PPROM AND TERM PROM Flashcards
Full meaning of PROM
- Prelabour rupture of membranes
- Premature rupture of membranes
Another term for PROM
Prelabour amniorrhexis
T/F: Premature rupture of membranes is rupture of membranes before the onset of labor, irrespective of gestational age
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3 types of PROM
- Preterm PROM = before 37wks
- Term PROM = 37 or more wks
- Previable PROM = Before 28 wks
What is latency period in PROM
Period from ROM to onset of contractions/labour
T/F: If a woman has ROM and goes into labour within 1 to 2 hours, it is not PROM
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Minimum latency period of PROM
1 - 2 hours
Median latency after PPROM
7 days
What is prolonged ROM
Any ROM that persists for more than 24 hours and prior to the onset of labor
Incidence of PROM in all pregnancies
12%
Incidence of PROM in term pregnancies
8%
Incidence of PROM in preterm deliveries
30%
3 pathways to preterm birth
- Spontaneous preterm labor (40%)
- Premature rupture of membranes (35%)
- Medical intervention (25%)
T/F: Multifetal pregnancies comprise 3% percent of all live births
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% of preterm births resulting from spontaneous preterm labour
40% (40 - 50%)
% of preterm births resulting from premature rupture of membranes
35% (25 - 40%)
% of preterm births resulting from medical intervention
25% (20 - 35%)
8 sequelae of PROM
Preterm delivery
Chorioamnionitis (13-60%; 53.4% Eleje et al)
Non-reassuring fetal status (8 %)
Cord Prolapsed
Abruptio placenta (4%)
Pulmonary hypoplasia
Cesarean
IUFD (1%; 8.7% Eleje et al)
Incidence of chorioamnionitis following PROM
13-60%
(53.4% Eleje et al)
Incidence of IUFD following PROM
1%
(8.7% Eleje et al)
Incidence of abruptio placentae as a consequence of PROM
4%
Incidence of non-reassuring fetal status as a consequence of PROM
8%
T/F: Latency increases with early EGA, AFI
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4 natural history of PROM in terms of delivery
- Delivery in 48hrs
- Delivery in 1 week
- Delivery in > 4 weeks
- Reseal
% of women with PROM that will deliver in 48hrs
30 - 50%
% of women with PROM that will deliver in 1 week
90 - 93%
% of women with PROM that will deliver in > 4 weeks
10%
% of PROM that will reseal
3 - 10%
9 risk factors for PROM
- Chorioamnionitis
- Vaginal infections
- Cervical abnormalities
- Vascular pathology (incl.
abruptio) - Smoking
- 1st, 2nd, 3rd, or multiple
trimester bleeding - Previous preterm delivery
(PPROM) - Acquired or congenital
connective tissue disorder - Nutritional deficiencies (Vit.C,
copper, zinc)
T/F: PROM can result from APH in any trimester
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3 examples of nutritional deficiencies that can lead to PROM
Vit. C
Copper
Zinc
6 mechanisms of preterm PROM
- Bacterial production of proteases
- Host response to blood or bacteria (MMP 1,2,9) or (TIMP1,3)
- Pre-existing weakness
- Strain from preterm uterine activity
- Direct membrane trauma (cerclage or amnio)
- Developmental “weak spot”
T/F: Mechanisms of preterm PROM can include:
ascending infection, stretch, necrosis and decidual adherence
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2 mechanisms of PROM at term
a normal physiologic weakening of the membranes combined with shearing forces created by uterine contractions
T/F: In the history of PROM, the patient reports a “Gush” of fluid or steady leakage of small amounts of fluid
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T/F: Digital examination of the cervix with PPROM has been shown to shorten latency and increase risk of infections
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For the ferning test, the slide should be allowed to dry for how long
10 mins
pH of amniotic fluid
Alkaline
7.1 - 7.3
Normal pH of vaginal secretions
3.8–4.5
Effect of amniotic fluid on nitrazine
Turns nitrazine pH indicator blue
Sensitivity of nitrazine test
90.7%
Specificity of nitrazine test
77.2%
% of false positive nitrazine test
17.4%
% of false negative nitrazine test
12.9%
Other fluids and infections can result in false positive nitrazine test
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Sensitivity of the ferning test
51.4%
Specificity of the ferning test
70.8%
% false positive results in fern test
5-30%
% false negative results in fern test
12.9%
Drawbacks of the fern test
Requires speculum exam, microscope with risks of contamination.
