P/PPROM+ Preterm labour

Question 1

What cause PROM?

Answer 1

increase in local cytokines, an imbalance in the interaction between matrix metalloproteinases and tissue inhibitors of matrix metalloproteinases, increased collagenase and protease activity, and other factors that can cause increased intrauterine pressure.

Question 2

What important points to ask in the hx of PROM?

Answer 2

contractions, fetal movement, time of possible rupture, amount of fluid, color and odor of fluid, vaginal bleeding, pain, recent sexual encounters, recent trauma, and recent physical activity.

Question 3

What are the clinical test to be done in PROM? What to look for?

Answer 3

A sterile speculum exam should always be performed. During the speculum exam, patient should be inspected for any signs of cervicitis, umbilical cord prolapse, vaginal bleeding, or fetal prolapse.

Question 4

How is PPROM managed?

Answer 4

Not in labour> regular monitoring is needed and can be managed as an outpatient after an initial inpatient review And advised to take her temperature 4 times a day.
If there is such a high risk of delivery corticosteroids should be given if PPROM occurs at less than 36 weeks. Prophylactic erythromycin has also been shown to improve fetal outcome.

Question 5

fetal compression syndrome
(Potter syndrome)

Answer 5

Adverse neonatal outcomes specific to periviable PPROM most commonly result from chronic oligohydramnios, and include pulmonary hypoplasia, limb deformities (eg, clubbed feet)

Question 6

Potter syndrome

Answer 6

refers to the typical physical appearance and associated pulmonary hypoplasia of a neonate as a direct result of oligohydramnios and compression while in utero.
- Findings at physical examination may include the following:
Potter facies (flattened nose, recessed chin, prominent epicanthal folds, and low-set abnormal ears)
Pulmonary hypoplasia
Features of Eagle-Barrett (prune belly) syndrome (deficient abdominal wall, undescended testes, dilated ureters, and a renal pelvis)
Skeletal malformations (hemivertebrae, sacral agenesis, and limb anomalies)
Ophthalmologic malformations (cataract, angiomatous malformation in the optic disc area, prolapse of the lens, and expulsive hemorrhage)
Cardiovascular malformations (ventricular septal defect, endocardial cushion defect, tetralogy of Fallot, and patent ductus arteriosus)

Question 7

Recurrence in one previous abruptio is (….) while two previous abruptio is ..%

Answer 7

Recurrence in one previous abruptio is (5-17%) while two previous abruptio is 25%

Question 8

When to Consider cesarean Section in Preterm Baby for fetal indications?

Answer 8

When GA 25 (0/7) or beyond
or at24(0/7) if EFW> 750gm

Question 9

four major causes Play a role in the etiology of Preterm labor

Answer 9

1- Uterine distension
2- maternal and fetal Stress
3- infection
4- Premature Cervical changes

Question 10

Bacterial vaginosis associated with

Answer 10

1) Spontaneous abortion
2) preterm labor
3) PPROM
4) chorioamnionitis
5) amniotic fluid infection.

Question 11

Transvaginal cervical length assessment typically done after … wks

Answer 11

16 wks

Question 12

Indication of cervical length measurement (per SMFM 2016)

Answer 12

Women with a history of prior spontaneous preterm birth.

Question 13

ACOG & MFMS Approved using Progesterone Therapy for Preterm labour Prevention for women who

Answer 13

have singleton Pregnancy with history of preterm labour or no prior history But Sonographically identified short cervix

Question 14

ACOG Criterion of intramnion infections Diagnosis

Answer 14

• Maternal temperature >39 celious degree
• Temperature BTW 38-39 + additional clinical risk factor :
  1- Low Parity
  2- Multiple digital examinations
  3-use of internal fetal or uterine Monitor
  4- Meconiam stained Amniotic fluid
  5- Presence of Genital tract Pathogens

Question 15

Criteria and indications of cerclage placement

Answer 15

• Asymptomatic women (no contractions)
• Singleton gestation (recent data doesn’t recommend against cercalage in twins)
• Prior painless spontaneous preterm birth less than 34 wks without evidence of labor or rupture
• evidence Cervical length less than or equal to 25 mm before or at 24 weeks of gestation
• history of three prior losses
• Patients who present with advanced cervical dilation in the absence of labor or abruption in a current pregnancy

Question 16

cervical length assessments start at

Answer 16

16 weeks of gestation and continue every 2 weeks up to 24 weeks of gestation. If the cervical length is noted to be shortened, then evaluations may occur weekly until the patient meets criteria for an ultrasound-indicated cerclage.

Question 17

17α-hydroxyprogesterone caproate use in preventing preterm birth increases the risk of

Answer 17

gestational diabetes mellitus (GDM)

Question 18

The sonographic findings of cervical funneling are associated with

Answer 18

Preterm labor,chorioamnionitis, abruption, rupture of the membranes and neonatal morbidity and mortality

Question 19

Cervical funneling is defined sonographically as a protrusion of amniotic membranes into the internal cervical os by greater than

Answer 19

5 mm from the shoulder of the original internal os as measured along the lateral border of the funnel.
This finding is usually accompanied by short cervical length (defined as <25 mm).

Question 20

Prrmaturity complications

Answer 20

respiratory distress syndrome, chronic lung disease, injury to the intestines, a compromised immune system, cardiovascular disorders, hearing and vision problems, and neurological insult, NND.

Question 21

Cutoff of fibronectin level in screen of preterm labour

Answer 21

50ng

Question 22

Dysmaturity” or “postmaturity” syndrome

Answer 22

refers to a fetus whose weight gain in the uterus after the due date has stopped, usually due to a problem with delivery of blood to the fetus through the placenta, leading to malnourishment.

