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Obstetrics > PROM and PPROM > Flashcards

PROM and PPROM Flashcards

1
Q

A pregnant women has reported a history of a sudden gush of fluid/leakage. What would your examination involve? (no signs/symptoms of labour)
What would you avoid doing?

what invx would you do?

A

Avoid digital vaginal examinations as may increase risk of infection.
Undertake a sterile speculum examination:
- visualise pooling of amniotic fluid or leakage from the cervical os with coughing.
- Visualise cervical length and dilatation
- Exclude cord prolapse

If required test vaginal secretions with immunoassay (e.g. AmniSurge) or pH stick (e.g. Nitrazine)

Invx:
Low vaginal and anal swab for GBS
If unable to confirm dx and/or repeat presentation with good history, consider USS of liquor volume,
Advise re risk of cord prolapse and emergency mng if this occurs.

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2
Q

What are the clinical indications for active mng of PROM (e.g. IOL or CS).

A 
Maternal choice
PROM > 24 hours
Head high or not fixed at pelvic brim
Group B strept positive or previous baby with early onset GBS 
Signs of maternal infection
Concern for maternal or fetal wellbeing
Mec/blood stained liquor
Cervical suture - remove and send for culture (IOL may/may not be inidcated)
Non-cephalic presentation (consider CS)
Contraindications to vaginal birth (CS)
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3
Q

Describe the role of ABX with PROM?

A

Routine prophylactic abx are not recommended for women with term PROM prior to the onset of labour.
PROM of 18 hours or more prior to birth is a risk factor for EOGBSD
- at onset of labour, if maternal risk factors for EOGBSD, recommend IV prophylactic abx. (e.g. benpen)
If chorio, abx as per chorio.

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4
Q

A women has ruptured her membranes. What are you concerned for with PROM and what questions would you ask her and what would you be looking for on examination?

A 
Concerned for infection. 
Therefore, assess signs and symptoms
- Feeling unwell or flu-like symptoms
- Maternal temp > 37.5C
- Offensive vaginal discharge or presence of meconium
- Uterine tenderness
- Maternal tachycardia 
- Fetal tachycardia (> 160 bpm)
- Maternal concern about fetal movements
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5
Q

A women has PROM. When would you recommend IOL and explain your reasoning?

A

If labour not established by 24 hours of PROM advise women:
- Risk of chorio almost double after 25 hours
- Limited high level evidence about maximum duration of expectant mng.
If woman chooses longer than 24 hours of expectant management then:
- Advise to return to hospital each 24 hours for fetal and maternal assessment.
Recommend IOL if
- Concern for maternal or fetal wellbeing
- Woman requests IOL

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6
Q

A women comes in with PROM but chooses to return home to await onset of labour. What advice would you give her?

A

To report (and return to hospital if at home) concern about fetal movements or if signs of infection, change in vaginal loss

  • Vaginal intercourse may be a/w increased risk of infection
  • Showering or bathing is not associated with increased risk of infection
  • To avoid tampon use
  • Return every 24 hours.
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7
Q

What would you assess for in a woman with PROM?

A 
Temp > 37.5C
Change in vaginal loss (odour, colour, amount)
Uterine tenderness
Feeling unwell 
Maternal or fetal tachycardia.
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8
Q

What are the benefits of active care in a woman with PROM?

A

Decreased risk of chorio, admission to nursery, neonatal sepsis

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9
Q

What outcomes remain equivalent between active mng vs expectant with PROM?

A

No difference in:

  • CS or operative birth
  • PPH
  • Cord proapse
  • Stillbirth
  • Apgar< 7 at 5 minutes
  • Perinatal mortality
  • Definite neonatal sepsis

No data on meningitis!

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10
Q

What are the indications for expectant care for PROM?

A

Active care not indicated.
Clinican available for advice and follow-up
Woman able to self-monitor for signs of infection and return to hosptial
Safe home environment.

