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MRCOG PART 2 SBAs and EMQs

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ESSAY 161 - PPROM

Posted by jyoti D.
This a difficult situation and patient should be dealt ina sympathetic and supportive manner. The diagnosis should be explained to the patient and asses whether she is in labour or not.
If in labour patient should be admitted and general condition should be assesed for any signs of sepsis like tacycardia and high temperature.Check urine for nitrates ,full blood count for leucocytosis,C-reactive protein (usually raised if acute infection) though nonspecific test can support the diagnosis,low vaginal swab for any evidence of infection .
Fetal monitoring by CTG,scan for liquorvolume and doppler (if associated medical problems like preclampsia
)causing fetal compromise.Inform the NICU and neonatologist so as to discuse with the mother regarding the perinatal mortality and morbidity at 28 weeks gestation.
Steroids (Inj.Bethamethasone 12mg 24hrs apart)aid in lung maturity is considered if no signs of chorioamnionitis and tocolysis to buy time for steroids to act and arrange inuterine transfer if required .Mode of delivery is by caesarian section, it is associated with increased risk of classical scar in view of early gestation and less liquor. Caesarian might be difficult so senior obstetrician should be involved and neonatologist should be present at the time of delivery.
If patient not in labour close maternal and fetal surviellance can be carried out either as an inpatient or outpatient .Maternal surviellance by full blood count ,c-reactive protein ,low vaginal swabs weekly.Asses patients general condition at each visit and exam per abdominally for any tenderness to rule out chorioamnionitis.Patient should be informed to report if she feels unwell or there is any change in the colour of liquor or if foul smellingl liquor.
Fetus is monitored by CTG\'S,liquor volume ,growth and doppler\'s and kick counts but value of these tests is still uncertain in preventing perinatal morbidity and mortality.The fetal risk because of oligohydramnious in the from of pulmonary hypoplasia is less at 28 weeks but can be a feature.Antibiotics should be prescribed as it is know by ORACLE TRIAL that it can reduce and prolong the delivery in PPROM.
If all the parameters remains normal then pregancy can be continued without any intervention.But if ever there any signs of infection are noticed plan should be immediate delivery in a tertiary center with NICU facilities.
Posted by mushabbar H.

