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MRCOG PART 2 SBAs and EMQs

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ESSAY 138 - PPROM

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		Posted by Sarwat F. Sat Jan 15, 2005 03:31 am
Justify your management of a 30 year old primigravida who presents with rupture of the fetal membranes at 28 weeks gestation Management will include history, examination, investigations and treatment and appropriate counseling of woman. In the history I will ask about whether she is married or single, then history of present pregnancy, history of smoking any symptoms like breathlessness, any feeling of overdistension of abdomen in view of poly hydramnios, history of any systemic infections, heart disease, any vaginal bleeding or offensive vaginal discharge present, any history of ultrasound done to find if she has singleton or twin pregnancy. Any of these factors if present can lead to preterm rupture of membranes. In the examination I will check the height and weight of patient to find the body mass index, her blood pressure, pulse and temperature. I will then do abdominal examination to check the lie of the fetus and fetal heart sounds. Then per speculum vaginal examination will be done to see if liquor is draining out and the degree of cervical dilatation. PH of amniotic fluid is checked using nitrazine sticks for confirmation of amniotic fluid. Investigations will be sent including full blood count (white cell count esp. important for chorioamnionitis), a c reactive protein, high vaginal swab for gram staining and culture and sensitivity. Regarding manangement this depends on several factors like presence of chorioamnionitis, availability of SCBU, whether the patient is in labour or not. Patient will be admitted and her monitoring will be done so that early signs of chorioamnionitis can be identified. Conservative management will be done if cervix is less than 4 cm dilated, there is no medical condition necessitating early delivery like preeclampsia, no signs of chorioamnionitis and no fetal distress present. Steroids will be given to prevent respiratory distress syndrome. According to ORACLE trial antibiotics have shown decrease perinatal morbidity so erythromycin will be started. Maternal monitoring will be done so that blood pressure, pulse and temperature are checked four times daily. Clinical examination like uterine tenderness and offensive vaginal discharge by application of a pad to vulva are checked daily. Blood tests that are white cell count and c reactive protein will be done three times a week. Daily cardiotocography will be done. Ultrasound will be done weekly to determine the amount of liquor, and fortnightly for fetal growth. As delivery of a premature baby is a stress factor for the couple, they should be offered sympathetic counseling giving the survival rate at this gestation which is almost 90 percent. Further management will depend on balancing the risk of infection against those of prematurity. Conservative management will be continued till fetus gains enough maturity usually 34 weeks provided there are no signs of infection developing. Tocolytic drugs atosiban or nifedipine can be used for threatened preterm labour to gain time for action of steroids Labour will be induced if there are any signs of chorioamnionitis as indicated by raised maternal pulse and temperature and rising levels of c reactive proteins. Prior to labour induction, neonatologist should also be involved in management and it is ensured that appropriate neonatal facilities are available. If neonatal facilities are not present, in utero transfer to tertiary care hospital having SCBU should be considered. Normal vaginal delivery can be allowed if cardiotocography is satisfactory in a singleton cephalic fetus and labour is progressing. For any fetal distress, caesarean section may be necessary. A neonatologist should be present at the time of delivery. After delivery baby may need nursery care and management will be in collaboration with a neonatologist. Patient should be counseled regarding the recurrence of this condition in future pregnancies.