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11
Q

What are the signs and symptoms of PTL(< 37 weeks) (5)

A 
Pelvic pressure
Lower abdominal cramping
Lower back pain
Vaginal loss - mucous, blood, fluid, 
Regular uterine activity
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12
Q

When would you aim in-utero transfer (specifically)?

A

If gestation < 28 weeks, accept high level of risk for birth en-route (unless it puts mother’s life at risk)

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13
Q

What things do you look for on physical examination of a woman report PTL?

A

Vital signs
Abdominal palpation
Fetal surveillance - FHR, CTG
Sterile speculum exam (identify ROM, visualise cx/membranes, high vaginal swab, test for fFN, TVCL (if available).

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14
Q

A woman has confirmed PROM, what investigations do you request?

A

High vaginal swab for M/c/s
Swab for GBS (vaginal/anorectal)
Midstream urine for m/c/s

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15
Q

When would you consider admission? (7)

A 
fFN > 50 ng/ml OR
Cervical dilation OR
Cervial change over 2-4 hours OR
ROM OR
Contractiosn regular and painful OR
Further observation or investigation indicated OR
Other maternal or fetal concerns
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16
Q

When would you recommend antenatal corticosteroids and what dose?

A

Recommend course of antinatal corticosteroids (< 35 +0)
betamethasone 2 doses
11.4mg IM then 2nd dose in 24 hours.
Consider 2nd dose at 12 hours if PTB likely within 24 hours
If risk of PTB remains ongoing in 7 days (or more) consider repeat dose.

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17
Q

When would you consider tocolysis and what is the regime?

A

Consider to facilitate in-utero transfer
Nifedipine 20mg oral
If contractions persist after 30 mins repeat dose
If contractions persist after 30 minutes repeat dose.
Maintenance therapy 20mg every 6 hours for 48 hours

Other options: indomethacin, salbutamol

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18
Q

What is the role of abx in PTL?

A

If established labour (or imminent risk of PTB) give intrapartum GBS prophylaxis regardless of GBS status or membrane status.
If chorioamnionitis (membranes intact or ruptured)
- Ampicillin (or amox) 2g IV initial dose, hten 1g IV Q6H
- Gentamicin 5mg/kg IV OD
- Metronidazole 500mg IV Q12H
If penicillin hypersensitivity and chorioamnionitis:
- Lincomycin OR clindamycin 600 mg IV Q6H (+ gent + metro)
If labour does not ensue (and no evidence of chorioamnionitis) and membranes intact then cease abx

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19
Q

What are indications for mag sulfate in PTL?

A

Recommend if gestation age < 30+0 wks if birth imminent within 24 hours.
Consider if age 30+0 -33+6 wks.
Labour established or birth imminent (w/i 24 hours)
- Loading dose 4g IV bolus over 15 mins
- Maintenance dose 1g/hour for 24 hours or until birth - whichever occurs first.

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20
Q

Define cervical incompetence:

A

Cx incompetence is defined as the woman’x inability to support a full term pregnancy due to a functional or structural defect ofhte x. Often characterised by dilatation and shortening of the cervix prior to 37 weeks gestation.

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21
Q

What is fetal fibronectin and what is considered an elevated level and when?

A

fFN is a glycoprotein thought ot promote adhesion between the fetal chorion and maternal decidua.
Rises as term approaches (present w/t K18-34-36 in low concentrations).
Elevated levels (typically > 50ng/ml) in cervicovaginal secretions after 22 weeks gestation are a/w an increased risk of PTB.

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22
Q

Stratify PTB by gestation into moderately, very preturn and extremely preterm.

A 
Moderately preterm: 32+0 -33+6 weeks
Very preterm (28+0 - 31+6 weeks)
Extremely preterm (less than 27+6 weeks)
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23
Q

Define a short cervix?

A

< 25mm in 2nd trimester.

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24
Q

Describe stats in Australia (in 2017) for PTB?