At gestations less than 34 weeks, the objective is to prolong the pregnancy if there are no signs of fetal or maternal infection in order to minimize the risk of prematurity. The most common complications that may occur in this woman are preterm labour, chorioamnionitis and significant oligohydramnios. Management will include certain investigations to decide subsequent treatment. Initial investigations to be performed to establish a baseline for subsequent comparisons include a full blood count, especially the white cell count and differential, a C reactive protein and a high vaginal swab for microscopy, culture and sensitivity. Unfortunately the parameters are not very sensitive in predicting chorioamnionitis. For example CRP is unreliable, although serial levels showing a consistent rise will be suggestive of infection not necessarily from uterus. Similarly a rise in white cell count, which is not uncommon in pregnancy, may be indicative of infection elsewhere in the body. However serial values showing significant changes will raise suspicions of chorioamnionitis unless other sources of infection can be identified. The full blood count and CRP need to be repeated twice weekly.
Early maternal manifestations of chorioamnionitis are pyrexia, tachycardia and tachypneoa. These may be identified by four hourly temperature, pulse and respiratory rate recordings. These need to be performed in this patient even if she is to be managed on outpatient basis. In addition to these daily palpation of the lower abdomen for tenderness and examination of a pad for the colour of liquor and its smell will help in identifying early chorioamnionitis. Unfortunately these signs may not always be present with infections. The value of serial vaginal swabs is limited, as frequent introduction of swabs in the vagina may increase the risk of ascending chorioamnionitis. Some argue that low vaginal swabs are useful but these may only yield lower genital tract flora of no clinical significance. The diagnosis of beta hemolytic streptococcus will however influence management.
An ultrasound scan in this patient will quantify liquor volume, assess fetal growth and affords an oppurtunity for Doppler studies of the umbilical and other fetal vessels. Serial ultrasound scans will allow for estimation of liquor volume but more importantly will allow assessment of fetal lung volume and breathing movements which is associated with a better prognosis. In the absence of liquor the prognosis is poor and amnioinfusion at this gestation is controversial. Problems with this procedure include infections and failure to achieve a satisfactory residual volume as it may leak out as soon as it is infused. This is not only a tedious process for a clinician but it is uncomfortable for the patient and may not be successful.
Neonatologists must be involved in the management of this patient. There is a need for counseling of the patient about the chances of survival (90% at this gestation), neonatal course and possible complications. Timing delivery must also be decided in close laision with neonatologists.
Steroids should be administered dexamethasone given in two doses 12 mg IM 12 hrs apart. This will accelerate lung maturity. Whether this should be followed by weekly booster is increasingly becoming controversial in view of recent publications suggesting an association with neurodevelopmental disability and IUGR. Tocolytic agents may be used if the patient starts having contractions, but these have not been shown to significantly prolong the pregnancy. ORACLE trial has concluded that prophylactic antibiotics in thes patients donot prolong pregnancy but reduce perinatal morbidity. Erythromycin will therefore be offered to the patient after admission.
The timing and mode of delivery depends on gestational age, neonatal intensive care facilities, presence of any chorioamnionitis and fetal distress (a CTG will help in predicting this) and also on past obstetric history. If SCBU is not available, in utero transfer is the best option. For any signs of chorioamnionitis, induction of labour or ceasarean section may be required.
Postnatally woman may need to be counseled regarding recurrence risk in future pregnancies.
Posted by khalid M.
Justify your management of a 24 year old woman who has ruptured her membranes at 28 weeks gestation.

Main aim of treatment is to prolong the pregnancy to achieve reasonable maturity.
A complete history should be obtained including the duration of rupture of membranes, any uterine activity, and flu like symptoms. Antenatal notes should be reviewed to exclude twin pregnancy, gestational diabetes and polyhydramnios.

A complete examination should be undertaken. Fever and tachycardia and abdominal tenderness are suggestive of chorioamnionitis. Which is associated with increased maternal morbidity and perinatal mortality.

Abdominal examination to note lie, presentation, uterine tenderness and irritability must be noted. A sterile speculum examination will confirm rupture of membranes, reveal cervical dilatation and exclude cord prolapse. High vaginal swab should be taken for culture and sensitivity to rule out ascending infection( GBS). Baseline investigations include full blood count (>WBC) and CRP.

Delivery should be expedited in chorioamnionitis and paediatrician informed.

Digital vaginal examination should be avoided because it increases the risk of ascending infection except in established labour.

She should be counselled that fetal survival rate at this gestational age is 75% and this can be further improved with steroid therapy , which reduces the incidence of respiratory distress and interventricular haemorrhage. Oral antibiotics ( Erythromycin) should be given to reduce the risk of ascending infection. In the presence of uterine activity tocolysis therapy is justified for 48 hours to get benefits of steroid therapy or inutero transfer if NICU facilities are unavailable.

Initially in-patient treatment should include checking temperature and pulse 4 hourly, twice weekly FBC & CRP and weekly high vaginal swabs to detect infection. An ultrasound examination should be performed to check for fetal presentation, estimate liquor volume & fetal weight. Doppler studies are justified if impaired uteroplacental blood flow is suspected. With severe oligohydramnios , amnioinfusion may be an option if expertise available.

Later on out patient therapy is justified to reduce the impact of family disruption. She should be advised to immediately contact hospital if feels feverish, flu like symptoms and reduce fetal movements. She can be monitored in the day case unit by twice weekly FBC, CRP and CTG.