		Posted by uma M. Sat Jan 15, 2005 06:40 am
prom
		Posted by uma M. Sat Jan 15, 2005 08:06 am
PROM for about 30-40% of preterm deliveries. Main risk with PROM for a 30 year old with prom at 28weeks is prematurity with its consequences & infection. Aim while managinig such pregnancy should be to improve pregnancy outcome History before initiation of any treatment should include duration of rupture of menbranes, assosiated pain abdomen , bleeding p/v(10% of cases have associated abruption), fever (chorioamnionitis),any medical conditions complicating pregnancy like diabetes, HTN, SLE,etc. Review her AN record for dating from LMP,early pregnancy scan as this needs to be accurate to give prognosis to the patient at this gestations. I would examine the patient _ note temperature- pyrexia if chorioamnionitis, PR for tachycardia, BP. abdominal examination for uterine height , tenderness in case of chorioamnionitis , look for any contractions. monitor fetal heart. Speculum examination will confirm ROM by noting the liquor draining out. Note any purulent or foul smell if infection. If any doubt then give her a pad and observe for few hours to note for wetting. To confirm if in doubt ferning can be noted on the slide. VE can be postponed unless she has uterine contractions ,as this carries risk of infection. Admit the patient into AN bed.Investigations include Hb, TC,DC,ESR to exclude infection.Urine microscopy , C/S, to rule out onfection.HVS, Endo cervical swab should be taken to exclude infection USG for amount of liquor, fetal growth, well being , placenta should be performed as further management depends on this. Main risk involved with PROM at this GA is prematuriy & infection both maternal ,fetal. After initial assessment further management is either immediate delivery or conservative management. If there is no evidence of chorioamnionitis , and fetal wellbeing tests are reassuring then she can be for conservative management. If e/o infection or fetal distress then she requires immediate delivery. She should be informed about her condition, explain her the nature of problem, likely complications, prognosis . Involve neonatologist to give prognosis regarding the fetus. she can make her decision regarding further management.Councel her that ther is risk of prematurity, increased neonatal infection, NICU/SCBU admissions, maternal infection. For Conservative management patient should be hospitalized. Continued clinical observation is required for early identification of any complications like infection. Monitor maternal temperature 4/day, PR 6th HRLY, TC,DC ,ESR daily for e/o chorioamnionitis. Fetal assessment includes NST, BPP, AFI monitoring 2/week.Loss fo fetal breathing movements is early sign of fetal infection. She should be councelled that 70-80% get into labour within 7 days. she should recieve tocolysis Betamethasone 12 mg 2 DOSES 24 HRS apart IM Injections as studies have shown to reduse the incidence of RDS ,IVH,NND, as she is at risk of preterm delivery. No role for multiple dose steroids as this has not shown to have additional benefit , not proven to be safe in humans. If she has threatened preterm or has preterm labour she should be started on tocolysis. Drug of choice should be either nifedepine or atosiban as studies have shown that these agents are effective with few maternal sideeffect due to its use. with Tocolysis we can buy time for steroid course to be completed and for shifting to tertiary center. Antibiotics Erythromysin 500mg 4 times a day for 10 days have shown to reduce maternal infections,delivery within 7 days, neonatal infection, and this has shown to be superior to co-amoxiclav (risk of NEC) in ORACLE trial . in utero transfer to tertiary centre for neonatal intensive care ,SCBU is advisable as project 27/28 has shown that this has better prognosis than for babies shifted after delivery and with some complication. Give her necessary support as she may be detached from her home for long. During conservative management if she gets into labour, develops complications she should be delivered. Mode of delivery- vaginal if ther are no contraindications.. c.section has not been shown to improve outcome.Continous EFM is advisable.Neonatologist should be present at time of delivery. Post partum increase in incidence of endometritis is noted .Be vigilant for this.Encourage breast feeding. Neonate should be screened for sepsis. Adequate documentation of management issues is essential for CRM in case of adverse outcome.
		Posted by narmin B. Sat Jan 15, 2005 10:38 am
A history should be taken. She should be asked about the amount of fluid that she has lost, as passing small amount of fluid may be due to urinary leakage or vaginal discharge. Usually there is considerable loss of fluid with rupture of membranes. In the presence of abdominal pain or tenderness there is a possibility of infection and chrioamnionitis. Also regular contractions may indicate active labour. An examination is necessary. Temperature, pulse should be checked. Raised temperature and tachycardia may be due to infection and chrioamnionitis. An abdominal examination is required to palpate the presenting part of the fetus and also to check for the presence of abdominal pain and contractions. A sterile speculum examination is required. It may show amniotic fluid in the vagina. If there was any doubt about the nature of fluid a nitrazine test can be performed. In the presence of amniotic fluid its colour will turn to blue. A high vaginal and endocervical swabs can be taken at this time to check for the presence of any infection. Also a closed and long cervix can be seen in this examination. Investigations include taking a blood sample for full blood count, CRP. Blood couture is necessary if the temperature was 38 or above. White cell count and CRP will be raised in the presence of infection Blood culture can determine the causative agent and recommend appropriate antibiotics. Cardiotocography (CTG) is necessary to identify any fetal distress. Ultrasound scan should be performed to check the amount of amniotic fluid and presenting part. In the presence of severe oliogohydramnios Doppler studies are also required to assess fetal well being. The management will depend on the findings of history, examination and investigations. If the woman is in active labour she should be admitted to the labour ward. As transfer of the baby to special care baby