A 
1 in 11 births PTB
8.7% of all singleton births
66% of all twin births
14.2% of all the births to ATSIs women
18.4% of all perinatal deaths
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25
Q

What is the % of PTB for which no cause is identified?

A

the cause of spontaneous PTL remains unidentified in up to half of all cases.

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26
Q

What are the maternal RFs a/w PTB?

A 
Age
- Younger than 20 years
- Older than 40 years
Women who smoke during pregnnacy (13.6% vs 8.1%)
Women residing in rural and remote areas. (13.5% vs 8.4% in major cities). 
ATSI (14.2 vs 8.5%)
Late or no antenatal care
Lack of continuity of care
Low SES 
High or low BMI
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27
Q

What are some medical and pregnancy conditions a/w increased risk of PTB?

A

Multiple birth
Presence of fFN.
Short cervical length
Previous PTB recurrence risk related to gestational age of prior PTB. Approx 30% of women who give birth prematurely in a prior pregnancy will give birth before 37 weeks in subsequent pregnancy.
Genital tract infections (Bacterial vaginosis risk of PTB double)
UTI
ART a/w 2-fold risk of PTB
PPROM
Surgical procedures involving the cervix.
Uterine anomalies
Polyhydramnios/oligohydramnios
Chronic medical conditions
Acute medical conditiosn (e.g. PET, antepartum haemorrhage)

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28
Q

Should you treat asymptomic bacteriuria?

A

Yes. screen and recommend treatment.

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29
Q

When would you recommend cx length measurement?

A

Recommend serial transvaginal cervial length measurement for high risk women with prior PTB. Optimal frequency not established.
From 14-24 weeks gestation, serial TVCL every 2 weeks may be appropriate.

30
Q

When would you recommend progesterone therapy to reduce risk of PTB?

A

Consider from 16-24 weeks gestation for women with a singleton pregnancy and a prior spontaneous PTB.
If indicated, recommend vaginal progesterone suppository 200mg OD until at least 34 weeks gestation, or ROM or birth, whichever occurs first.

NB: no intervention has been shown to improve outcomes for women with a short cervix and a multiple pregnancy.

31
Q

When would you consider cervical cerclage?

A

Consider for women with history of:

  • one or more prior spontaneous PTB and/or second-trimester loss related to painless/painful cervical dilation and in the absecne of labour or placental abruption OR
  • Prior cerclage due to painless cervical dilation in 2nd trimester OR
  • cervical incompetence.

May be indicated if TVCL less than 25mm before 24 weeks if:

  • PPROM in a previous pregnancy OR
  • A h/o cervical trauma/surgery OR
  • Prior spontaneous PTB before 34 weeks gestation and
  • Current pregnancy singleton.

Limited evidence re rescue cerclage beyound 24 weeks gestation.
Multiple dilation and evacuations or cervical surgery (e.g. cone biopsy, LLETZ, laser ablation, diathermy ) or other abnormalities (e.g. Mullerian anomaly) are not themselves an indication for cerclage.

Not indicated for women with:

  • funnelling of hte cervix w/o cervical shortening of 25mm or less
  • An incidentally idnetiifed short cervix w/o a h/o spontaneous PTB or 2nd trimester loss.
  • Multiple pregnancy.
32
Q

What % of women who present with S&S of PTL will deliver preterm?

A

10%

33
Q

Name signs and symptoms of PTL?

A

The most common sequence preceding PTB is cervical ripening (shortening of cx) , followed by decidual membrane activation and then contractions characterised by:

  • cervical effacement/dilation
  • pelvic pressure
  • lower abdominal cramping
  • lower back pain
  • vaginal loss (mucous, blood or fluid)
  • regular uterine activity
34
Q

Physical examination for someone with suspected PTL?