If spontaneous labour does not intervene, delivery at 34-35 weeks is recommended. Vaginal delivery should be aimed for and caesarean section reserved for obstetrics indications.
Posted by Nitin P.
Prematurity is the commonest cause of perinatal morbidity and mortality. Preterm Labour may be spontaneous in this case or induced for maternal or fetal compromise. The risks of prematurity have to be balanced against the risk of continuing pregnancy with risk of chorioamnionitis, maternal septicaemia, intrauterine death and periventricular malacia in survivors.
History is noted regards certainty of dates and early pregnancy dating scans. Nature of discharge regards colour and smell indicative of infection. Fetal movements is a poor predictor of fetal well being. Presence of contractions indicates that she is already in labour. Past obstetric history regards number of deliveries as children at home may affect decision regards in patient management. Mode of deliveries in the past, as affects decision regards induction. Medical history of heart disease, diabetes, hyperthyroidism, contraindicates use of beta mimetics for tocolysis.
On examination, tachycardia and hypotension, indicate severe sepsis. Pulse and temperature monitored for early sign of maternal infection. Abdomen palpated to confirm number of pregnancies, size and lie. Contractions best detected by palpation.
Vaginal examination to determine cervical status and presence or absence of labour.
Frequent V/Es not indicated as may be a source of infection.
Investigations aimed at confirming maternal and fetal well being. Full blood count for elevated white cells, normally seen in pregnancy. Anaemia contraindication for use of beta mimetics. Elevated CRP non specific indicator of infection, rising values useful in monitoring. High and low vaginal swabs for organisms and sensitivity to guide appropriate antibiotic use. Mid stream urine for organisms and sensitivity as UTI is a cause of preterm labour. Blood cultures indicated if temperature or rising CRP or white cell count to determine nature of infection.
Fetal well being confirmed with ultrasound scan with special reference to amniotic fluid volume. The detection of anomalies may be difficult in presence of oligohydramnios. Singleton pregnancy is confirmed. CTG and BPP, if normal are good indicators of fetal well being. Dopplers to be considered as absent or reversed flow in case of severe intrauterine infection.
The patient is managed as inpatient initially atleast. Outpatient management with daily monitoring possible once fetal and maternal well being confirmed. Effect on family and travel time to be considered in any decision.
Referral to a tertiary centre with Special Care Baby Unit (SCBU). Meeting with neonatologist arranged. Visits to SCBU and handling of premature child explained.
The patient is counselled regards short and long term morbidity of prematurity.
If not in labour and no evidence of fetal or maternal compromise, continue monitoring with FBP and CRP for maternal infection. CTG, BPP and twice weekly ultrasound scan for fetal monitoring. No evidence regards the frequency of CTG and BPP to be performed. Commonly used protocol is CTG daily and BPP twice weekly.
If in labour, continuous fetal monitoring advised. Avoid vacuum before 34 weeks. No evidence regards benefit of caesarean section for breech at this gestational age, although commonly considered.
Maternal or fetal compromise warrants early delivery. Induction of labour if favourable Bishop?s score. Unfavourable Bishop?s score or urgent delivery consider caesarean section. General anaesthesia preferred over regional in case of sepsis.
Good evidence regards role of steroids in reducing respiratory distress syndrome and intraventricular haemorrhage as well as mortality. Best effect if delivery after 24 hrs and before 7 days. No good evidence regards repeat doses.
Tocolytics to be considered only if time gained is used for in utero transfer or for steroids to act. Atosiban and nifedepine more effective than beta sympathomimetics with better side effect profile.
Antibiotics improve out come as per ORACLE trial. Erythromycin preferred to CoAmoxiclav in view of lesser risk of necrotising enterocolitis.
Neonatologist should be present for delivery.
Post natal follow up visit to advise regards risk of recurrence and answer doubts regards management.
Posted by Mangala sundari R.
This patient at 28 weeks is at high risk for preterm labour and chorioamniotis and the fetus is at high risk for prematuriy and increased perinatal morbidity and mortality.
History is taken about the parity and h/o previous preterm labour, the colour , durationof liquor draining,any associated fever,bleeding, pain or contractions,or trauma to the abdomen,any histroy of infection like respiratory or urinary, or systemic illness. Previous obstetric history noted and the antenatal notes are reviewed for any medical or surgical complications of pregnancy, like diabetes, PIH, multiple pregnancy, polyhydramnios, and previous operative deliveries.. smoking or drugs history taken.Investigations sofar done are noted .

