Pre-labour (Pre-term) Rupture of Membranes Flashcards
Describe Term Pre-labour Rupture of Membranes?
- Spontaneous rupture of membranes before onset of labour at term (≥37 weeks)
- Occurs in ≤10% of women
What are the causes of term PROM?
Natural physiological
- i.e. Braxton Hicks contractions + cervical ripening → weakening of membranes
Describe Pre-term Pre-labour Rupture of Membranes?
- Spontaneous rupture of membranes before onset of labour in pregnancy between 24+0 and 36+6 weeks
- Can be caused by weakening of membranes due to infective cause (often subclinical)
- Occurs in 2% of pregnancies
What are the signs and symptoms of PPROM?
- Sudden gush of fluid PV → constant trickle
- Contractions (regular & painful = PTL; not Braxton-Hicks)
- General examination → assess for signs of infection
- Do not offer VE in PPROM/PROM (or placenta praevia)
What are the appropriate investigations for suspected PPROM?PROM?
Do not perform diagnostic tests for PPROM if labour becomes established (i.e. bulging membranes, abdominal pain) in a woman reporting signs/symptoms suggestive of PPROM à admit to labour ward
- 1st = Speculum examination
- Os → open or closed
- Pooling → diagnostic of PROM/PPROM
- Do not use KY jelly – will complicate FFN result
- Only perform if ROM not evident
- 2nd = IGFBP-1 or PAMG-1 (PartoSure)
- Are very sensitive, so if a -ve result, a very low chance of PPROM
- 3rd = Foetal fibronectin
- <24 weeks - FFN glue is liquid → detectable
- 24-34w - FFN dried → not detectable
- >34w - contractions stimulate release of FFN → detectable
- Manage the pregnancy as per
- Membranes not ruptured = PTL
- Membranes ruptured = PPOM, PROM
What should be done if a >30w patient presents with contractions and a closed os?
- TVUSS for cervical length
- <15mm → likely to be preterm labour
- >15mm → unlikely to be preterm labour
What are the risk factors for PPROM?
- APH
- Trauma
- UTI
- Previous PROM/PTL
- Uterine abnormalities
- Cervical incompetence
- Smoking
- Multiple pregnancy
- Polyhydramnios
What is the management of PPROM?
- Admission + expectant management until 37w (if no complications)
- Medications:
- Do not offer tocolysis
- Erythromycin - ≤37 weeks for 10 days or until in established labour
- Corticosteroids - ≤34 weeks for 24 hours
- Induces a DKA in diabetics so co-administer with insulin
- MgSO4 - ≤30 weeks and labour or planned birth <24 hours
- Chorioamnionitis – carefully monitor
- Clinical assessment
- Bloods - CRP and WCC
- CTG - monitor foetal HR
What are the complications of PPROM?
- Maternal
- Sepsis
- Cord abruption
- Foetal
- Chorioamnionitis
- Cord prolapse
- PTL
- Pulmonary hypoplasia
- Limb contractures
- Death
- Perinatal
- Increased perinatal mortality due to sepsis
What are the types of HHV?
- HHV-1 and HHV-2 = HSV 1 and 2
- HHV-3 = VZV
- HHV-4 = EBV
- HHV-5 = CMV
- HHV-6 and HHV-7 = Roseolovirus
- HHV-8 = Kaposi’s sarcoma-associated HV
What is the site of latent VZV infection?
Dorsal root ganglia
What is the site of latent EBV infection?
B cells
What is the site of latent CMV infection?
Monocytes
What is the most common congenital infection?
CMV - 0.5-1 in 1,000
How is CMV transmitted?
- Sexual contact
- Blood-borne
- Bodily fluids - saliva, urine
- Vertical
What are the risk factors for CMV?
- Higher socioeconomic class = no childhood immunity
- Immunosuppression
What are the signs and symptoms of CMV in a mother?
- Often asymptomatic
- Non-specific - fever, malaise, fatigue
- May have lymphadenopathy
What are the signs and symptoms of CMV in a child?
