OBSTETRICS 3: PPROM, Chorioamnionitis, Infections in Pregnancy, Itching in Pregnancy, IOL, Puerperal Pyrexia

Question 1

What is the difference between PROM and PPROM?

Answer 1

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

Question 2

How can PPROM present and what are the RFs?

Answer 2

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

Question 3

How is PPROM investigated?

Answer 3

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

Question 4

How is PPROM managed generally?

Answer 4

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

Question 5

What are the 3 main causes of neonatal mortality assoc. with PPROM?

Answer 5

• prematurity
• sepsis
• pulmonary hypoplasia

Question 6

What does inpatient management of PPROM include in terms of managing infection risk?

Answer 6

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

Question 7

What does outpatient management of PPROM include in terms of managing infection risk?

Answer 7

2-6x daily temperatures at home
Low threshold for attending hospital

Day care/maternity triage/AN ward 1-2/w
- obs, CTG, WCC, CRP

Question 8

How should preparation for delivery be managed in PPROM?

Answer 8

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

Question 9

What are antenatal corticosteroids assoc. with?

Answer 9

GOOD = reduction in neonatal deaths, respiratory distress syndrome, IVH

BAD = increase in neonatal hypoglycaemia, developmental delay, DKA in diabetics so co-administer w/insulin

Question 10

How is deciding on the time of delivery managed in PPROM?

Answer 10

<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

Question 11

What is chorioamnionitis?

Answer 11

Intraamniotic infection
Acute inflammation of membranes and chorion of placenta typically due to ascending polymicrobial infection in setting of membrane rupture

Question 12

What are RFs for chorioamnionitis?

Answer 12

Premature labour
Prolonged labour
Internal monitoring of labour

Multiple vaginal exams
Meconium stained amniotic fluids

GBS, UTI, BC, short cervix

Question 13

How is chorioamnionitis diagnosed?

Answer 13

Presence of fever + 2 other signs:
- uterine tenderness
- maternal tachycardia
- fetal tachycardia
- foul/purulent amniotic fluid

Question 14

How is chorioamnionitis managed?

Answer 14

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

Question 15

What are complications of chorioamnionitis?

Answer 15

Neurological damage
Premature labour
HIE
Cerebral palsy
Periventricular leukomalacia

Question 16

What is group B strep?

Answer 16

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

Question 17

How should a woman be advised if she is identified as having GBS colonisation/bacteriuria/infection during her current pregnancy?

Answer 17

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

Question 18

How is GBS managed in pregnancy?

Answer 18

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

Question 19

What are indications for IAP and what antibiotics are used?

Answer 19

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

Question 20

What are signs of EOGBS?

Answer 20

• 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

Question 21

What is the risk of transmission of HIV during pregnancy?

Answer 21

1.5-2% mother to child transmission occurs transplacentally

Vast majority of infections due to maternal foetal transmission during childbirth or postnatally through breastfeeding.

Question 22

What procedures should be undertaken with caution in a HIV positive pregnant woman?

Answer 22

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.

Question 23

How should HIV in pregnancy be managed antenatally?

Answer 23

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

Question 24

How should HIV be managed in women who present in labour at term and weren’t on previous ART?

Answer 24

Nevirapine 200mg stat + zidovudine 300mg PO + lamivudine 150mg BD + raltegravir 40mg BD + zidovudine IV for duration of labour

Question 25

How should mode of delivery be managed in a HIV pregnancy?

Answer 25

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

Question 26

How should SROM be managed in a HIV pregnancy?

Answer 26

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.

Question 27

How is the baby treated in a HIV pregnancy post delivery?

Answer 27

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

Question 28

What is rubella? How does it present?

Answer 28

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

Question 29

How is rubella in pregnancy managed?

Answer 29

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)

Question 30

How is rubella in pregnancy investigated?

Answer 30

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

Question 31

How should a baby be investigated when there is rubella exposure in pregnancy?

Answer 31

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)

Question 32

What is chicken pox and how does it present?

Answer 32

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

Question 33

How is chickenpox exposure in pregnancy managed?

Answer 33

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

Question 34

How should chickenpox infection in pregnancy be managed for the baby?

Answer 34

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

Question 35

How does fetal varicella syndrome present?

Answer 35

Skin scarring in dermatomal distribution, eye defects (microphthalmia, chorioretinitis -> cataracts), limb hypoplasia, microcephaly, LD, IUGR

Question 36

What are indications for IOL?

Answer 36

• 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

Question 37

What are contraindications for IOL?

Answer 37

• Breech
• VBAC (relative CI, PG increases risk of uterine rupture)
• Heart disease

Question 38

What is intrahepatic cholestasis of pregnancy?

Answer 38

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

Question 39

What are complications of intrahepatic cholestasis of pregnancy?

Answer 39

Increased chance of developing PET, GDM

Increased risk of stillbirth especially in presence of other comorbidities like gestational diabetes, PET, multifetal pregnancy

Question 40

How should intrahepatic cholestasis of pregnancy be managed?

Answer 40

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.

Question 41

How should timing of delivery in intrahepatic cholestasis of pregnancy be managed?

Answer 41

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.

Question 42

When should a woman with intrahepatic cholestasis of pregnancy be referred to hepatologist?

Answer 42

Itching + abnormal LFTs or liver function in 1st or 2nd trimester

If no resolution of itch + biochemical abnormalities after birth

Question 43

When is diagnosis of intrahepatic cholestasis of pregnancy actually confirmed?

Answer 43

Postnatal period of at least 4w after birth = resolution of itching + normalisation of LFTs + bile salts.

Question 44

What should occur in future pregnancies if there was prev. intrahepatic cholestasis of pregnancy?

Answer 44

Higher chance of ICP in subsequent pregnancies

Baseline LFTs and bile acid concentrations w/booking bloods

Question 45

What is acute fatty liver of pregnancy?

Answer 45

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

Question 46

How is acute fatty liver of pregnancy investigated?

Answer 46

BLOODS = LFTs, clotting, hypoglycaemia

IMAGING = USS showing hypoechogenic fatty liver, CT/MRI - reduced attenuation in liver

BIOPSY = dx but coag levels often preclude it

Question 47

How is acute fatty liver of pregnancy managed?

Answer 47

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

Question 48

What is HELLP syndrome?

Answer 48

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

Question 49

What are risk factors for HELLP syndrome?

Answer 49

Age >35
Nulliparity
Multiple pregnancy
APL
Prev. HELLP syndrome

Question 50

What are features of HELLP syndrome?

Answer 50

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.

Question 51

How is HELLP syndrome investigated?

Answer 51

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

Question 52

How is HELLP syndrome managed?

Answer 52

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

Question 53

What are complications of HELLP syndrome?

Answer 53

MATERNAL = DIC, AKI, placental abruption, eclampsia, severe ascites, cerebral oedema, pulmonary oedema, death

FETAL = perinatal death, IUGR, preterm delivery, neonatal thrombocytopenia

Question 54

What is puerperal pyrexia? What is caused by?

Answer 54

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

Question 55

How should puerperal pyrexia be investigated?

Answer 55

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

Question 56

How should puerperal pyrexia be managed?

Answer 56

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

Question 57

How should mastitis in pregnancy be treated?

Answer 57

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