Examination includes, Pulse, BP, Temp,any respiratory /urinary/ flu like signs of infection .
Per abdomen, the fundal height, any tenderness over the abdomen, or contractions,and FHs checked. Speculum examination done to confirm the liquor draining ,and to look at the colour and if foul smelling and cervical dialatation if any.High vaginal swab is taken for culture and sensitivity. No per vaginal examination to be done .Sometimes excessive vaginal discharge or incontinence of urine may mimic liquor draining. If in doubt. to do a nitrazine test to confirm the liquor( amniocater test positivity).
Investigations Complete blood count , U&E, Urine C&S, ESR, C reactive protein(CRP) High Vaginal Swab C& S(HVS),CTG.
Ultrasonography is done to assess the fetal well being, amount of liquor and the estimated fetal weight..
Patient will be treated as an inpatient, and the findings and the plan of management will be explained to her. If she has any signs of chorioamniotis like fever, tachycardia,tachypnea , uterine tenderness, the delivery has to be expedited. Otherwise the pregnancy should be prolonged till a reasonable maturity is reached. She will be started on Iv antibiotics ( ampicillin and erythromycin). Oracle trial has proved that the antibiotics will not prolong the pregnancy but reduce the perinatal morbidity.Steroids are given for lung maturity, Inj betamethasone 12 mg im for 2 doses, at 24 hrs interval.This reduces the RDS and necrotising enterocolitis, and also the intraventricular hemorrhages which are the common complications in a preterm infant.The role of steroids and the dose is still a controversy in twins. But the same is usually given in multiple pregnancy. In diabetics, steroids can be given and the blood sugar level should be controlled with sliding scale. If the patient is in threatened preterm labour, she should be started on tocolytics to prolong the pregnancy till the steroids take effect or if she need to be tranfeered to another unit for preterm care ( with the fetus in utero). Neonatologists will be consulted and kept informed about the lobour progression and the need for SCBU care.
Most of the patients >80% go into preterm labour and deliver by 48 hrs or deliver by 7 days. Patients should be followed by biweekly CBC , ESR HVS swabs for any evidence of infection.. Fetal well being should be followed by serial ultrasound for growth and liquor volume ,BPP. If there is any indication of chorioamniotis, or fetal compromise, she should be delivered immediately.
The preterm labour may be complicated by malpresentaions , oligo hydramnios, abruptio placenta .May need emergency Lscs for failure to progress or chorioamnionitis or fetal distress or a classical Csection in a poorly formed lower segment. Thromboprophylaxis will be done as per the risk factors and the protocol of the dept.
In few patients the liquor draining may stop and the pregnancy may continue .They can be discaharged with instructions about the regular follow up, signs of infection and to report as and when required.
Post nataly the recurrence risk is explained for future pregnancies.