A

Vital signs
Abdominal palpation ot assess uterine tone, contractions, fetal size and presentation
Sterile speculum examination to:
- confirm or exclude rupture of membranes
- Assess liquor (e.g. clear, meconium stained, bloody)
- visualise cervix and membranes
Collect high vaginal swab for micro culture/sensitivity to test for BV
Perform test for the presence of fFN (if not C/I)
TVCL if indicated
Collect either vaginal-rectal or a vaginal-perianal swab for GBS
Assess cervical dilatation by sterile digital vaginal examination unless contraindication by:
- ROM
- Suspected placental praevia.

35
Q

With confirmed PTL how would you go about monitoring fetal wellbeing?

A

FHR
Continuous CTG (interpret with caution if < 28 weeks)
US of fetal growth and wellbeing
- looking for fetal number, presentation, liquor volume and placenta location.

36
Q

A women has suspected PTB, which laboratory invx would you order?

A

HVS for BV
Genital swab for GBS (vaginal rectal or vaginal -perianal)
Midstream specimen of urine for bacteriology (m/c/s)

37
Q

When would you considertherapeutic interventiosn for short TVCL

A

When TVCL < 25mm

Consider fFN testing in conjunction with TVCL.

38
Q

What is the role of fFN?

A

it is a glycoprotein thought to promote adhesion b/w the fetal chorion and maternal decidua.
Rises as term approaches.

39
Q

When is fFN significant and at what amount?

A

> 50ng/ml after 22 weeks is a/w an increased risk of PTB.

A neg fFN is a/w a 99.5% negative predicitve value for PTB w/i 7 das and 99.2% in the next 14 days.

40
Q

When is fFN testing indicated?

A

Symptomatic women with threatened PTL
- Between 22+0 and 36+0 weeks gestation and
- Intact membranes AND
- Cervical dilatation less than or equal to 3cm.
OR
- Asymptomatic women, greater than 22 wks, with a history of:
- cervical surgery/trauma OR
- PTB in previous pregnancy OR
- late miscarriage

41
Q

What are the C/I to fFN testing?

A

Cervical dilatation more than 3 cm
Ruptured membranes
Cervical cerclage in situ
Presence of soaps, gels, lubricants or disinfectants.

42
Q

Outline procedure for fFN testing?

A

Sterile speculum examination prior to examining cx or vagina.
Use only sterile water as a lubricant
Obtain sample for testing from the posterior fornix of the vagina.

43
Q

Define a negative fFN result and what it means.

A

fFN less than 50ng/ml.
low risk of birth within 7-14 days.
fFN less than 10ng/ml
-> higher negative predictive value for PTB
False negative result may occur due to
- use of lubricant with speculum examiantion
- intravaginal disinfectants.

44
Q

Define positive fFN result and what this means?

A

fFN 50ng/ml or more = positive.
High risk of birth within 7-14 days.
fFN greater than 200ng/ml
-> higher positive predictive value for PTB (38%)
-> Provides reassurance to clinicians to provide immediate intervention and/or transfer
False positive may occur as a result of recent:
- > vaginal intercourse
- > Digital vaginal examination
- > Transvaginal US
- > bleeding

45
Q

A women presents with concern for PTL. When is admission indicated?

A

(Consider in following instances):
- fFN test greater than or equal to 50ng/ml
(admission recommended if fFN testgreater than 200ng/ml)
- TVCL changes and/or less than 25mm (if measured)
- Cervical dilaton (painless or painful)
- Contractions regular and painful.
- Further obs or invx indicated
- other maternal or fetal concerns.

46
Q

Admission for PTL not indicated….?

A

if fFN less than 50ng/ml and

  • maternal vitals /wNL
  • normal FHR and/or CTG relevant to gestational age.
  • No signs of chorioamnionitis
  • Contractions infrequent/irregular.
  • No/minimal cervical chnage.

Note: if fFN between 10-49ng/ml return for medical r/v within 7 days.

