PPROM or PROM Flashcards
GBS precaution
There is an increased prevalence of GBS colonisation amongst women giving birth preterm.
Recommend vaginal and rectal cultures for GBS
If there is imminent risk of birth, commence intrapartum antibiotic prophylaxis
If labour ensues, give intrapartum antibiotic prophylaxis irrespective of GBS status
If there is PPROM without labour, Erythromycin is the preferred antibiotic
Definitions of PPROM and PROM
PROM Premature Rupture Of Membranes refers to membrane rupture prior to onset of uterine contractions
• PPROM Preterm Premature Rupture Of Membranes: membranes ruptured at < 37 weeks gestation
Incidence of PPROM and PROM
2-3% of all pregnancies
• Accounts for 1/3 of preterm births
Risk of PPROM and PROM
Preterm labour: <28/40: 50% will deliver within 7 days , 28-34/40: 50% will deliver within 24h, 80-90 % will deliver within 7 day
Infection 15-25% : chorio-amnionitis, neonatal sepsis ( up to 20%) (may lead to CP), Endometritis / puerperal sepsis
Abruption 4-7%
Cord prolapse
Oligo-hydramnios: Pulmonary hypoplasia, Limb positioning defects
Diagnosis of PPROM, PROM
- History
• Pooling of liquor on sterile speculum
• If no obvious pooling: PPROM test (ie actim PROM test) or Nitrazine test
Work up of PPROM, PROM
History fluid contractions Fetal movements Examination Vitals Abdo palp CTG Bedside USS presentation, liquor volume Sterile speculum Visualize pooling of liquor, exclude cord prolapse, cervical dilatation, take swabs, PPROM test AVOID digital exam Investigation bloods Swabs and MSU Formal USS Management depends on: gestation, signs of labour, signs of infection, fetal lie/presentation, fetal wellbeing, GBS 34 wk expectant increase risk of Chorioamnitotis when compared to delivering but decrease jaundice. 30-34 wk same results except Jaundice was equal principles admit to hospital Antibiotics - Erythromycin 10 days after PPROM GBS prophylaxis in labour Prophylaxis Tocolysis - evidence says not to use it? Green top guidelines Steroids - for PPROM 24wk to 34 wks Timing and mode of delivery Surveillance for infection and wellbeing (H E I ) Notify NICU
Define PTL
PTL: regular painful contractions associated with dilatation and/or effacement of the cervix, at < 37 weeks gestation
Incidence of PTL
- Developed world: 5-10% • Developing world: up to 25% Of all deliveries: 1-1.5% are <32/40 0.5-1% are < 28/40
Risk factors for PTL
• Low BMI, smoker, lower SES, black race, stress • Prev Hx of PTB Mullerian anomalies <18 or >35yr Ethnicity Smoker Stress Current pregnancy: Multiple APH infections - vagina or UTI PPRom
Risks of PTL
Preterm birth!
• Prematurity: major cause of neonatal mortality and morbidity
• In Australia: prematurity accounts for 40%of NND, infection for 9%
How to determine likelihood of PTL
Fetal fibronectin / Actim Partus test:
only useful in symptomatic women, 24-34 weeks, intact membranes, <3cm dilated on sterile speculum.
High NPV: if negative: risk of PTL in next 7- 10 days <2%
>50ng/ml is high
to minimise unnecessary interventions ie transfer, hospital admission, steroids etc
Cervical length measurement on TV USS
symptomatic women: > 30 mm excludes PTL or < 30 mm may need further Ix ie fFN
Screening for bacterial vaginosis
Strong evidence supports relationship b/w BV and PTL.
Screen women with risk factors for PTL for BV < 20 weeks: treatment will reduce risk of PTL
Diagnosis of PTL
See definition: regular painful contractions associated with dilatation and/or effacement of the cervix, at < 37 weeks gestation
contractions/ tightenings with a closed cervix but positive fFN or short cervix on USS: treated as PTL
Work up for PTL
History: Previous, Current
Examination: Vitals, Abdo palp, CTG
Bedside
USS - presentation, liquor volume
Sterile speculum - cervical length and dilatation, take swabs, fFN/actim parts test
Investigations:
Bloods
Swabs and MSU
Formal USS later on, including cervical length
Management:
Admit if : fFN >50ng, Cervical dilation, Cervical changes over 2-4 hr, ROM, Contractions regular and painful, Maternal or fetal concerns
CTG
Contact NICU
What’s the aim of your management? to delay delivery for long enough to allow transfer to tertiary centre and administer steroids
Tocolysis
Corticosteroids
MgSO4 for neuro-protection
protects against Cerebral palsy and other damage
give if <30/40 in PTL or needing early delivery
When to use tocolysis and when not to use in PTL
indication: signs of PTL, 24-34wk
Contraindicated any fetal or maternal reason not to prolong pregnancy: ie severe PET, eclampsia, chorio- amnionitis, advanced labour, abruption, severe IUGR, fetal distress, lethal congenital anomalies,
Duration: for 48hr, until steroids loaded.
Types
Nifedipine AE: headache, flushes, palpitations, hypotension, tachycardia
B-mimetics
Oxytocin receptor antagonists
other
when to use Corticosteroid in PTL
When to give:
24-34 weeks
Spontaneous PTL, PPROM , elective early delivery for maternal or fetal indications
Repeat doses may be given as required (at birth: slightly reduced birth weight/ SGA;
at 2y: nil difference, except ? More attention problems)
How to give: 11,4 mg betamethasone IM at 0 and 24 hrs