Posted by Sreekala S.
The initial assessment should include history and examination. History should include the onset, duration of membrane rupture as she may require GBS prophylaxis if rupture of membranes were there for more than 18 hrs, colour and quantity of liquor, presence of meconium,frequency of uterine contrations if any, presence of fever, bleeding P/V and medical illnesses.
Past obstetric history should include previous caesarean sections, preterm labours and GBS status. Pulse rate, BP and Temperature should be noted to see if there is any evidence of Chorioamnionitis.Uterus should be palpated for any uterine contractions, presentation and liquor volume. Speculum examination should be done to confirm rupture of membranes and swabs taken. Vaginal examination should be done to assess cervical dilatation and effacement. CTG should be commenced to detect any fetal heart abnormalities or to pick up uterine contractions. Ultrasound scan should be done for fetal well being , presentation, number of fetuses and liquor volume. FBC, CRP and MSSU should be done to detect any evidence of chorioamnionitis or UTI.
Management should be by a multidisciplinary approach involving the consultant obstetrician and the paediatric team. The neonatal intensive care unit should be kept informed if she sets in to labour. The woman should be counselled about the possibility of preterm labour and the necessity of keeping the baby in the NICU and probable risks of perinatal morbidity and mortality especially due to RDS and the possibility of an operative delivery if she develops fever with vaginal delivery not being imminent.
Corticosteroids should be administered to the woman as soon as possible once the diagnosis is established to benefit the baby from fetal lung maturity. Corticosteroids reduce the incidence of RDS, intraventricular haemorrhage and neonatal death. The cost and duration of neonatal intensive care is also reduced. Corticosteroids are contraindicated in the presence of systemic infections like TB but, caution needs to exercised in the presence of chorioamniotitis as it is associated with periventricular leucomalacia and cerebral palsy. The RCOG scientific advisory committee recommends betamethasone as the steroid of choice for lung maturity as it is associated with a decreased risk of cystic periventricular leucomalacia when compared to dexamethasone. 2 doses of 12mg betamethasone IM should be given 24 hrs apart. Alternatively, 4 doses of dexamethasone 12mg 12 hrs apart can be given. The optimal treatment-delivery interval for administration of corticosteroids is more than 24hrs but fewer than 7 days after start of treatment. However, there is a trend towards benefit in babies delivered before and after the optimal treatment interval has elapsed. Steroid therapy should be initiated even when delivery within few hours is anticipated. Antenatal corticosteroids can be administered even if the woman has multiple pregnancy or Gestational diabetes mellitus although a significant reduction in RDS is not demonstrated. Inpatient supervision is required to regulate blood sugars if diabetes mellitus is present. If repeated doses of steroids are contemplated, then senior opinion should be sought as there is lack of evidence to show any significant benefit.