  • less than 2% birth w/i 2 weeks
  • 5-15% birth before 34 weeks.
47
Q

What are the mainstays of managing PTL? (2)

A

Tocolysis and steroids.

T/F to a centre with higher servie capability may also be necessary.

48
Q

For women requiring admission for PTL, what things would you consider in managing her?

A
  • in-utero transfer (as relevant to service capability)
  • analgesia
  • CCS if less than 35+0
  • TVCL if resources available.
  • Multidisciplinary team (e.g. neonatology consultation, SW, anaesthetic)
  • If labour established or birth appears imminent, and gestational age is less than 30 weeks, commence mag sulfate for neuroprotection of teh fetus.
49
Q

In what clinical circumstance would you consider tocolysis?

A

To allow in utero transfer.

e.g. less than 28+0 -> accept high level of risk of birth occurring en-route when gestational age is less than 28+0

50
Q

A women in PTL is transferred in utero. She delivers. What basic mng should you implement or advise?

A

keep baby warm, administer oxygen, provide CPAP via bag and mask..

51
Q

Administration of CCS at less than 35+0 weeks gestation is a/w reductions in which neonatal outcomes?

When should you repeat the dose?

A

neonatal death, resp distress syndrome and IVH.
Reduction in necrotising enterocolitis, respiratory support, ICU admissions and systemic infections in the first 48 hours of life compared with no treatmet or treatment with placebo

NB: Beneficial effect demonstrated regardless of membrane status.

If the risk of PTB persists seven or more days after initial course, repeat dose(s) are a/w:

  • > less resp distress and fewer serious health problems in the first few weeeks after birth.
  • small reduction in size at birth.
52
Q

What are the recommendations surrounding antenatal CCS?

A

Recommend to women with a viable fetus who are at increased risk of PTB before 35+0 weeks gestational age.

53
Q

What is the dosing of antenatal CCS in PTB?

A

Two doses, 24 hours apart.

  • 1st dose: betmethasone 11.4mg IM
  • 2nd dose: betamethasone 11.4mg IM, 24 hrs after 1st dose (if PTB likely within 24 hours, consider reepat dose at 12 hours).

Repeat dose of antenatal CCS (singel dose)
betameth 11.4mg IM

54
Q

What are the reasons that you may use tocolysis?

A

Administration of CCS
Administration of MgSO4-
In-utero transfer to an appropriate level facility

55
Q

when would you recommend tocolysis?

A

When a 48 hour delay in birth will benefit the newborn/

56
Q

What are the C/I to tocolysis?

A

Maternal C/I to tocolysis (agent specific)
Any condition where prolongation of pregnancy is contraindicated including but not limited to:
-> in utero fetal death/lethal fetal anomalies
- > Suspected fetal compromise
- > Maternal bleeding with hemodynamic instability
- > Severe PET
-> Placental abruption
- > chorioamnionitis.

57
Q

Which agent is tocolytic agent of choice (as per QH guideline)?

A

Nifedipine IR.

58
Q

What are the C/I to nifedipine tocolysis?

A

Maternal hypotension or cardiac disease (risk of fluid overload)
Previous adverse reaction to CCB.

Use cautiously with MgSo4- (concomitant use may increase effects of Mg SO4- and teh risk of hypotension).

59
Q

What is the dosing of nifedipine used for tocolysis?

Once stable, what is the maintenance dose?

A

Nifedipine 20mg PO stat.
If contractions persist after 30 mins repeat nifedipine 20mg PO .
If contracts persist after a further 20mng repeat nifedipine 20mg PO.

maintenance dose:
- If BP remains stable: nifedipine 20mg PO Q6 hourly for 48 hours - max dose 160mg/day.
(Further maintenance therapy is ineffective).

60
Q

When administering nifedipine tocolysis, what and how often would you do observations?

A

CTG until further contractions cease
BP, pulse and RR
- > every 30mins for first hour, then Q1H for 4 hours
-> temp Q4 hourly.