unit (SCBU) may be required, this unit should be informed. If there were no special care facilities, intrauterine transfer to another hospital should be considered. Intrauterine transfer is associated with less perinatal mortality and morbidity. .A paediatrician also needs to see the patient to discuss about complications of prematurity such as respiratory distress syndrome, prolonged oxygen requirement and the possibility of keeping baby in the hospital for a few weeks. Steroids should be given to the mother. Dexamethasone 12 mg 12 hours apart is the usual dose. This reduces the rate of fetal respiratory distress syndrome and intraventricular haemorrhage. Tocolytics such as nifedipin or atosiban can be given. Ritodrine should be avoided as it is associated with more maternal complications (cardiac and respiratory). The reason for giving tocolytics is to prolong labour for 48 hours. This time is required for the effect of steroids or intrauterine transfer to another unit. There is no benefit from long term administration of tocolytics. If the presenting part was cephalic normal delivery with continuous monitoring of the fetal heart can be allowed. Although it has not been proved in randomised control trials, Caesarean section is recommended if there was malpresentation as it is associated with less fetal trauma. Intravenous antibiotics such as pencillin or erthromycin should be given to prevent infection. A paediatrician should attend for delivery of the baby because neonatal resuscitation may be required.Mother should be informed about all the steps of management, because she needs to understand her condition in order to cooperate with her treatment. If the mother is not in labour and there is no sign of infection, outpatient management should be considered. The patient should be asked to report any pain or raised temperature. Daily CTG and weekly scan for amniotic fluid and Doppler is required to assess fetal well being. Administration of oral Erythromycin can prolong duration of labour but does not reduce the rate of mortality and morbidity. Steroids should be given for fetal lung maturity.There is no need for repeat dose of steroids as it has not been proven to have any benefits and may cause neurological problems inthe fetus.If there was any evidence of chorioamnionitis, she should be admitted, intravenous antibiotics must be administered and labour should be induced, as there is high risk of maternal and perinatal mortality and morbidity.
		Posted by Nibedita R. Sat Jan 15, 2005 12:53 pm
Preterm PROM poses risk to the mother and to the foetus. Potential maternal risk of chorioamnionitis, abruption placentae and increased obstetric intervention (induction and caesarean section) and anaesthesia. Increased foetal risk of prematurity and associated problems (immaturity, respiratory distress syndrome, long term sequelae), infection, foetal distress due to cord complications, chorioamnionitis and abruption and perinatal mortality upto 30-40%. Confirmation of diagnosis should be done first from history (gush of fluid from vagina/ trickling, worse on coughing) and sterile speculum examination for liquor loss. Maternal examination includes ? pulse, BP, temperature, uterine size, presence of uterine contractions, uterine tenderness. Foetal presentation/ lie, foetal heart rate. If no signs of labour, foetal distress or infection (chorioamnionitis) ? at gestation of 28 weeks, the objective is to prolong the gestation. If the loss is negligible and in the absence of infection, patient can be managed as outpatient with monitoring in day assessment unit. Investigations include high vaginal swab, FBC, CRP to identify any evidence of infection and repeat tests if indicated. If adequate neonatal care facilities for preterm baby are lacking she should be transferred to tertiary centre with SCBU. It is necessary to screen continuously for appearance of infection or foetal distress. Monitoring the maternal and foetal well being by pulse, temperature, liquor loss/ colour of liquor, uterine tenderness and daily CTG, twice weekly BPP and Doppler studies, two weekly growth scan is recommended. Vaginal examination is avoided unless the woman is in established labour, due to increased risk of ascending infection. A course of corticosteroids to induce foetal lung maturity is recommended. The benefit of repeated dose of corticosteroids is not proven and use of corticosteroids is not associated with increased risk of infection. There is evidence that cortisteroids have a role in reducing perinatal mortality and morbidity in preterm babies, reduced risk of RDS, IVH, NEC and duration and cost of neonatal therapy. Arrangement should be made for joint parental counselling with the neonatal team. Use of antibiotics is beneficial (Oracle Trial) in increasing the delivery interval and decreases risk of infection. Erythromycin 250mg and /or coamoxyclav 325mg four times daily for 10days/ till delivery is used. However, there is no evidence that their use would reduce prenatal death or maternal morbidity. In the presence of preterm threatened labour she should be admitted. Use of tocolytic drugs such as nifedipine or ritodrine is recommended to delay labour for at least 48 hours, the time required for action of steroids on the foetal lung, or in-utero transfer to a centre with neonatal care facilities. Indomethacin use is not recommended as it is associated with premature closure of ductus arteriosus and risk of masking early signs of intrauterine infection (uterine tenderness). Betamimetics are not useful to prolong gestation for many days. When combined with corticosteroids, there is risk of pulmonary edema and strict control of fluid balance is necessary. Value of amniocentesis (transabdominal) and culture of the amniotic fluid is doubtful, although some cases show positive culture in preterm PROM without clinical signs of infection. At any time if signs of infection or foetal distress develop, delivery should be conducted immediately by the safest possible route i.e. induction of labour or caesarean section. Neonatal team must be present at delivery to resuscitate the preterm baby. Perinatal outcome will depend on the gestational age at delivery, signs of infection and availability of advanced neonatal care facilities. Post delivery counselling and support may be required and discussion of the risk of recurrence in future pregnancy must be considered.
