PPROM_Flashcards
What is the incidence of preterm prelabour rupture of the membranes (PPROM)?
PPROM occurs in around 2% of pregnancies but is associated with around 40% of preterm deliveries.
What are the fetal complications of PPROM?
Prematurity, infection, pulmonary hypoplasia.
What are the maternal complications of PPROM?
Chorioamnionitis.
How is PPROM confirmed?
A sterile speculum examination should be performed to look for pooling of amniotic fluid in the posterior vaginal vault, but digital examination should be avoided due to the risk of infection.
What should be done if pooling of fluid is not observed during speculum examination?
NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1. Ultrasound may also be useful to show oligohydramnios.
What is the first step in the management of PPROM?
Admission.
What regular monitoring should be done for a patient with PPROM?
Regular observations to ensure chorioamnionitis is not developing.
What medication should be given to a patient with PPROM?
Oral erythromycin should be given for 10 days.
What other treatment should be administered for PPROM?
Antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome.
When should delivery be considered in a patient with PPROM?
Delivery should be considered at 34 weeks of gestation, balancing the risk of maternal chorioamnionitis with the decreased risk of respiratory distress syndrome as the pregnancy progresses.
summarise PPROM
Preterm prelabour rupture of the membranes
Preterm prelabour rupture of the membranes (PPROM) occurs in around 2% of pregnancies but is associated with around 40% of preterm deliveries
Complications of PPROM
fetal: prematurity, infection, pulmonary hypoplasia
maternal: chorioamnionitis
Confirming PPROM
a sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection
if pooling of fluid is not observed NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSureµ) or insulin-like growth factor binding protein-1
ultrasound may also be useful to show oligohydramnios
Management
admission
regular observations to ensure chorioamnionitis is not developing
oral erythromycin should be given for 10 days
antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
delivery should be considered at 34 weeks of gestation - there is a trade-off between an increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
A 26-year-old primigravida with twins, presents to the obstetrics department at 33+4 weeks gestation. She felt an increase of ‘wetness in her underwear’ this morning but denies any abdominal pain, presence of blood or change to the vaginal discharge.
Her past medical history includes an abortion at 10 weeks.
She has been up to date with all the antenatal care and scans and there have been no complications with the pregnancy thus far.
What is the most appropriate next step in investigating this patient?
Cardiotocography
Digital vaginal examination
High vaginal swab
Speculum examination
Ultrasound scan
Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes
The most likely diagnosis for this patient is premature prelabour rupture of membranes (PPROM). PPROM can present with a gushing of fluid and continual wetness in the underwear. Multiple pregnancies, previous cervical trauma, previous abortion, and urine and fetal infection are some of the risk factors for premature labour, two of which this patient has.
The most appropriate investigation is a speculum examination to look for pooling of amniotic fluid. If unsure, a fetal fibronectin test can be performed to confirm rupture of membranes.
Digital examination must be avoided to reduce the risk of introducing infection to the uterus and fetus.
A CTG and ultrasound scan are important to check the health of the fetus but should be performed after the speculum examination, as the speculum is more likely to give you the diagnosis in this case.
A high vaginal swab should be done if infection is suspected.
A 28-year-old woman self-presents to the Emergency Department, extremely concerned regarding her pregnancy. She is 33 weeks pregnant and thus far, the pregnancy has been uncomplicated. However, several hours ago whilst out shopping, she felt a sudden gush of fluid from her vagina and a subsequent wetness of her underwear.
Her observations have already been taken by one of the triage nurses and are stable, within normal ranges.
Given the likely diagnosis, what is the first-line investigation?
Digital examination
Obstetric abdominal examination
Speculum examination
Ultrasound scan
Placental alpha microglobulin-1 (PAMG-1) vaginal fluid test
Speculum examination
Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes
Important for meLess important
The history is highly suggestive of preterm prelabour rupture of the membranes. As per RCOG Green-top guidelines, to confirm this diagnosis, the initial investigation should be a sterile speculum examination, to look for pooling of amniotic fluid in the posterior vaginal vault.
Digital examination should be avoided due to the risk of introducing infection.
Abdominal examination would not aid the process of diagnosing rupture of the membranes.
Ultrasound may be useful in demonstrating oligohydramnios, but this is not the first-line investigation to perform.
