a HIV positive pregnant woman?
Invasive prenatal diagnostic testing should be deferred until HIV viral load <50.
ECV offered to women with plasma viral load <50.
Fetal blood sampling contraindicated regardless of undetectable viral load.
How should HIV in pregnancy be managed antenatally?
Joint HIV + obstetric clinic
Women already taking cART (combination antiretroviral therapy) or PCP prophylaxis before pregnancy should continue their medication.
Not already on cART:
- all women should have commenced cART by week 24 in 2nd trimester
- continue lifelong treatment
- if viral load >100,000 and/or CD4 <200 = start within first trimester
cART rx = tenofovir DR or abacavir + emtricitabine or lamivudine + efavirenz or atazanavir
How should HIV be managed in women who present in labour at term and weren’t on previous ART?
Nevirapine 200mg stat + zidovudine 300mg PO + lamivudine 150mg BD + raltegravir 40mg BD + zidovudine IV for duration of labour
How should mode of delivery be managed in a HIV pregnancy?
Decision made after r/v of plasma viral load at 36w
<50 + no CI = SVD
>50 or women taking zidovudine monotherapy as alternative to ART = ELCS
How should SROM be managed in a HIV pregnancy?
Again based off viral load
<50 = immediate IOL or augmentation, aim delivery within 24hrs
> 50 = immediate CS
Cord clamped ASAP and baby bathed immediately after birth.
How is the baby treated in a HIV pregnancy post delivery?
VERY LOW RISK = woman on cART for >10w + 2 documented maternal viral loads <50 during pregnancy at least 4w apart + viral load <50 at 36w = 2w zidovudine monotherapy
LOW RISK = maternal viral load <50 at 36w but doesn’t fulfil other VLR criteria = 4w zidovudine monotherapy
HIGH RISK = maternal viral load >50 on day of birth, uncertainty about adherence, viral load is not known = combination PEP
FEEDING:
- safest = formula milk
- offer cabergoline to suppress lactation
What is rubella? How does it present?
RNA virus, transmission by aerosol route, vertical, very uncommon infection in UK.
Sx = prodromal phase, maculopapular rash behind ears spreading to head, neck then body, posterior auricular lymphadenopathy, arthralgia, soft palate lesions
How is rubella in pregnancy managed?
Symptomatic managements, rest + fluids
Refer to fetal medicine unit
Notify HPU (notifiable condition)
Inform <20w gestation = greater risk of complications from rubella exposure (>20w no published case reports of CRS)
How is rubella in pregnancy investigated?
Indistinguishable from parvovirus B19 infection - both may be checked in pregnant women who come into contact w/either.
CHECK IMMUNITY STATUS:
Immune to rubella = 2 prev. bloods results showing immunity or 1 immune blood result + documented vaccination or 2 documented doses of vaccine
IF IMMUNE = check for parvovirus B19 + no further action
NON-IMMUNE/UNKNOWN = bloods w/IgG or IgM serology
- <16w +ve IgM = offer TOP
- >20w = reassure
How should a baby be investigated when there is rubella exposure in pregnancy?
Antenatally = amniocentesis, USS fetal abnormalities
Postnatally = blood IgM (doesn’t cross placenta), unexplained persistence of rubella IgG (doesn’t drop at 2-fold dilution/month as maternal IgG)
What is chicken pox and how does it present?
VZV transfer to baby can be transplacental, ascending vaginal or contact after delivery with lesions.
Exposure = being in the same room as someone for >15mins or F2F contact
Incubation 7-21d
Sx = prodromal fever, malaise, myalgia, generalised rash w/different lesions at different stages
How is chickenpox exposure in pregnancy managed?
PREV. CHICKENPOX = no further action
UNSURE STATUS =
1. check for varicella ab
2. no antibodies present = give VZIG
- effective when given up to 10d after contact or up to 10d since appearance of rash
- cannot be given once sx
SYMPTOMS PRESENT =
- oral aciclovir (800mg 5/d for 7d)
- <20 + 0w = consider oral aciclovir
- >20w = give if presenting within 24hr of rash onset
- avoid delivery of baby until at least 7d since rash appeared
How should chickenpox infection in pregnancy be managed for the baby?
If birth <7d after onset of maternal rash or if mother develops chickenpox <7d after delivery = neonatal VZIG
If neonatal infection treated = aciclovir
Inform women that infection at <28w is assoc. w/small risk of fetal varicella syndrome = refer to fetal medicine specialist = amniocentesis to detect varicella
How does fetal varicella syndrome present?
Skin scarring in dermatomal distribution, eye defects (microphthalmia, chorioretinitis -> cataracts), limb hypoplasia, microcephaly, LD, IUGR
What are indications for IOL?
- Macrosomia
- Post dates pregnancy 41w
- ROM, >24hr if PROM, immediate if GBS + >34w
- Meconium stained fluid
- Obstetric cholestasis
- PET >37w = IOL or CS within 24-48hrs
- BMI >35
- DM - 37-38+6w
- GDM - 40+6w
- SROM HIV - IOL if <50 viral load
What are contraindications for IOL?
- Breech
- VBAC (relative CI, PG increases risk of uterine rupture)
- Heart disease
What is intrahepatic cholestasis of pregnancy?
Most common in 3rd trimester
To be considered in pregnant women w/itching in skin of normal apperance + raised peak random total bile acid concentration >19mm/L
Liver failure not a typical feature
DDx e.g. PET should always be considered before ICP dx
What are complications of intrahepatic cholestasis of pregnancy?