		Posted by Vaijayanti R. Sat Jan 15, 2005 07:27 pm
reterm PROM is associated with significant morbidity both for the mother ( chorioamnionitis ) and the fetus( prematurity, hypoxia); management is directed to reducing / preventing the same. A brief history and review of previous records will confirm gestational age( LMP, prior USG),and identify any associated factors that may modify management ( Diabetes Mellitus, Hypertension). Symptoms of infection such as fever, pain abdomen, foul smelling vaginal discharge are elicited. Examination will identify signs suggestive of chorioamnionitis (fever > 38deg C, maternal or fetal tachycardia, tender uterus,purulent vaginal discharge), as well as confirm uterine size, fetal viability, presentation.It will also rule out labor or any placental abruption. A sterile speculum examination is carried out after she has rested for 20 to 30 mins to reconfirm ROM( direct visualization of amniotic fluid trickling through the os / pooling of fluid in the posterior fornix). Any meconium staining of the fluid at this gestational age may indicate an intrauterine infection.The degree of cervical dialtation and effacement are also noted.Digital examination is best avoided, unless the patient is in active labor / cord prolapse is suspected. Bloods are collected for CBC, CRP assay; grouping and cross matching;coagulation profile may also be done as PPROM is associated with a 5% risk of placental abruption. The baseline total and differential WBC counts along with C-reactive protein have limited role in diagnosis, but are useful prognostic indicators.Vaginal cultures are also collected; urine for microscopy and culture. USG is done for fetal viability and liquor volume. Oligoamnios( AFI<2.0) is associated with a higher risk of intrauterine infection CTG / Biophysical profile will identify any fetal compromise The patient is counselled extensively, and any intervention is done with informed consent. She is transferred to a tertiary care centre (with facilities for Neonatal care as delivery is likely within the next 7 days) Immediate delivery is indicated if there is evidence of chorioamninitis, placental abruption , fetal hypoxia or the patient is in active labor. Expectant management is offered if there is no indication for immediate delivery Antibiotics Erythromycin and ampicillin ( IV for 48 hrs followed by oral adminstration for 5 days) are given as this has been proven to delay delivery as well reduce maternal and neonatal morbidity and mortality. Oral Erythromycin 250 mg QID for 10 days is equally effective( Oracle 1 trial). Coamicolxav is best avoided as it is associated with a an increased incidence of necrotising enterocololitisin the neonate. Maternal steroid adminstration ( betamethasone 12mg x 2 doses , once in 24 hrs) will help reduce the effects of prematurity on the neonate( RDS, IVH, NE) without any significant deleterious effect on the mother. The role of Tocolysis is doubtful ? no definite benefit has been proven; however,they may be used to cover transfer to a tertiary centre, and allow time for steroid action.Oral Nifedipine or Atosiban IV may be used. Fetal monitoring ? BPP / modified BPP is done daily. Blood is collected for total and differential WBC counts once in 2 days, and vaginal cultures are repeated weekly. Vaginal delivery is the rule except in breech presentations and for obstetric indications..There is no contraindication for epidural analgesia. A senior Obstetrician is present at the delivery along with a Neonatologist to receive the baby.Continuous fetal monitoring during labor is recommended as cord complications are frequent ? cord prolapse/ compression. Anticipate postpartum hemorrhage and take the necessary measures.Antibiotic prophylaxis is given as there is a higher incidence of post partum endometritis. Anticipate postnatal problems including impaired lactation,and psychosocial sequelae. She may require counselling to help in mother- infant bonding The infant would require an infection screen. Anti D ( 250 IU im in the deltoid within 72 hrs) is given if RH negative and non immunized. Post delivery she is counselled regarding the risk of recurrence( 21%) in subsequent pregnancies and is advised to control associated risk factors -smoking. The management would be the same for a single or a multiple gestation, except for the fact that the perinatal outcome may be poorer in high order multiples
		Posted by SWATI M. Sun Jan 16, 2005 12:22 pm
