PPROM

Question 1

A woman presents with premature rupture of membranes at 32 wks. How would you manage this? Discuss both premature rupture of membranes progressing to labour and not progressing to labour.

Answer 1

Impression
PPROM is pre-term premature rupture of membranes. Concerned about risks of infection, pre-term birth.

Conduct through Hx/Ex/Ix to guide appropriate management plan for patient.

Aim of management is to determine whether patient is in labour, or whether labour is imminent, and maximise benefits of increasing fetal maturity in-utero while minimising potential risks.

Question 2

PPROM - History

Answer 2

History

• sx: characterise timing of suspected PPROM, associated sx (pain, bleeding, fevers),
• O&G hx: details of current pregnancy, any abnormalities, GTPAL, scans to date, yellow-book, fetal movements
• PMHx, PSHx
• Medications, allergies
• psychosocial Hx

Question 3

PPROM - Examination

Answer 3

Examination

• general appearance + vitals
• antenatal assessment
• CTG (ensure fetes is stable, likelihood of labour)
• Speculum assessment (if placenta/vasa praevia ruled out): estimate cervical dilation, exclude cord prolapse. Do not perform digital examination due to risk of infection

Question 4

PPROM - Investigations

Answer 4

Investigations
Is predominantly a clinical diagnosis.

• Key/diagnostic: nitrazine paper test (amniotic fluid pH is 70-7.3), amnisure (immunoassay)
• Laboratory: crevice-vaginal sobs - MCS, FBC, coags, UEC< G+H/xmatch, kleihauer
• Imaging: abdominal ultrasound: assess fetal presentation, FHR< amniotic fluid volume

Question 5

PPROM - Management

Answer 5

Management

• admit mother for monitoring for 48-72 hours
• escalate to O&G reg/consultant for review and planning
• consider need for transfer to higher-level services

Expectant management

• prophylactic ABX: amoxicillin/ampicillin
• regular obs for infection
• corticosteroids if imminent labour
• consider tocolysis for 48 hours to allow administration of steroids for fetal resp development.
• magnesium sulphate for neuroprotection

Active management
- induction of labour with syntocinon (if intrauterine infection, placental abruption, non-reassuring CTG trace, high risk of cord prolapse, or GBS positive)

Other
- psychosocial supports