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OB > PPROM & Chorio-amnionitis > Flashcards

PPROM & Chorio-amnionitis Flashcards

1
Q

What are the causes of premature rupture of membranes in pregnancy?

A

1- idiopathic weakness of fetal membranes
2- bacterial endotoxin or TNF-a -> release of fetal fibronectin (fFN) -> increased PGE2 & degradation of collagen
3- cervical incompetence
4- trauma: ECV, amniocentesis, cerclage
5- abruptio placenta
6- polyhydramnios
7- multi-fetal pregnancy
8- fetal malpresentation
9- preterm labour

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2
Q

What are the predisposing factors for PPROM?

A

1- low BMI < 19
2- heavy maternal smoking
3- frequent sexual activities
4- recurrent vaginal infections/UTI
5- past history of PPROM/PTL
6- cervical conization
7- low socio-economic status

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3
Q

What are the signs of premature rupture of membranes in pregnancy?

A

1- low fundal height
2- uterus is lax
3- easily palpable fetal parts
4- sterile speculum examination

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4
Q

What investigations should be done for PPROM?

A

1- CBC + urine culture + HVS for C&S
2- ultrasound examination + NST
3- fetal fibronectin >50mg/ml
4- test for IGFBP-1 by Actim PROM & PAMG-1 by AmniSure ROM
5- test for Phosphatidylglycerol (>35w)
6- amniotic fluid index: normally 5 - 25cm
- oligohydramnios <5cm
- polyhydramnios >25cm

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5
Q

What are the maternal complications of PROM?

A
  • chorioamnionitis -> puerperal sepsis & subinvolution -> atonic postpartum hemorrhage
  • abruptio placenta -> APH
  • oligohydramnios -> malpresentation
  • complications of the cause
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6
Q

What are the fetal complications of PROM?

A
  • neonatal sepsis -> perinatal M&M
  • maternal fetal transmission of HIV
  • cord compression/prolapse -> fetal distress
  • prematurity -> RDS + intracranial hemorrhage + CP + NE
  • severe oligohydramnios -> pulmonary hypoplasia + fetal deformities
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7
Q

How is PROM managed?

A

management depends on presence of: labour pains, signs of infections, fetal distress
- if present -> terminate pregnancy no matter the GA
- if not present
-> if GA is < 34 weeks: complete bed rest + corticosteroids + MgSO4 + erythromycin 250mg/6h for 10 days
-> if GA is > 34 weeks: wait 24-48hrs for spontaneous labour pain + give corticosteroids, MgSO4, & Erythromycin -> if labour doesnt occur: induce labour

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8
Q

How should vaginal delivery be managed in case of PROM?

A

1st Stage of Labour
- sedation & analgesia
- asepsis precautions
- strict monitoring

2nd Stage of Labour
- avoid prolongation

3rd Stage of Labour
- guard against postpartum hemorrhage
- guard against puerperal sepsis

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9
Q

When is C section indicated in case of PROM?

A
  • maternal sepsis (chorioamnionitis + SIRS)
  • fetal distress
  • malpresentation
  • failed induction
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10
Q

What are the predisposing factors for chorioamnionitis?

A
  • PPROM - PROM
  • vaginal cervical cerclage
  • invasive procedures: amniocentesis, foetoscopy
  • immuno-suppression: DM, steroid therapy
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11
Q

What are the organisms that may cause chorioamnionitis & what are their routes of infection?

A
  • Mixed infection: G. vaginalis, Fusobacterium, Mycoplasma hominis, & U. Urealyticum
  • gonorrhea & chlamydia trachomatis
  • GBS, Listeria, Bacteroids
    ascending or trans-placental
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12
Q

What is the clinical picture of chorioamnionitis?

A
  • fever, malaise
  • lower abdominal pain
  • abnormal vaginal discharge &/or bleeding
  • reduced fetal movements

Signs of maternal sepsis (infection + SIRS)
2 are diagnostic:
- hyperthermia >38C or hypothermia <36C
- tachypnea >20 breaths/min
- tachycardia >90bpm
- leucocytosis >12000 or leucopenia <4000

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13
Q

What will be found on physical examination of a patient with suspected chorioamnionitis?

A
  • period of amenorrhea
  • Leopold’s grips -> easily palpable fetal parts, tender uterus
  • fetal tachycardia
  • sterile speculum examination -> fluid pooling in vagina or leaking from cervical os
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14
Q

What investigations are done for diagnosis of chorioamnionitis?

A

1- CBC + urine analysis + HVS for C&S
2- vaginal + perianal + anal swabs -> GBS
3- ultrasound examination + NST
4- fetal fibronectin >50ng/ml
5- test for IGFBP-1 by Actim PROM & PAMG-1 by AmniSure ROM
6- test for phosphatidylglycerol (>35w)

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15
Q

What are the indications for conservative treatment of chorioamnionitis?

A
  • gestational age < 34 weeks
  • mother is not in active labour
  • no evidence of sepsis
  • fetus is alive + not distressed + no CFMF
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16
Q

What are the indications for termination of pregnancy in chorioamnionitis?

A
  • gestational age > 34 weeks
  • mother is in active labour
  • evidence or suspicion of sepsis (+ SIRS)
  • fetus is dead or distressed or lethal CFMF
17
Q

How is a lady with chorioamnionitis treated conservatively?

A

1- hospitalization & sedation to avoid anxiety

2- maternal follow up
- daily observation of vaginal discharges, vital signs, abdominal pain or tenderness
- antibiotics: erythromycin 250mg/6hr for 10 days
- if +ive GBS: Benzyl Penicillin, Cefazolin, or Clindamycin
- corticosteroids 24-34 weeks
- MgSO4 24-30 weeks
- remove cerclage before 24hrs from PROM

3- fetal follow up
- non-stress test
- BPP weekly
- notify NICU

18
Q

What drugs are contraindicated incase of chorioamnionitis?

A
  • amoxicillin-clavulanate -> neonatal necrotizing enterocolitis
  • never give tocolysis
19
Q

How is induction of labour done in case of chorioamnionitis?

A
  • PG (prostin-E2) -> augmentation of labour by oxytocin infusion
  • C section -> if there are indications
20
Q

How is septic shock managed in chorioamnionitis?

A

Lactate >2mmol -> ICU

1- resuscitation (20ml/kg crystalloids + packed RBCs + FFP) -> maintain CVP >10cm/h2O
2- Vasopressors (epinephrine) + Inotropes (Doputamine) -> maintain MAP > 65mmHg
3- assisted ventilation -> O2 saturation > 96%
4- steroids + diuretics (if urinary output <30ml/h)
5- broad spectrum antibiotics within 1st hour -> ampicillin + gentamicin + metronidazole
6- septic focus -> hysterectomy in toto

OB (42 decks)

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