61
Q

What are some of the considerations with betamimetics (salbutamol, terbutaline) for tocolysis?

When would you consider using these agents for tocolysis?

A

maternal death from pulmonary oedema

These agents not recommended unelss there are C/I to other tocolytics.

62
Q

When would you consider abx and what time re PTL?

No evidence of chorio

A

If PTL ensures or imminent risk of PTB, give intrapartum abx for prevention of early onset GBS irrespective of GBS status or membrane status.

63
Q

Describe S&S of chorioamnionitis and mng?

A

S&S:

  • Matenral fever > 38C
  • Maternal tachycardia > 100 bpm
  • Uterine tenderness
  • Offensive smelling vaginal discharge
  • Fetal tachycardia > 160 bpm
  • Increased WCC (> 15 x 10^9/L)
  • Elevated CRP

Mng:

  • Do NOT inhibit labour, but consider hastening birth under broad spectrum IV ABX.
  • Suspect chorio in PPROM if labour ensues.
  • If not local protocols establish, use:
    > amp 2g IV then 1g IV Q6 hourly.
    > Gent 5mg/kg IV daily
    > metro 500mg IV BD

If allergic to ben pen can use, linco or clinda 600mg IV + gent + metro

  • Continue abx treatment until after birth.
64
Q

What are we trying to prevent with MgSO4 infusion in PTL?

A

Used for neuroprotection to prevent cerebral palsy.

65
Q

When would you recommend MgSO4- in PTL

A

Recommend to any women with a viable fetus before 30+0 weeks gestation where birth is expected or planned within 24 hours.
(Can consider Mag for women b/w 30+0 and 33+6)
If birth is plannned, commence administration as close to 4 hours prior to birth as possible.
Best effect when given at least 4 hours within 6 hours prior to birth.

66
Q

What are some considerations with PTB and mode of delivery?

A

Preterm CS is usually technically more difficult to perform and is not w/o risk to the baby as the lower segment is usually not well formed.
-> a Classical incision may be required with risks to further pregnancies including scar dehiscence, uterine rupture, placental adherence and maternal death.

  • > if singleton vertex, recommend VB unless there are specific C/I to vaginal birth or maternal conditiosn necessitating CS.
67
Q

In PPROM, what % of women go on to labour in 1 and 2 weeks respectively?

A

50% in 1 week

75% in 2 weeks.

68
Q

How is the dx of PPROM made? (i.e. Hx, ex, invx?)

A

Hx:
Sudden gush or ocntinued leakaage of fluid from vagina
Ex:
Sterile spec, pooling of amniotic fluid or leakage from cervical os with coughing.
-> Exclude cord prolapse!
Invx:
Test vaginal secretions e.g. amnisure, pH stick (e.g. Nitrazine).

69
Q

What are the benefits of abx in PPROM?

Which abx should you give and doses?

A

prolong latency and reduce maternal and fetal infection following PPROM.

Erythromyicin 250mg Q6H for 10/7 OR
Amox/amp 2g IV Q6H for 48 hours, followed by amox 250mg Q8H for a total of 7 days (IV +PO) PLUS erythromycin 250mgQ6H for 7 days.

70
Q

Which abx should you avoid in PPROM and why?

A

amox/clav - > increases risk of necrotising enterocolitis in baby.

71
Q

A woman has come in with PPROM. What advice about self-care would you give her?

A

Risk of infection
Personal hygiene - i.e. change pad Q4H (or more)
Wipe front ot back after toileting
Showering in preference to baths
Avoiding tampon use, vaginal intercorse, immersion in water (e.g. swimming, bathing, spat)
Attending all review appts.

72
Q

What are the risks/benefits of planned birth at K34 for PPROM vs expectant care.

A

Decreased chorioamnionitis
Decreased APH
Increased resp distress

Generally speaking, less than 34 weeks favours waiting. (prior to less only benefit is decreased endometritis)

Obstetrics (14 decks)

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