PPH, C/S, LBAOUR, ROM Flashcards
what are some of the investigations done for PPH
- Hb
- Ultrasound
- Clotting time
- Blood clotting screen
- CTG for differential diagnosis/fetal wellbeing
- Blood gases
- Check renal function
- PV to assess cervix if diagnosis certain for AP, NO PV for PP
When does preterm labour occur and preterm rupture of membranes
before 37 weeks
Diagnosis:
* Regular painful contractions with cervical changes with/without ROM.
* Threatened preterm labour if only uterine contractions
what are come of the cause preterm labour and preterm rupture of membranes
- Infection: chorioamnionitis, genital tract infection e.g. group B strep
- Maternal pyrexial illness: pyelonephritis, RTI
- Cervical incompetence
- Multiple pregnancies
- Polyhydramnios
- Placenta praevia
- Abruptio placenta
- IUGR
- Uterine abnormalities
- Fetal abnormalities
what are the risk factors associated with preterm labour and preterm rupture of membranes
- Previous preterm labour
- Unbooked
- Lower SES
- Smoking, alcohol
- Malnutrition
what investigations are done in the event of preterm labour
- Midstream urine MC&S
- High vaginal swab
- CTG
- Ultrasound
what are some of the contraindications to tocolytic drugs
- Fetal distress
- Pre-eclampsia
- Lethal fetal abnormality
- Chorioamnionitis
- IUGR
- APH
what are tocolytics
they are drugs that are used to suppress labour in order to administer steroids to enhance fetal lung maturity. only continued for 48 hours.
brief summary on Calcium channel blockers
- E.g. Nifedipine (drug of first choice) Adalat®
- Dose: initially 30mg orally then 20mg after 90 minutes and if contractions persist,
20mg every 6 hours - Side effects: headache, flushing and nausea
- Contra-indications: hypovoleamia, cardiac conditions
brief summary on Β2adrenergic agents
- E.g. Salbutamol (Ventolin®) uterine smooth muscle relaxant
- Dose: 250mcg diluted in 9.5mls water as a slow IV bolus
- Side effects: maternal and fetal tachycardia, hyperglycaemia
- Contra-indications: stenotic valvular heart lesions, shock, diabetes, thyrotoxicosis
brief summary on Prostaglandin antagonists
- E.g. Indomethacin (blocks the conversion of arachidonic acid to prostaglandin E2 and
F2α) - Dose: 100mg rectally 12 hours apart for 48 hours
- Side effects: GIT irritation, renal failure, suppression of platelet function, premature
closure of fetal ductus arteriosus - Contra-indications: thrombocytopaenia, peptic ulcer disease, fetal gestation> 32
weeks
brief summary on steroids
Enhance fetal lung maturity, prevent intraventricular haemorrhage and necrotizing enterocolitis.
Betamethasone 12mg intra-muscularly 24 hours apart (2 doses)
Usually only a single course given but a rescue course may be given if the initial dose is given at a very early gestation e.g. 27 weeks.
brief summary on antibiotics
Use of antibiotics is controversial
The ORACLE II trial showed no benefit except in those patients in whom membranes had also ruptured
* In South Africa, we do not routinely screen for infections such as Group B Strep infection, but patients with clinical signs and symptoms suggestive of Group B Strep (such as preterm labour, PROM, PPROM), should receive intravenous Ampicillin to protect the baby.
* Identified infections such as pyelonephritis should be treated with appropriate antibiotics - based on microbiological culture results.
preterm rupture of membranes
Confirm membrane rupture by history, examination & special investigations.
Perform a sterile speculum examination. Liquor observed draining from the cervical os confirms the diagnosis. The patient can be asked to cough is liquor is not initial evident. If fluid is observed pooling in the posterior fornix, a specimen should be taken aspirating liquor with the plastic cannula of a jelo/IV catheter.
how is the diagnosis of preterm rupture of membranes made
- Litmus lesting: Liquor is alkaline and turns red litmus blue.
- “Ferning can be observed under a microscope if liquor is placed on a slide and left to dry.
Amnisure: Is used for the detection of PAMG-1 (placental alpha macroglobulin 1) in amniotic fluid using test strips. Expensive test therefore use litmus as initial test and Amnisure only in uncertain cases.
Highly sensitive and specific for amniotic fluid. - Fetal fat cells stain orange with 1% Nile blue sulphate (after 30 weeks)
what is the management of preterm rupture of membranes before 34 weeks
- Admit the patient and counsel about risks of preterm labour.
- Avoid vaginal examination unless prolapsed cord suspected because of abnormal fetal heart rate.
- Administer antibiotics Azithromycin 500mg daily for 3 days
- Administer Betamethasone 12mg IMI 12 hourly x 2 doses
- Midstream urine to exclude urinary tract infection
- Twice weekly white cell counts
- Use of sterile pads
- Growth ultrasound
- If labour supervenes, consider tocolysis for 48 hours to administer steroids
- If there are signs of infection such as maternal pyrexia, uterine tendernes or fetal tachycardia or rising white cell count, induce labour urgently regardless of the gestational age.