If the woman is contracting, then tocolysis should be considered to provide sufficient time for the steroids to act or until in utero transfer to a tertiary centre with neonatal intensive care facilities is done. Ritodrine is no longer the tocolytic of choice because of side effects like palpitations, tremor, nausea, headache, chest pain and palpitations. Atosiban and nifedepine are the tocolytics with comparable effectiveness and fewer side effects but, only atosiban is licensed in the UK for this purpose and nifedepine is not. Atosiban is administered in a 3 step procedure- 6.75 mg as a bolus over 1 min, followed by 18mg/hr as an infusion for 3 hrs and then 6mg/hr for 45 hrs. Maximum duration of treatment should be for 48 hrs and total dose should not exceed 330mg. The main disadvantage is that it is very expensive and it may cause nausea. Alternatively, nifedepine can be given 10mg Sub lingually every 15 min for the first hr until contractions stop then 60-160mg/ day as a slow release preparation. The advantage with nifedepine is that it is cheap and can be given orally but, is not licensed. Maintenance tocolysis is not recommened.
Administration of antibiotics prophylactically in PPROM delays the birth and reduces the risk of both maternal and neonatal infections but does not seem to reduce perinatal mortality. According to the ORACLE trial, Erythromycin is superior to Co-amoxiclav(Augmentin) as there is a statistically significant increase in neonatal necrotising enterocolitis. Erythromycin 500mg Qid for 10days is the recommened regime.
The woman should be kept admitted and monitored 4th with temp, PR , BP and daily CTG and twice weekly scans for the fetal well being and liquor volume.
If the contractions increase and she sets into labour, vaginal delivery should be preferred to operative delivery but, caesarean section may have to considered in the presence of chorioamnionitis with delivery not being imminent or if there is breech presentation. The mother should involved in making decision regarding the mode of delivery keeping the risks of perinatal morbidity/mortality in mind. The baby should be handed over to the neonatal team immediately and the mother provided with support in caring for the preterm baby.
If the leakage subsides spontaneously with no uterine contractions , no evidence of infection and with a reassuring scan with good liquor volume, the woman can be discharged to continue Erythromycin for 10 days and come back if there is evidence of infection or any other concerns.
Posted by hassan M.
PPROM is associated with increased maternal and fetal morbidity and mortality .The aim of treatment is to prolong pregnancy and prevent risk to mother from chorioamninitus.By prolonging the pregnancy by one day the risk of fetal mortality is reduced by 2%.At 28 weeks fetal birth weight is about 1000gms and most of NICUs have fetal survival rate of 75%.Mother must be very anxious as this stage so attitude should be sympathetic and reassuring.
Her antenatal notes are reviewed regarding recurrent UTIs,BV. gestational diabetes,polyhydramnios,multiple pregnancy and Rh status as it may give us an indication about the cause of premature rupture of membranes. Patient should be admitted to labour room for initial investigations and management .On admission pulse and temperature is taken to check for fever and tachycardia.Abdominal examination is carried out to exclude tenderness and assess fundal height and presentation. Fetal heart is heared with doptone to confirm viability.Sterile speculam examination is carried out to check for amount and colour of liquor and to exclude cord prolapse. High vaginal swabs can be collected at the same time.Initial vaginal examination should be carried out carefully and gently to exclude cord and to check for effacement , dilatation and presentation.Repeated vaginal examinations should be avoided as it may introduce infections.USS is done to estimate fetal birth weight ,presentation,lie , AFI and for placental localisation.BPP should be carried out.FBC is done to check for WBC and differential count,MSU is done to exclude UTI and CRP to check for presence of acute infections .Antibiotics ie erythromycine Its should be given 500mg qid Iv to prevent fetal morbidity associated with chorioamninitus Its efficacy has been proved by ORACLE study. CTG monitering is started to for fetal surveillance .If chorioamnionitus is detected arrangement should be made for immediate delivery,though steroids can be given but delivery should not be delayed to give it time to work...NICU should be informed to make sure about the availability of cots and if NICU facility is not available patient should be transferred to a tertiary center.
If patient is in labour in the absence of chorioamnionitus Betamethasone is given 12 mg 12 hourly for 24 hours to reduce the risk of ARDS,IVH and NEC.
Tocolytics in the form of atosiban can be given .Atosiban is expensibe but has better side effect profile compaired to riterodine which is associated with palpitation ,headache and pulmonary odema.It is given to achive time for steroids to work but are contraindicated if there is any sign of infection in that case it is better to deliver the baby .Mode of delivery in these cases is by LSCS and may need a classical lscs by a senior obstetrician due to malpresentation and oligohydramnios..Snr Neonatologist should be informed and should have a prior discussion with parents about the risks and out come of premature baby.Delivery should be attended by neonatologist.If parents refuse LSCS or patient is in advanced labour vaginal delivery may be allowed There is risk of PPH and endometritus during post natal period .
