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Y5 O&G > Pre-labour (Pre-term) Rupture of Membranes > Flashcards

Pre-labour (Pre-term) Rupture of Membranes Flashcards

1
Q

Describe Term Pre-labour Rupture of Membranes?

A
  • Spontaneous rupture of membranes before onset of labour at term (≥37 weeks)
  • Occurs in ≤10% of women
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2
Q

What are the causes of term PROM?

A

Natural physiological

  • i.e. Braxton Hicks contractions + cervical ripening → weakening of membranes
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3
Q

Describe Pre-term Pre-labour Rupture of Membranes?

A
  • 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
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4
Q

What are the signs and symptoms of PPROM?

A
  • 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)
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5
Q

What are the appropriate investigations for suspected PPROM?PROM?

A

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
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6
Q

What should be done if a >30w patient presents with contractions and a closed os?

A
  • TVUSS for cervical length
    • <15mm → likely to be preterm labour
    • >15mm → unlikely to be preterm labour
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7
Q

What are the risk factors for PPROM?

A
  • APH
  • Trauma
  • UTI
  • Previous PROM/PTL
  • Uterine abnormalities
  • Cervical incompetence
  • Smoking
  • Multiple pregnancy
  • Polyhydramnios
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8
Q

What is the management of PPROM?

A
  • 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
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9
Q

What are the complications of PPROM?

A
  • Maternal
    • Sepsis
    • Cord abruption
  • Foetal
    • Chorioamnionitis
    • Cord prolapse
    • PTL
    • Pulmonary hypoplasia
    • Limb contractures
    • Death
  • Perinatal
    • Increased perinatal mortality due to sepsis
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10
Q

What are the types of HHV?

A
  • 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
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11
Q

What is the site of latent VZV infection?

A

Dorsal root ganglia

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12
Q

What is the site of latent EBV infection?

A

B cells

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13
Q

What is the site of latent CMV infection?

A

Monocytes

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14
Q

What is the most common congenital infection?

A

CMV - 0.5-1 in 1,000

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15
Q

How is CMV transmitted?

A
  • Sexual contact
  • Blood-borne
  • Bodily fluids - saliva, urine
  • Vertical
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16
Q

What are the risk factors for CMV?

A
  • Higher socioeconomic class = no childhood immunity
  • Immunosuppression
17
Q

What are the signs and symptoms of CMV in a mother?

A
  • Often asymptomatic
  • Non-specific - fever, malaise, fatigue
  • May have lymphadenopathy
18
Q

What are the signs and symptoms of CMV in a child?

A
  • 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
19
Q

What are the appropriate investigations for suspected CMV?

A
  • 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
20
Q

What is the management of CMV?

A
  • Mother = no treatment
    • TOP if evidence of CNS damage
  • Child = ganciclovir (IV)/valganciclovir (oral) for 6m + audiology follow-up + ophthalmology follow-up
21
Q

What are the complications of CMV?

A
  • 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
22
Q

What is the management of PROM?

A
  • 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
  • Meconium → induce labour ASAP
23
Q

What counselling should be given to women with PROM?

A
  • 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
24
Q

What are the complications of PROM?

A

Ascending infection

25
Q

Define Pre-term, Very Pre-term and Extremely Pre-term labour.

A
  • PTL = 32-37w GA labour
  • Very PTL = 28-32w GA labour
  • Extremely PTL = <28w GA labour
26
Q

What are the risk factors for pre-term labour?

A
  • 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
27
Q

What are the appropriate investigations for suspected pre-term labour?

A
  • CTG monitor
  • Urine dip ± MC&S (if indicated) → 20-40% of spontaneous PTL is from infection
28
Q

What is the management of pre-term labour?

A
  • 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
    • Surgical = Emergency ‘rescue’ cerclage
      • Indications
        • 16w to 28w
        • Dilated cervix
        • Exposed unruptured membranes
      • Contraindication
        • Infection
        • Bleeding
        • Uterine contractions
29
Q

What are the indications for prophylactic vaginal progesterone or cervical cerclage?

A
  • History of PTL + cervical length <25mm
  • History of >16w miscarriage + cervical length <25mm
  • History of PPROM + cervical length <25mm
  • Cervical trauma + length <25mm
30
Q

What are the complications of pre-term labour?

A
  • Big four = RDS, NEC, IVH, PVL
    • Respiratory Distress Syndrome
      • Low O2 → complication (i.e. retinopathy of prematurity
    • Necrotising Enterocolitis
    • Intraventricular Haemorrhage
    • Periventricular Leukomalacia
  • Sepsis

Y5 O&G (69 decks)

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