5 causes of false positive nitrazine test
Alkaline urine
Semen (recent coitus)
Cervical mucus
Blood contamination
Vaginitis (e.g. Trichomonas)
2 reasons for false negative nitrazine test
Remote PROM with no residual fluid
Minimal amniotic leakage
What are the drawbacks of pooling as a technique of PROM diagnosis
Speculum exam. Subjective. Other fluids
T/F: USS is a reliable screening test for PPROM
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Not a reliable screening test if used alone
Used only to help confirm
Diagnosis
% of women with PPROM that have reduced amniotic fluid on USS
50 - 70%
Gold Standard for diagnosis of rupture of membranes
Amnio-dye infusion
Drawbacks of amnio-dye infusion
Accurate, but highly invasive (requires amniocentesis). Expensive
Describe the technique of amnio-dye infusion
Transabdominal Instillation of dilute indigo carmine into the amniotic cavity and confirmation of rupture of membranes by documenting leakage of dye into the vagina (staining of tampon) [Tampon placed in vagina and checked for blue staining 30-60 mins after procedure]
Drawbacks of amnio-dye infusion
Accurate, but highly invasive (requires amniocentesis). Expensive
9 techniques for diagnosing PROM
- History of fluid leakage
- Pooling of liquor in post. fornix
- Nitrazine test
- Ferning test
- Amnio-dye infusion
- Ultrasound
- PAMG-1 (Amnisure)
- Fetal fibronectin
- Amnioquick duo plus test
Placental Alpha Microglobulin-1 (PAMG-1) is a protein expressed by the cells of the —
decidual part of placenta
T/F: Extremely low background level of PAMG-1 is measured in cervico-vaginal secretions when the fetal membranes are intact
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T/F: During pregnancy, PAMG-1 is secreted into the amniotic fluid in great quantities
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The immunochromatographic assay using monoclonal antibodies to detect PAMG-1 protein works within a wide range of PAMG-1 concentrations in vaginal secretion from
5 ng/ml to 100 mcg/ml
T/F: PAMG-1 test has consistently high diagnostic accuracy at all gestational ages and with equivocal cases of ROM
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Accuracy, sensitivity and specificity of PAMG-1 test
97.2%, 97.4%, and 96.7%
Describe the procedure for administering the PAMG-1 (amnisure) test
Procedure
Step One: Vaginal swab (2-3 inches deep).
Step Two: Swab is dipped into the vial of solvent for one minute.
Step Three: Test strip is placed in the vial containing the specimen extracted from the swab by the solvent.
Step Four: Remove the strip after 5-10 minutes and read the results.
Reading the Results
1 line in the test region means No Rupture
2 lines in the test region means There is a Rupture
Diagnostic accuracy of SCA (standard clinical assessment)
83.4%
Diagnostic accuracy of pooling as a test of ROM
77.7%
Diagnostic accuracy of nitrazine test
84.8%
Diagnostic accuracy of fern test
69.2%
T/F: The nitrazine test has a high sensitivity (92.6%) but a poor specificity (60.7%)
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At what GA is fetal fibronectin seen in cervical secretions
<22wks and >34wks
T/F: Fetal fibronectin is used for assessment of potential PTB
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T/F: Positive result of fetal fibronectin may be indicative of PROM and represents disruption of decidua-chorionic interface
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Value for positive fetal fibronectin test
> 50ng/dL
Sensitivity of fetal fibronectin with PROM
98.2%
Specificity of fetal fibronectin in PROM
26.8%
2 components of amnioquick duo plus
Insulin-like growth factor binding protein - 1 and alpha fetoprotein
T/F: Amnioquick duo plus and PAMG-1 have a comparatively high diagnostic accuracy in identifying women with PROM
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T/F: The diagnosis of chorioamnionitis is histological
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A retrospective diagnosis
The Chorioquick test (for the diagnosis of chorioamnionitis) is composed of three strips incorporated in a single cassette device for detection of —-
IL-6 at three different thresholds (namely IL-6 low, IL-6 medium and IL-6 high).