If mother is not in active labour and no sign of chorioamnionitus she should be managed conservatively by checking temperature and pulse 4 hourly,FBC,CRP alternate day &HVS weekly .If UTI or BV is detected should be treated with antibiotic according to sensitivity.Abdominal palpation is carried out daily to check for tenderness and inquire about the colour and smell of liquor and if there are sign of infection arrange for delivery.USS should be carried out weekly to assess liquor volume and BPP .If patient has prolong leaking with out chorioamninitus baby may develop structurel deformities and parents should be informed about it .Amninfusion has not proved to be benefiscial and may introduce infections instead.There are chances of subclinical chorioamnionitus as well and baby will need need NICU for a long period of time .Parents should be given a chance to visit NICU prior to delivey to have an idea about what to expect once baby is born .
Posted by Farzana N.
Rupture of membranes at 28 weeks of carries risks both to mother and fetus. Fetal risks include mainly prematurity (80% chance of delivery within seven days), choriamnionitis and fetal infections. Mother is also at risk of serious systemic infection.
Management of this case would aim at prolonging pregnancy to reduce the morbidity and mortality associated with prematurity, reducing the risk of infection by identifying infection as early as possible and its treatment.
Parents should be counseled at each stage regarding treatment, mode of delivery and SCBU facilities, jointly with neonatologist .Patient should be advised admission and in ?patient treatment.
History is taken regarding the duration, amount and color of liquor, any offensive smell.Meconium stained liquor will indicate a compromised fetus and prompt active management with continuous fetal monitoring. Antenatal records are checked for parity and mode of previous deliveries, any pre existing medical illnesses, such as diabetes, hyperthyroidism, anemia or heart disease. These would influence the use of beta mimetics for tocolyis.USG is checked for assessment of gestational age, presentation, congenital anomalies or IUGR.H/o contractions will indicate that she may be in labor.
General examination ?pulse and temperature noted which is raised in infection. Abdominal ex- for the size of uterus, lie and presentation, any abdominal tenderness and palpable contractions are noted to see if she is in labor.CTG should be done to detect any early fetal compromise.
Vaginal examination is avoided to prevent infection. Speculum examination is done to confirm leaking and note color of liquor. If cx is not visualized, vaginal examination may be required to check cervical dilatation.
Investigations will include FBC and CRP .some leucocytosis is normal in pregnancy, but CRP is more sensitive at detecting early infection.HVS should be taken to detect vaginal infection that may be a cause of PPROM.An USG is arranged to note presentation as malpresentation is common at this stage, with increased risk of cord prolapse.
Tocolysis is given to stop premature contraction.Although tocolysis dos not reduce fetal mortality and morbidity ,it is helpful in prolonging delivery for up to 48hrs until SCBU is arranged or in utero transfer is arranged to a tertiary centre.This gives time for .Dexamathasone to take effect. It is given in two divided doses to promote lung maturity,. according to recommendations by RCOG.It helps in reducing the incidence of RDS, IVH and NEC and duration and cost of NICU.IF the patient does not deliver in one week, multiple doses of steroid injection is a controversial issue.
Prophylactic antibiotics should be given.Erythromycin is more effective than Augmentin ,as there is reduced risk of NEC. According to ORACLE trial this helps in prevention of infection and also delivery time.
Patient should be counseled about the mode of delivery. She should be reassured that chances of survival at this stage are as high as 90%.She may go in spontaneous preterm labour.Immediate delivery should be arranged in case of signs of chorioamnionitis or any malpresentations.Ceasarian section poses problem during delivery, hence a senior obstetrician should be involved. Neonatologist should be actively involved during delivery.
If there are no signs of infection patient can b managed expectantly and delivery can be planned at 34-36wks.Patient should be closely monitored during this period for any signs of infection.Temp, pulse and uterine contractions and liquor loss is checked daily.CTG is done daily.FBC andCRP is done 2-3times /wk.Serial growth scan should be done /2wks as abdominal examination only may not be accurate.
Patient should also be counseled that risk of recurrence of PPROM is as high as 20-30%
in future pregnancies.
Posted by Rani M.
Premature rupture of membrane(PROM) preceeds 30-40% of preterm deliveries and may be associated with clinical or subclinical choriomanionitis. PROM and preterm births are significant cause of perinatal mortality and morbidity( CESDI)