Question 23

PPROM protocol of Antibiotics

Answer 23

a 7-day course of therapy of latency antibiotics with a combination of intravenous ampicillin and erythromycin followed by oral amoxicillin and erythromycin is recommended during expectant management of women with preterm PROM who are at less than 34 0/7 weeks of gestation.
intravenous ampicillin (2 g every 6 hours) and erythromycin (250 mg every 6 hours) for 48 hours followed by oral amoxicillin (250 mg every 8 hours) and erythromycin base (333 mg every 8 hours)

Question 24

CONTRAINDICATIONS of cervical Cercalge

Answer 24

● Fetal anomaly incompatible with life
●Intrauterine infection
●Active preterm labor
●Preterm prelabor rupture of membranes (PPROM)
●Fetal demise
●Active uterine bleeding (eg, placental abruption); however, placenta previa is not an absolute contraindication to cerclage placement.

The presence of fetal membranes prolapsing through the external cervical os is a relative contraindication (up to 65 percent of patients will experience iatrogenic rupture of the membranes)

Question 25

UPPER AND LOWER GESTATIONAL AGE THRESHOLDS FOR CERCLAGE PLACEMENT

Answer 25

Most cerclages are placed between 12 and 24 weeks of gestation.

procedure generally is not performed before 12 weeks of gestation because results of aneuploidy screening may not be available. If aneuploidy screening is not performed, waiting until the end of the first trimester allows most miscarriages related to aneuploidy to occur. Even if it is known that the fetus is euploid, waiting until the end of the first trimester permits sonographic evaluation for major fetal anomalies.

Question 26

Preoperative assessment of cervical Cercalge

Answer 26

Fetal assessment — Before scheduling the cerclage, the clinician should:

●Confirm fetal cardiac activity and gestational age
●Obtain a fetal anatomic survey for identifiable structural anomalies that could affect the patient’s decision to continue the pregnancy
●Offer aneuploidy screening if not already performed
Evaluation for infection If the patient is symptomatic or at high risk of acquiring a sexually transmitted infection and has no documentation of recent negative test results, the author tests for gonorrhea and chlamydia. If antibiotic therapy is indicated for positive test results, treatment is completed prior to cerclage placement.

Question 27

Cervical Cercalge COMPLICATIONS

Answer 27

• PPROM ( 2 percent )
  ●Intraamniotic infection — The median frequencies of intraamniotic infection after history-indicated and nonhistory-indicated cerclage are 2 and 25 percent, respectively.
  ●Suture migration — Suture migration has been reported in 3 to 13 percent of cases.
  ●Other — Cervical dystocia and cervical trauma in labor have been reported in fewer than 5 percent of patients, Excessive bleeding and fistula formation are also rare.

Question 28

PPROM treatment

Answer 28

Treatment included intravenous ampicillin plus erythromycin every 6 hours for 48 hours, which was followed by oral amoxicillin plus erythromycin, every 8 hours for 5 days.

Question 29

β-agonist infusion used as tocolytic resulted in serious and even fatal maternal side effects. Like what ?

Answer 29

Pulmonary edema is a special concern, and its cause is multifactorial. Risk factors include tocolytic therapy with β-agonist drugs, multifetal gestation, concurrent corticosteroid therapy, tocolysis for more than 24 hours, and intravenous infusion of large volumes of crystalloid. βAgonist agents cause retention of sodium and water, and with time—usually 24 to 48 hours—these can cause volume overload (Hankins, 1988). The drugs have been implicated in increased capillary permeability, cardiac rhythm disturbances, and myocardial ischemia. For example, in an earlier study, tocolysis was the third most common cause of acute respiratory distress and death in pregnant women during a 14-year period in Mississippi (Perry, 1998).

Question 30

Magnesium sulfate treatment side effect

Answer 30

has been associated with pulmonary edema (Samol, 2005).
the FDA (2013) has warned against prolonged use of magnesium sulfate given to arrest preterm labor because of bone thinning and fractures in fetuses exposed for more than 5 to 7 days.

Question 31

Prostaglandin Inhibitors (indomethacin) side effects

Answer 31

Most studies have limited indomethacin use to 24 to 48 hours because of concerns for oligohydramnios, which can develop with therapeutic doses. (reversible with drug discontinuation) there is also considerable debate on the association of necrotizing enterocolitis or early ductus arteriosus closure and use of indomethacin

Question 32

Preterm labor biomarkers

Answer 32

These include fetal fibronectin (fFN), phosphorylated insulin-like growth factor–binding protein 1 (phIGFBP-1), and placental alpha microglobulin 1 (PAMG-1).

Question 33

When fFN test for preterm labor considered positive ?

Answer 33

values exceeding 50 ng/mL are considered positive. Sample contamination by amnionic fluid and maternal blood should be avoided.
The American College of Obstetricians and Gynecologists (2021c) does not recommend screening with fFN tests.

Question 34

Cerclage placement may be used to prevent preterm birth in at least three circumstances.

Answer 34

First, the procedure may benefit women who have a history of recurrent second-trimester loss and who are diagnosed with cervical insufficiency. A second instance is the woman identified during sonographic examination to have a short cervix. The third indication is a “rescue” cerclage, done emergently when cervical incompetence is recognized in women with threatened preterm labor.

Question 35

Symptomatic UTI infections were associated with a —fold higher preterm delivery rate in those <37 weeks.

Answer 35

Symptomatic UTI infections were associated with a 1.4-fold higher preterm delivery rate in those <37 weeks.