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YR5 Obstetrics and Gynaecology > Premature rupture of membranes (PROM) > Flashcards

Premature rupture of membranes (PROM) Flashcards

1
Q

Define PROM.

A

Spontanous rupture of membranes in the absence of uterine contractions after 37w

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2
Q

What are the risk factors for PROM?

A

Prior preterm birth

Cigarette smoking

Polyhydramnios

Urinary and sexually transmitted infection

Prior PROM

Low BMI

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3
Q

Summarise the epidemiology of PROM.

A

8% of pregnancies

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4
Q

What are signs and symptoms of PROM?

A

Sudden gush of fluid PV, followed by constant trickle

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5
Q

What investigations should be performed for PROM?

A

General: Assess signs of infection (fever, tachy)

Vaginal: Avoid bimanual if poss!

Speculum: confirm pooling of liquor in vagina

TVUSS: cervical length <15mm?

Foetal Fibronectin (FFN)

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6
Q

What is the management for PROM?

A

Admit for 4 hourly temperature + 24h fetal monitoring.

If clear liquor: expectant Mx for 24h, if >24h –> IOL

If meconium stained/ known GBS: IOL asap +
Abx: benzylpenicillin

Postnatal: Observe neonate for 12h minimum.

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7
Q

What are complications associated with PROM? What is the prognosis for PROM?

A

Increased risk of ascending infection.

60% labour within 24h.

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8
Q

Define preterm labour

A

Regular contractions of the uterus resulting in changes in the cervix that start before 37w of pregnancy.

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9
Q

Give 6 major causes of neonatal morbidity arising from preterm birth

A

Intraventricular hemorrhage grade
Seizures
Hypoxic-ischemic encephalopathy
Necrotizing enterocolitis
Bronchopulmonary dysplasia
Persistent pulmonary HTN

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10
Q

Give 3 minor causes of neonatal morbidity arising from preterm birth

A

Hypotension requiring Tx
Respiratory distress syndrome
Hyperbilirubinemia requiring Tx

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11
Q

How is preterm birth classified?

A

extremely preterm: <28w
very preterm: 28-32w
moderate to late preterm: 32 to <37w

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12
Q

Wha† is threatened pre-term labour?

A

uterine contractions but without cervical dilatation

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13
Q

Give 5 risk factors for pre-term labour

A

Infection
Hx preterm delivery
Multiple pregnancy
Preterm premature rupture of membranes
Problems with the uterus, cervix or placenta

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14
Q

What surgery can increase chance of preterm labour?

A

LLETZ

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15
Q

Give 5 maternal risk factors for preterm laobur

A

HTN / DM
Smoking
IVDU
Underweight/ overweight before pregnancy
Stressful life events

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16
Q

Give 2 prophylactic measures to prevent preterm labour

A

Vaginal progesterone: start between 16-24w + continue to at least 34w

Cervical cerclage between 12-14w

17
Q

In which women are prophylactic measures to prevent preterm labour indicated?

A

Hx spontaneous preterm birth (up to 34+0w) or mid-trimester loss (from 16+0w onwards)
+
Results from TVUSS between 16+0 and 24+0w that show cervical length of ,<25 mm

18
Q

What are the indications and contraindications for rescue cerclage?

A

Cervical dilatation in absence of contractions before 23w + unruptured membranes

CI: Bleeding, infection, uterine contractions

19
Q

What investigations are used for preterm labour?

A

Pelvic exam (speculum, digital examination)

CTG

TVUSS

Lab tests

20
Q

If clinical assessment suggests preterm labour when ,<29+6 w, what action should be taken?

A

Tx for preterm labour

21
Q

If clinical assessment suggests preterm labour when >,30w what action should be taken?

A

TVUSS measure cervical length

> 15mm: unlikely in preterm labour

,<15mm: Tx for preterm labour

22
Q

Describe management for preterm labour

A

Admit to antenatal ward

Maternal corticosteroids to accelerate fetal lung maturation

Tocolytics to delay delivery long enough for steroid administration/ transfer to specialised unit

IV magnesium sulphate for neuroprotection of neonate if birth expected in next 24h

23
Q

What steroids are given in preterm labour?

A

IM Betametasone in 2 divided doses of 12mg 24h apart

or Dexamethasone in 4 divided doses 6mg every 12h

24
Q

What Tocolytics are used in preterm labour?

A

1st line: Nifedipine (calcium channel blocker)
2nd line: Atosiban (Oxytocin receptor antagonist)

25
Q

Why must caution be taken when giving magnesium sulphate? What can be done?

A

Toxicity results in resp depression + arrhythmias
Monitor every 4h: obs + deep tendon reflexes

Antidote: 10ml 10% calcium gluconate over 10 mins + stop MgSO4

26
Q

If TVUSS is indicated for >,30w pregnancies, but not available what investigation should be performed?

A

Fetal fibronectin

Determines likelihood of birth within 48h

27
Q

What is fetal fibronectin?

A

Protein produced by fetal cells

Found at interface of chorion + decidua

“biological glue” binding fetal sac to uterine lining

leaks into vagina if pre-term delivery likely

28
Q

How is a fetal fibronectin test taken?

A

To avoid false +ve: before pelvic exam + TVUSS

Speculum + swab

29
Q

4 things that increase risk of false +ve in fetal fibronectin test

A

ROM
Recent SI
PV bleeding
Recent cervical manipulation

30
Q

Interpret results of fetal fibronectin test

A

-ve = conc. ,<50 unlikely in preterm labour

+ve= con >50 preterm labour likely: steroids + tocolysis

31
Q

What does a negative fetal fibronectin indicate?

A

Highly unlikely for preterm labour in next 14d

32
Q

Define premature pre labour rupture of membranes

A

Spontaneous rupture of membranes prior to onset of labour <37w

33
Q

What investigation is used for PPROM?

A

Speculum

If pooling of amniotic fluid- offer care consistent with PPROM

If no pooling of amniotic fluid, perform diagnostic testing

USS estimation of amniotic fluid vol can give helpful additional info

34
Q

What diagnostic testing is performed if there is no pooling of amniotic fluid in suspected PPROM?

A

Insulin like growth factor binding protein-1 test
or
Placental alpha- microglobulin-1 test of vaginal fluid

35
Q

Describe management of PPROM

A

Admit
Prophylactic Abx
Intense surveillance for chorioamnioitis or preterm labour
Maternal corticosteroids
IV Magnesium sulphate if birth expected in 24h

DO NOT administer Tocolytics

36
Q

What prophylactic antibiotics are used in PPROM?

A

Erythromycin PO 250mg QDS for max. 10 days or until in labour (whichever sooner)
2nd line= Penicillin PO

37
Q

Why should tocolytics be avoided in PPROM?

A

Increased risk of infection

38
Q

If >34w and positive group B strep at any point in current pregnancy, how should a woman with PPROM be managed?

A

Immediate IOL

39
Q

What can be measured to assess for chorioamniotis in PPROM?

A

Clinical assessment
Maternal CRP + WCC
Fetal + Maternal HR

YR5 Obstetrics and Gynaecology (73 decks)

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