Increased chance of developing PET, GDM
Increased risk of stillbirth especially in presence of other comorbidities like gestational diabetes, PET, multifetal pregnancy
How should intrahepatic cholestasis of pregnancy be managed?
ADVICE: monitor fetal movements + present for immediate assessment if any concerns
No treatments that improve pregnancy outcome.
Consider topical emollients or antihistamine agents e.g. chlorphenamine (sedative) at night.
Do not routinely offer ursodeoxycholic acid for purpose of reducing adverse perinatal outcomes.
How should timing of delivery in intrahepatic cholestasis of pregnancy be managed?
MILD ICP = bile acids 19-39
- weekly monitoring as they approach 38w to inform timing of birth
- delivery by 40w
MODERATE ICP = bile acids 40-99
- weekly testing as they approach 38w to inform timing of birth
- delivery by 38-39w
SEVERE ICP = >100
- further routine testing of bile acids might not impact on decision making and therefore may not be routinely required
- delivery by 35-36w; will need continuous electronic fetal monitoring during labour
IOL should be considered unless other reasons for CS present.
When should a woman with intrahepatic cholestasis of pregnancy be referred to hepatologist?
Itching + abnormal LFTs or liver function in 1st or 2nd trimester
If no resolution of itch + biochemical abnormalities after birth
When is diagnosis of intrahepatic cholestasis of pregnancy actually confirmed?
Postnatal period of at least 4w after birth = resolution of itching + normalisation of LFTs + bile salts.
What should occur in future pregnancies if there was prev. intrahepatic cholestasis of pregnancy?
Higher chance of ICP in subsequent pregnancies
Baseline LFTs and bile acid concentrations w/booking bloods
What is acute fatty liver of pregnancy?
Fatty infiltration of liver in pregnancy, rare and tends to occur late in pregnancy, most common in 3rd trimester, considered obstetric emergency
Life threatening condition that can progress to acute liver failure within 1-2w
Sx = prodromal phase -> jaundice -> fulminant liver
Majority of patients have assoc. HTN +/- proteinuria at initial presentation
How is acute fatty liver of pregnancy investigated?
BLOODS = LFTs, clotting, hypoglycaemia
IMAGING = USS showing hypoechogenic fatty liver, CT/MRI - reduced attenuation in liver
BIOPSY = dx but coag levels often preclude it
How is acute fatty liver of pregnancy managed?
Stabilisation
- admit to ITU
- supportive care
- continuous maternal and fetal monitoring
- correct coagulopathy, electrolytes, hypoglycaemia
Consider early delivery
- as soon as maternal condition stable or as soon as possible if maternal condition deteriorating
- delivery is definitive mx to prevent deterioration
Condition usually resolves after delivery w/complete recovery
What is HELLP syndrome?
Haemolysis, Elevated Liver enzymes, Low Platelet count
Complication of pregnancy usually presents in women w/pre-eclampsia or eclampsia and can lead to eclampsia
Most commonly in 37-37w
Rapid onset, can also present post partum usually within 48hr of delivery
Obstetric emergency
Usually resolves after delivery
What are risk factors for HELLP syndrome?
Age >35
Nulliparity
Multiple pregnancy
APL
Prev. HELLP syndrome
What are features of HELLP syndrome?
Non-specific sx = headache, visual sx, malaise, fatigue, N&V (similar to eclampsia)
Signs of liver damage = hepatomegaly, easy bruising/purpura, oedema/HTN/proteinuria, tenderness RUQ
Abnormalities in blood clotting = easy bruising
Exacerbated at night, relief during day.
How is HELLP syndrome investigated?
BLOODS:
- microangiopathic haemolytic anaemia (MAHA) = blood film w/shisotocytes, raised LDH >600, raised bilirubin
- liver injury = raised transaminases
- low PLTs = <100
- clotting studies
FETUS ASSESSMENT:
- USS assessment of fetal growth + volume of amniotic fluid
- doppler velocimetry of umbilical arteries
How is HELLP syndrome managed?
HDU care
Most effective rx = prompt delivery
Transfusion of blood products indicated clinically by blood and coagulation tests
BP control essential
Severe liver damage = transplantation
What are complications of HELLP syndrome?
MATERNAL = DIC, AKI, placental abruption, eclampsia, severe ascites, cerebral oedema, pulmonary oedema, death
FETAL = perinatal death, IUGR, preterm delivery, neonatal thrombocytopenia
What is puerperal pyrexia? What is caused by?
Fever >38 in a woman within 6w of giving birth
CAUSES:
- UTI, pyelonephritis
- genital tract infection
- mastitis
- post op infection following CS
- skin/soft tissue infection
- DVT
- RPC
- pneumonia
How should puerperal pyrexia be investigated?
EXAM: obs, uterus palpation, assess any perineal wounds + lochia, top to toe examination
High vaginal swab, urine MC&S, FBC, blood culture x2, USS ?RPC
If indicated sputum culture, other swabs as felt necessary
How should puerperal pyrexia be managed?
GP SETTING - decide whether to refer to A&E or treat in community
A&E - decide whether to admit
MEOWS chart
MEDICAL MX = sepsis 6 if septic
- broad-spectrum IV abx within 1hr of suspicion of severe sepsis (piperacillin/tazobactam or carbapenem + clindamycin)
- advice from micro if pt breastfeeding
- analgesia but avoid NSAIDs
SURGICAL = abscess drain or ERPC
How should mastitis in pregnancy be treated?
Treat if: systemically unwell, nipple fissure present, sx don’t improve after 12-24h of effective milk removal, culture indicates infection
Infection = staph aureus = rx w/flucloxacillin 10-14d