Preterm PROM increases perinatal morbidity and mortality due to preterm delivery,infections and can cause infectious morbidity in mother. Management is influenced by presence of chorioamniotis,gestational age,any medical disorder, fetal condition. History of duration of rupture of membranes,history suggestive of chorioamniotis such as fever, foul smell of vaginal discharge enquired .Confirmation of gestational age by LMP, review dating ultrasound scan. Review her antenatal records for any associated disease such as diabetes,hypertension. Clinical examination includes pulse ,temperature for evidence of infection.Abdominal examination to note any uterine activity,tenderness, fetal heart rate,fetal presentation .Speculum examination undertaken to confirm rupture of membranes,note cervical dilatation,cord prolapse,collect sample to confirm leakage for nitrazine test if doubt and endocervical swab for culture.Vaginal examination is avoided as it might introduce infection. Investigations includes FBC with differential leucocyte count,CRP to look for any evidence of chorioamnionitis.Cardiotocography is performed to know fetal condition.Ulrasonography perfomed to note fetal presentation(malpresentations are common at this gestation) amniotic fluid volume. Management would depend on results of investigation and clinical examination.Neonatologist should be involved during decision regarding management.Delivery is indicated if evidence of chorioamnionitis,fetal compromise,any associated medical disorder such as preeclampsia which demands early intervention.Conservative approach is appropriate in others.Woman should be admitted in hospital.She should be monitored by pulse,temperature every 4-6 hourly. FBC and CRP performed every 2 days.Fetus is monitored by daily CTG . Erythromicin given orally as it reduces neonatal morbidity, need for oxygen requirement and surfactant therapy. Betamethasone 12 mg 2 doses 24 hours apart given to enhance fetal lung maturity. It reduces incidence of RDS , intraventricular haemorrhage thus reduces neonatal morbidity and mortality.Tocolytics such as nifedipine should be given if threatened preterm labour to prolong delivery by 48 hours to establish action of corticosterdiods or allow in-utero transfer .If fascilities for neonatal intensive care are not available in- utero transfer should to organized to tertiary centre. During labour fetus should be monitored by continuous electronic fetal monitoring as increased risk of cord compression and abruption causing fetal distress.Keep informed SCBU and neonatalogy team about the patient and should be present at delivery.Vaginal examinations kept to minimum and aseptic precautions should be observed to minimize infection. Explain the management plan to the mother and keep her informed at all stages about her condition. She should be involved in making decisions and her choices should be respected.
		Posted by Nibedita R. Sun Jan 16, 2005 09:02 pm
Dear Dr Paul, I think my answer has been missed. It has not been marked. Please mark the answer. thanks
		Posted by Iman B. Mon Jan 17, 2005 11:24 pm
A complete history should be taken, as to time of rupture and history of any systemic disease, the patient should be admitted into the hospital, for treatment and the neonatologist on call notified of the possible delivery within twenty four to forty eight hours of a twenty eight weeks baby. If there are no facilities for care of a 28 week baby, then notification of the nearest centre with a SBCU or NICU Under aseptic conditions, a High vaginal swab is taken and sent for culture. A urine culture is also taken along with full blood count, CRP and an ultrasound scan is arranged. The scan should check for visible congenital anomalies, and fetal lie and whether single or multiple pregnancy. The baby should be heard at least four times per day, and the mother told to notify if the fetal movements decrease. The vital signs are taken and a temperature chart started four hourly, to check for signs of starting chorioamnionitis. Then start a dose of erythromycin, 250 mg qid for ten days, according to the oracle trial, this regime will reduce neonatal morbidity, with decrease in the incidence of respiratory distress, and neonatal infection. If the patient doesn?t suffer from debilitating systemic disease as tuberculosis which is untreated, and there are no clinical signs of chorioamnionitis, such as high fever, then two doses of betamethasone should be given. Betamethasone at a dose of 24 mg over a forty eight hour period have been shown to decrease the incidence of not only babies with respiratory distress but also those with intraventricular leucomalacia. Intramuscular doses have been found to be more effective than oral corticosteroids. Betamethasone was shown to decrease the incidence of intraventricular leucomalacia, and so is the drug of choice, in its absence dexamethasone should be used. In those patients on oral prednisolone they should also be given betamethasone as prednisolone doesn?t cross the placenta in sufficient quantities. The use of tocolysis may prolong the time to