- Asymptomatic = 90%
- 10% develop sensorineural hearing loss (SNHL)
- Congenital CMV = 10%
- 65% have SNHL
- Peri-ventricular calcification
- Chorioretinitis → cataracts
- Jaundice ± ‘blueberry muffin’ rash
- IUGR
- Microcephaly
- Hepatosplenomegaly
What are the appropriate investigations for suspected CMV?
- Prenatal diagnosis → PCR of virus (>21w GA)
- Postnatal diagnosis → PCR of virus (<21d neonate; +ve result beyond this will not confirm congenital CMV)
- Maternal serology – seroconversion
- USS of foetus
- Amniocentesis PCR – 6-9 weeks after primary infection
What is the management of CMV?
- Mother = no treatment
- TOP if evidence of CNS damage
- Child = ganciclovir (IV)/valganciclovir (oral) for 6m + audiology follow-up + ophthalmology follow-up
What are the complications of CMV?
- Increased risk of miscarriage and still birth
- Congenital CMV
- IUGR
- Microcephaly
- Periventricular calcifications
- Blindness
- Sensorineural deafness
- Hepatosplenomegaly
- Skin rash
- Pneumonitis
- Mental retardation
- Prognosis - rate of transmission to foetus is 40% → 10% of these develop congenital syndrome
- 90% babies symptomatic at birth will later have neurodevelopmental problems
What is the management of PROM?
- Clear liquor
- 0-24 hours = expectant management (60% labour within 24h)
- You may follow expectant management for up to 96 hours
- >24 hours = IOL
- 4-hourly temperature and 24hr foetal monitoring
- Augment with prostaglandin or oxytocin infusion
- 0-24 hours = expectant management (60% labour within 24h)
- Meconium → induce labour ASAP
What counselling should be given to women with PROM?
- Risk of neonatal infection is 1%
- Only 0.5% for intact membranes
- 60% of women will go into labour in 24 hours
- Attempt to induct after 24 hours
What are the complications of PROM?
Ascending infection
Define Pre-term, Very Pre-term and Extremely Pre-term labour.
- PTL = 32-37w GA labour
- Very PTL = 28-32w GA labour
- Extremely PTL = <28w GA labour
What are the risk factors for pre-term labour?
- Previous:
- PTL/PROM/PPROM
- Miscarriage between 16-24w
- Cervical biopsy
- Infection - 20-40% are due to infection
- Structural - uterine abnormalities, pre-eclampsia
- Mechanical (stretch) - fibroids, polyhydramnios, multiple pregnancy, concealed APH
- Social lifestyle - smoking, high BMI, drugs, extreme ages, ethnicity
What are the appropriate investigations for suspected pre-term labour?
- CTG monitor
- Urine dip ± MC&S (if indicated) → 20-40% of spontaneous PTL is from infection
What is the management of pre-term labour?
- Ruptured membranes → PPROM guidance
- Non-ruptured membranes
- Medications:
-
Tocolysis - ≤34 weeks
- 1st line = Nifedipine (CCB)
- 2nd line = Atosiban
-
Corticosteroids - ≤34 weeks; for 24 hours
- Induces DKA in diabetics so co-administer with insulin
- MgSO4 - ≤30 weeks
-
Tocolysis - ≤34 weeks
- Surgical = Emergency ‘rescue’ cerclage
- Indications
- 16w to 28w
- Dilated cervix
- Exposed unruptured membranes
- Contraindication
- Infection
- Bleeding
- Uterine contractions
- Indications
- Medications:
What are the indications for prophylactic vaginal progesterone or cervical cerclage?
- History of PTL + cervical length <25mm
- History of >16w miscarriage + cervical length <25mm
- History of PPROM + cervical length <25mm
- Cervical trauma + length <25mm
What are the complications of pre-term labour?
- Big four = RDS, NEC, IVH, PVL
-
Respiratory Distress Syndrome
- Low O2 → complication (i.e. retinopathy of prematurity
- Necrotising Enterocolitis
- Intraventricular Haemorrhage
- Periventricular Leukomalacia
-
Respiratory Distress Syndrome
- Sepsis
