P-PROM

Question 1

Define P-PROM + Epidemiology

Answer 1

Rupture of membranes in absence of any uterine activity before 37wks (24 to 36+6wks)

Occurs in 2% of pregnancies, associated with 40% of preterm deliveries

Question 2

Risk factors for P-PROM?

Answer 2

Smokers, STI, previous P-PROM, multiple pregnancy

Question 3

Complications of P-PROM?

Answer 3

Foetal: Premature baby, infection, pulmonary hypoplasia
Maternal: Chorioamnionitis

Question 4

A lady who is 33wks pregnany presents to triage with fluid trickling out of her vagina and doesn’t know if she has broken waters or not. She hasn’t felt any contractions. What are the next steps in management?

Answer 4

1. Admit her to antenatal ward for sterile speculum examination - look for pooling of amniotic fluid in posterior vaginal vault.
   If no pooling, can USS to look for oligohydramnios.
2. Prophylactic PO erythromycin 250mg QDS for max 10 days or until labour (whichever is sooner). (2nd line penicillin). This is for prophylaxis of chorioamnionitis
3. Maternal IM Betamethasone 24mg in 2 divided doses 12hrs apart
4. Intense clinical monitoring for pre-term labour + chorioamnionitis. Up to 28wks = inpatient. Post 28wks = outpatient monitoring 2-3x/wk

IV magnesium sulphate for neonatal neuroprotection if birth is expected in next 24hrs

NO tocolytics - increased risk of infection

Question 5

When should baby be delivered in patient with P-PROM?

Answer 5

Ideally want to keep baby inside mum for as long as possible, but also need to balance risk of infection as well.

Aim to deliver for 37wks.
Delivery advised if foetal lung maturation confirmed OR if there is infection

Question 6

Counsel the patient who has been diagnosed with P-PROM

Answer 6

1. Explain what P-PROM is
2. Explain we need to admit her because it carries serious risks to both mother and baby.
3. Explain the risks of a premature baby. Because we don’t want a premature baby we want to keep the baby inside mum for as long as possible, but we must balance this with risk of infection as well.
4. Explain that we will be monitoring her closely with CTG and maternal observations. She will need to come into DAU 2-3x a week as an outpatient (or admit if <28wks)
5. Explain that we will be giving her prophylactic erythromycin 250mg QDS for max 10 days (to prevent infection) and IM betamethasone 24mg split into 2 doses 12hrs apart for foetal lung maturation. If birth is expected we may also need to give IV magnesium sulphate for neonatal neuroprotection
6. Explain that we will consider delivering around 34wks. As gestation gets longer, there’s a trade-off between higher risk of infection, and lower risk of resp. distress syndrome when baby is born.