Sensitivity of the chorioquick test
97.5%
Specificity and accuracy of the chorioquick test
87.9%
93.2%
T/F: IOL (stimulation of labour) reduced the time from ROM to birth, rates of chorioamnionitis or endometritis, or both. reduced admission to NICU without increasing the rates of cesarean birth or operative vaginal delivery
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T/F: women with PROM viewed induction of labor more positively than expectant management
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T/F: IOL (stimulation of labour) with vaginal prostaglandins has been shown to be equally effective for labor induction compared with oxytocin but was associated with higher rates of chorioamnionitis
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Necessitates sublingual route
T/F: There is insufficient evidence to justify the routine use of prophylactic antibiotics with PROM at term in the absence of an indication for GBS prophylaxis
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T/F: patients with Term PROM benefit from induction of labor (stimulation of labour) compared with expectant management
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T/F: Induction may help reduce infection in the woman and neonate without increasing the risk for cesarean birth
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T/F: For women with PROM at 37+0/7 weeks of gestation or more, if spontaneous labor does not occur near the time of presentation in those who do not have contraindication to labor,
labor induction should be recommended, although the choice of expectant management for a short period of time may be appropriately offered
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T/F: a period of 12–24 hours of expectant management is reasonable as long as the clinical and fetal conditions are reassuring, and patient is adequately counseled regarding the risks of prolonged PROM and the limitations of available data
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T/F: 80% and 95% of patients with PROM start labor spontaneously within 12 hours and 24 hours respectively
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T/F: For women who are GBS positive, administration of antibiotics for GBS prophylaxis should not be delayed while awaiting labor, and immediate IOL rather than expectant management is recommended
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HOW LONG SHOULD IOL LAST IN TERM PROM?
During IOL with oxytocin, a sufficient period of adequate contractions (at least 12–18 hours) should be allowed for the latent phase of labor to progress before diagnosing failed induction and moving to cesarean section
6 signs of infection in the expectant management of PROM
Temperature
Maternal pulse rate (Tachycardia signifies imminent chorioamnionitis)
Maternal heart rate
Fetal heart rate
Uterine tenderness
Contractions
4 tests for fetal lung maturity
- Lecithin/sphingomyelin ratio
- Phosphatidyl glycerol
- Fluorescence polarization
- Lamellar body count
T/F: The tests for fetal lung maturity in PROM are performed after 32 wks
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If negative, proceed with expectant management until 34 wks
Value of lecithin/sphingomyelin ratio indicating fetal lung maturity
> 2
Value of phosphatidylglycerol associated with minimal respiratory distress
</= 0.5
Value for the lamellar body count
30,000 - 40,000
Value for the fluorescence polarization test
> 55 mg/g of albumin
2 benefits of expectant management in PROM
Mature lung profile
Advancing GA (reducing risks associated with PTB)
6 risks associated with expectant management in PROM
Abruption
Chorioamnionitis
Cord Prolapse
Pulmonary Hypoplasia (<19 weeks PPROM
Skeletal Deformities
Endometritis (1/3)
7 indications for delivery in PROM
Maternal-Fetal Distress
Infection
Advanced labour
Abruption
Cord Prolapse
Fetal death
Repetitive fetal heart rate decelerations
T/F: Individualized management of PPROM may prolong pregnancy, and reduce preterm birth <32 weeks, need for neonatal support and neonatal intensive care unit admissions without an increase in histological chorioamnionitis, funisitis, neonatal infection-related morbidity and adverse short-term maternal and neonatal outcomes
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T/F: In infection surveillance serial monitoring of leukocyte counts and other markers of inflammation have not been proved to be useful
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They are nonspecific when there is no clinical evidence of infection,
especially if antenatal corticosteroids have been administered
T/F: Use of vaginal progesterone to prolong latency is cases of preterm PROM is not recommended
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T/: 17-hydroxyprogesterone caproate should not be used in patients with preterm PROM specifically for the purpose of extending latency
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T/F: tocolytic agents in preterm PROM may be associated with a prolongation of pregnancy and an increased risk of chorioamnionitis
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T/F: Tocolytic agents can be considered in preterm PROM for steroid benefit to the neonate
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T/F: Tocolytic therapy is recommended in the setting of preterm PROM between 34+0/7 weeks of gestation and 36+6/7 weeks of gestation