RCOG guidelines suggest performing vaginal fluid tests for PAMG-1, or insulin-like growth factor-binding protein 1, if amniotic fluid is not demonstrated on speculum examination, to guide further management.
A 27-year-old woman who is 34 weeks pregnant presents to the Emergency Department as she feels her ‘waters have broken’. She says she noticed a gush of clear fluid from her vagina which has lessened to a trickle and feels some pressure in her pelvis.
What is the most appropriate investigation to perform next?
Bimanual examination
Cardiotocography
Fetal blood sample
Speculum examination
Transvaginal ultrasound
Speculum examination
Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes
Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes.
Bimanual exam should be avoided to reduce the risk of introducing infection.
Cardiotocography may be used to investigate foetal wellbeing, but it is not the most appropriate first line investigation.
Foetal blood sampling would not be the most appropriate first line investigation and carries the risk of infection and miscarriage.
Transvaginal ultrasound also may carry a risk of introducing infection, but could be used to supplement a diagnosis of preterm prelabour rupture of membranes (PPROM) by identifying oligohydramnios. Transperineal ultrasound may be preferred in some centres to reduce infection risk. Ultrasound should be performed after speculum examination however.
A 26-year-old primigravid woman who is 34 weeks pregnant presents to the emergency department as she felt some fluid coming from her vagina 1 hour ago. The fluid was clear, not bloodstained, and has not continued to flow. Up to now, her pregnancy has been progressing well with normal antenatal scans and screening tests. She is otherwise well with no allergies.
Her observations are normal. Obstetric palpation reveals a longitudinal lie and cephalic presentation, and the head is not engaged in the pelvis. A cardiorespiratory examination is normal.
What is the most appropriate investigation to perform?
Digital vaginal examination
Insulin-like growth factor-binding protein 1 (IGFBP-1)
Nitrazine strip
Sterile speculum examination
Transvaginal ultrasound
Sterile speculum examination
Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes
The correct answer is sterile speculum examination. This woman is presenting with symptoms that are suggestive of preterm prelabour rupture of membranes (P-PROM), as she has felt a release of clear fluid from the vagina prior to 37 weeks gestation. The first-line investigation is a careful speculum examination of the vagina and cervix, attempting to visualise fluid pooling in the posterior vaginal vault - the diagnosis of P-PROM is made on the basis of maternal history and a speculum examination. Further tests can be performed if no amniotic fluid is seen in the vagina, but a speculum examination is the most appropriate to perform first. This should be sterile to reduce the risk of introducing infection to a vulnerable area.
Digital vaginal examination is incorrect because when P-PROM is suspected, the best test to perform in the first instance is a sterile speculum examination. A digital examination does not allow the clinician to actually visualise any amniotic fluid pooling in the vagina so should only be performed if cervical dilatation cannot be assessed by speculum examination. This type of examination carries the risk of introducing infection, so is not recommended in cases of suspected P-PROM. It is also important to note that if foetal fibronectin is going to be tested (to investigate the likelihood of birth), a digital examination may cause false results. In this situation, a sterile speculum examination should be performed instead of a digital vaginal examination.
Insulin-like growth factor-binding protein 1 (IGFBP-1) is incorrect because this test is used to assist in the diagnosis of P-PROM only if no fluid can be seen in the vagina on sterile speculum examination. This biomarker is found in amniotic fluid, so can be used to test whether membranes have ruptured. However, it should not be used in isolation and the whole clinical condition of the patient as well as her history and gestational age should be considered when diagnosing P-PROM.
Nitrazine strip is incorrect because this method of analysing the properties of vaginal fluid is not recommended for diagnosing P-PROM by NICE. This traditional test looks at the pH of the fluid in the vagina with the theory that amniotic fluid is more alkalotic than vaginal fluid but is no longer used due to the high risk of false positive and negative results. Instead, actual visualisation of amniotic fluid pooling in the posterior vaginal vault (where gravity will pull the fluid while supine) is the best investigation to diagnose P-PROM.
Transvaginal ultrasound is incorrect. Whilst ultrasound may be useful in identifying oligohydramnios (low amniotic fluid volume) which could be supportive of P-PROM, it is not a diagnostic test for ruptured membranes and a sterile speculum examination should be performed first line. Measurement of cervical length is also not diagnostic of P-PROM but may be helpful for determining the likelihood of birth within 48 hours.