delivery which will enable both the full dose of corticosteroid to be given and also to transfer if necessary intrauterine before delivery. The RCOG no longer recommends use of ritodrine for the cessation of uterine contractions, but the use of atosiban which is licensed in the UK may be used, although it is rather expensive. An alternative is unlicensed nifedipine, which has shown to be just as effective. In case of those patients who are found to be diabetic under strict control, they should be admitted under strict care of both the obstetrician and the internist. Their babies will probably benefit from use of betamethasone, with a decrease in respiratory distress. Those patients found to be epileptic on antiepileptic treatment should have a double dose of betamethasone, to counter the the increased metabolism. Epileptics on treatment should also take Vitamin K as ten mg oral daily until the time of delivery to, this will decreae the incidence of hemorrhagic disease in the babies. There is no recommendation of prophylactic use of vitamin K for any other group of patients. If the patient doesn?t deliver within seven days, then a consultation with the senior obstetrician as to the feasibility of using further doses of corticosteroids. As yet, there is no proof that multiple doses of corticosteroids will have a beneficial effect on the baby. The Canadian Macs trial is still underway to determine the benefit of repeated doses of corticosteroids.
		Posted by vijaya L. Tue Jan 18, 2005 06:03 am
Management of pprom at this early gestational age depends upon underlying obstetric factors, well being of the fetus and maternal wishes. A detailed history regarding duration of leak, fever, pain abdomen, appreciation of fetal movements and bleeding per vagina is taken. Hospital records are checked for predisposing factors like polyhydramnios, multiple pregnancy, vaginal infections and maternal systemic diseases like diabetes, renal disease and connective tissue disorders. The survival of the infant depends largely upon the gestational age and if dating scan has been performed, will be of help. A complete physical and obstetric examination should be carried out, especially looking for pyrexia, tachycardia, tender uterus or labour contractions and position and lie of the fetus. Rupture of membranes can be confirmed by using a sterile speculum and digital examination should be avoided. If there is any doubt about the leak, demonstration of alkaline PH by litmus paper and fern pattern formation of vaginal fluid on drying provide reasonable evidence of rupture membranes although these results can be obtained in vaginal infections as well. Swabs are taken from cervix and vagina for microbiological examination, as infection is said to be the most important cause for pprom. Blood sample examined for FBC, CRP. U & E. although total count is elevated during pregnancy, counts beyond 15000 along with raised CRP are useful in the diagnosis and follow up of the infection. Detailed ultrasonogram is requested to rule out congenital anomalies if not already done and for measurement of AFI, which also indirectly suggests the leaking. Fetal activity and reactivity (acceleration with movement) are looked at. Although fetal breathing movement can be lost in the infections it cannot be depended upon at this gestation. Routine amniotic fluid sampling is not necessary as risks outweigh the benefits. After ruling out overt infection steroids are recommended which decreases the incidence of RDS, Intraventricular hemorrhage and necrotising enterocolitis and also decreases the stay in the neonatal intensive care unit. Parents should be given an option between expectant management and active management and their wishes are respected. Expectant management or delay of delivery in the hope of prolonging the intra uterine stay there by achieving more maturity should be weighed against risk of chorio-amnionitis for the mother and adverse effects of in utero infection on the development of the fetal brain. Close monitoring with thrice weekly FBC, CRP, AFI and NST are recommended. In active management risks of prematurity should be weighed against chances of reducing the maternal infection. The figures for survival and long-term morbidity should of the unit in which the neonate is going to be nursed. In utero transfer should be considered if facilities are not available. In cephalic presentation vaginal delivery should be aimed for and delivery should optimized by ensuring warm room, presence of a senior pediatrician, delayed clamping of the cord, vit K administration and considering artificial ventilation and prophylactic surfactant. In case of breech presentation route of delivery is controversial and it is generally felt that cesarean section may be beneficial .