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T/F: Use of antenatal steroids reduce neonatal mortality, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis
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T/F: Antenatal corticosteroids are not associated with increased risks of maternal or neonatal infection regardless of GA
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T/F: Consider a course corticosteroids for pregnant women who are at risk of preterm birth within 7 days
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T/F: Consider a course of corticosteroids for women with ruptured membranes as early as 23+0/7 weeks of gestation
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T/F: A single course of corticosteroids is recommended for pregnant women between 24+0/7 weeks of gestation and 33+6/7 weeks of gestation with PROM
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T/F: A single course of antenatal corticosteroids should be considered routine for all preterm deliveries
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T/F: Corticosteroids should not be used in late preterm (>34wks) PROM
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delivery should not be delayed, and antenatal corticosteroids should not be used in the late preterm period
T/F: Late preterm (>34 weeks) administration of antenatal corticosteroids is not indicated in women diagnosed with clinical chorioamnionitis
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T/F: corticosteroids do not increase the risk of chorioamnionitis
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T/F: Delivery should be delayed to achieve a rescue course of corticosteroids
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Rescue course is for women who have received a previous course
Who qualifies for a rescue course of antenatal corticosteroids?
women with preterm PROM who are less than 34+0/7 weeks of gestation, are at risk of preterm delivery within 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously
Who qualifies for magnesium sulphate for fetal neuroprotection?
Women with preterm PROM anticipating birth before 32 weeks. Reduces the risk of cerebral palsy in surviving infants
T/F: Magnesium sulphate administered for fetal neuroprotection prolongs the latency period
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Magnesium sulfate administration for this indication does not appear to affect latency interval
T/F: Administration of broad-spectrum antibiotics prolongs pregnancy in preterm PROM
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Antibiotic regimen in preterm PROM
To reduce maternal and neonatal infections and gestational-age-dependent morbidity, 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
T/F: The parenteral formulation of erythromycin as recommended by the NICH study is not readily available in Nigeria
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The antibiotic regimen used in the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network trial for PROM
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)
T/F: Some centers have replaced the use of erythromycin with azithromycin (such as a single oral dose of azithromycin 1 g)
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In situations in which erythromycin is not available or not tolerated, and this substitution is a suitable alternative
T/F: The use of amoxicillin–clavulanic acid is not recommended in PROM
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Has been associated with increased rates of NEC
T/F: The outpatient management of preterm PROM with a viable fetus is not recommended
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T/F: Previable PROM may be considered for home care after a period of assessment in the hospital
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T/F: Cerclage retention for more than 24 hours after preterm PROM is associated with pregnancy prolongation
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T/F: cerclage retention with preterm PROM has been
associated with increased rates of neonatal mortality from sepsis, neonatal sepsis, respiratory distress syndrome, and maternal chorioamnionitis
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T/F: If a cerclage remains in place with preterm PROM, prolonged antibiotic prophylaxis beyond 7 days is not recommended
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T/F: The duration of the interval between ROM and labor is not correlated with risk of vertical transmission (HIV) in patients who receive highly active antiretroviral therapy, have a low viral load, and receive antepartum and intrapartum zidovudine
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T/F: In cases involving a very early GA in which the patient is being treated with ARV medications and the viral load is low, a period of expectant management is likely to be appropriate
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T/F: Regularly scheduled repeat courses or more than 2 courses of antenatal corticosteroids are not recommended.
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T/F: Expectant management in PROM should not extend beyond 37+0/7 weeks of gestation
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T/F: Tocolytic therapy is not recommended in the setting of
preterm PROM between 34+0/7 weeks of gestation and 36+6/7 weeks of gestation
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