PROM and Preterm Labor Flashcards
Premature rupture of membranes (PROM) definitions
- Premature rupture of membranes (PROM)
*>37wks but before onset of contractions (10%)
+not a big deal b/c mother is at term but the longer you wait to take to delivery the greater the chance of infections w/ a ruptured membraned
Preterm premature rupture of membranes (P-PROM)
- <37wks but before onset of contractions
*3% pregnancies
*30-40% preterm deliveries
*leading identifiable cause preterm delivery
PROM Diagnosis
- History
- Pooling…direct observation of amniotic fluid in the vagina
*sometimes women can pee themselves unintentionally during pregnancy so you can tell whether they pee’d or broke their water by observing amniotic fluid in the vagina
- Nitrazine; a pH strip that tests for amniotic fluid (pH 7.0-7.5)
- Ferning
- Indigo carmine…amniocentesis
*blue dye that can be injected into the uterus and with a tampon in the vagina if they then leak blue fluid we know theres been a rupture
- Ultrasound
- Markers
Digital exam for ruptures
- B/c digital cervical exams increase the risk of infection and add little info to that available w/ speculum exam, digital examinations should be avoided unless the pt is in active labor or imminent delivery is planned
Initial management of PROM
- Obtain gestational age
- Fetal presentation assessed
- Well-being assessed
- DNA probes and cultures; infection could have caused the rupture (most common reason)
*GC
*Chlamydia
*Group B strep
Management of PROM Chronologically Chart
Term Terminology Graph
Leading cause of neonatal death in the US
- Preterm birth
*preterm labor precedes 40-50% preterm births
Preterm labor definition
- Regular contractions <37wks and are assoc. w/ changes in the cervix
Fetal complications assoc. w/ preterm birth
- Respiratory distress syndrome (hyaline membrane disease)
- Intraventricular hemorrhage
- Necrotizing enterocolitis
- Sepsis
- Seizures
- Death
Long term complications
- Bronchopulmonary dysplasia
- Developmental abnormalities
Risk factors for preterm birth
- Prior PTB
- Multiple gestation
- Short cervical length
- Low maternal BMI
- African American
- Maternal age
- Smoking
- Infections
*chorio, BV, pyelonephritis
- Excessive uterine distention
*multiple gestations
*polyhydramnios
- Cervical insufficiency
- Uterine abnormalities
*fibroids, septum, etc
- Placental abnormalities
*abruption or previa
- Substance abuse
- Trauma, abruption
Fetal fibronectin
- Protein that “glues” the membranes to the uterine lining
- When FFN is negative, 97% chance that pt will not go into preterm labor within the next 2wks
*if its neg. then you can be assured that nothing has ruptured
- Performed on pts b/w 24-34wks gestation
*vaginal swab
- Good neg. predictive value bad pos. predictive value
Preterm management
- Transfer pt to hospital w/ NICU
- Goal is to delay delivery to get optimal steroid benefit
- Tocolytics
- GBS prophylaxis
*ampicillin, clindamycin, erythromycin, penicillin, or vancomycin
- Steroids up to 34wks
*betamethasone or dexamethasone
Steroids benefit to preterm
- Help lungs mature by induction of proteins that regulate type II pneumocyte cells in fetal lungs that produce surfactant
- Dose
*betamethasone 12.5mg IM every 12-24hrs x 2 doses
*dexamethasone 6mg IM every 12hrs x 4 doses
Tocolysis
- Prolong gestation 2-7 days
- Administer steroids
- Transport to facility w/ NICU
Tocolytic Drugs
- MgSO4
- Beta agonists
- Calcium channel blockers
- Prostaglandin synthetase inhibitors
MgSO4 for preterm
- Tocolytic
- Competes w/ calcium going into cells to decrease availability for actin-myocin interaction and decreases myometrial contraction
- Side effects: respiratory depression, loss of reflexes, toxicity, pulmonary edema, hypotension
- Always have on hand an amp of calcium gluconate to reverse MgSO4
Terbutaline (brethine)
- Tocolytic
- Beta agonist
- Selective for beta 2 receptors, acts on calcium channels, relaxes smooth muscle
- Side effects: hypotension, tachycardia, anxiety, chest pain, pulmonary edema
Nifedipine (procardia)
- Tocolytic
- Calcium channel blocker
- Prevents calcium entry into muscle cells
Indomethacin
- Tocolytic
- Prostaglandin synthetase inhibitor
- Decreases prostaglandins by blocking the conversion of free arachidonic acid to PG
- Side effects
*premature constriction and closure of ductus arteriosus especially after 32wks
*oligohydramnios
Contraindications to tocolysis
- Advanced labor
*if dilated 5cm, usually can’t stop labor
- Lethal fetal anomaly
- Intrauterine fetal demise
- Chorioamnionitis
- Large amt of vaginal bleeding (i.e. suspected abruption) w/ hemodynamic instability
- Severe preeclampsia
- Nonreassuring fetal status
- PROM
- Maternal contraindications to tocolysis (agent specific)
17 Alpha-Hydroxyprogesterone Caproate
- Recommended for:
*prevention of recurrent PTB
+current singleton pregnancy
+prior preterm birth due to SPTL or P-PROM (20-37wks EGA)
- Considered for:
*symptomatic short cervix (<15mm)
*routine cervical length screening not recommened
- Start 16-20wks
*b/c we want to be passed the point during 1st trimester where mothers can miscarry or abort for other reasons (like if there was a chromosomal abnormality which is going to abort b/c its a non-viable pregnancy; we dont want to be given something to keep the fetus in when naturally it should be coming out)
- Continue to completed 36th week
- IM injection
- Ok to use in diabetics