History is taken from this woman regarding duration of leaking, associated labour pains,symptoms suggestive of choriomanionitis such as fever, foulsmelling discharge as these will influence the management.
She is enquired regarding symptoms suggestive of UTI , and bacterial vaginosis as infections are most common cause of PROM.
Past obstetric history of preterm labour, history of GBS neonatal sepsis in previous offspring is taken.

She is examined for obvious signs of chorioamnionitis such as fever, tachycardia, abdominal tenderness or foul smelling liquor though these features may be absent in subclinical chorioamnionitis.
Per abdominal examination is done to look for fetal lie, presentation, fetal heart, CTG and contractions which may suggest preterm labour.
Per speculum examination is essential to look for colour of liquor, foul smell and obvious cervical dilatation. Vaginal examination is avoided unless there are contraction or obvious cervical change on speculum examination. Repeated vaginal examination should be avoided and must be undertaken with full aseptic precautions in order to minimise introducing infection.

Full blood counts are done as leucocytosis may suggest subclinical chorioamnionitis. C.R.P. is done but both CRP and leucocytosis should be interpreted with keeping in mind physiologically raised levels in pregnancy.Rising levels or very high levels are significant.
High vaginal swab for bacterial vaginosis which is an important cause of PROM and preterm labour. low vaginal & urethral swabs for Group B streptococcus are taken.
as treatment of this will improve the prognosis for baby.
Mid stream sample of urine for UTI or asymptomatic bacteruria should be done as they are common cause of preterm labour.

Her further management will be dictated by the clinical and investigation findings. There is a place for domiciliary mangement if there is no signs and symptoms of chorioamnionitis , if she is not in labour and fetal condition is good, and if woman desires so. But she should be instructed not to have sex, and to report early in case of problems and frequent visits to day care unit are required.Otherwise hospital admission is a better option for 48-72 hours.

Oral erythromycin is started as there is evidence, its use is associated with significant reduction in neonatal surfactant requirement, babies requiring 21% oxygen, neonatal positive blood cultures and it prolong pregnancy by 48 hours ( ORACLE Trial )Co amoxiclav though has similar advantage has been seen to be associated with higher incidence of necrotising enterocolitis, so it is not prescribed.

If there are contractions tocolysis is given in the abscence of contraindication ( chorioamnionitis ), to prolong preganancy till the effect of antenatal corticosteroids take place or for in utero transfer of mother to a tertiary center with NICU facilities.Beta agonist such as ritodrine has been used traditionally but have significant maternal adverse effects and require careful monitoring. Nifedepine can be given orally and is associated with less adverse effects. Atosiban is another alternative with better side effect profile.

Corticosteroids are recommended and prescribed as there is evidence that there use leads to significant reduction in respiratory distress syndrome, neonatal death and intraventricular hemorrhage. Betamethasone is preferred over dexamethasone as has been associated with reduction in periventricular leucomalacia in neonates.There is no role of multiple and repeated doses of steroids. Optimum drug- delivery interval is 48 hours to 7 days after starting therapy.

If bacterial vaginosis is detcted , treated with oral clindamycin or metronidazole.Concurrent infections detected should be treated such as UTI, GBS ( intrapartum penicillin

An appointment must be arranged with paediatrician for couple to know neonatal implications, care requiered, admission in NICU.With good care at this gestaion neonatal survival of upto 80% is expected ( EPICURE )

If she develops signs & symptoms of chorioamnionitis pregnancy need to be terminated as risks of continuing preganancy then are more than benefits of prolonging preganancy. Usually labour ensures with in 7 days in 80 % of cases.

Cesarean section is not indicated unless for any other associated obstetric indicaion.there is no role of prophylactic instrumental delivery. Some advocate routine episiotomy but evidence is limited for this. peadiatrician must attend the delivery. there is no contraindication for epidural analgesia.
Recurrence risk is about 20- 30 %.
Posted by Shakira B.
Rupture of membranes at 28 weeks of carries risks both to mother and fetus. Fetal risks include mainly prematurity (80% chance of delivery within seven days), choriamnionitis and fetal infections. Mother is also at risk of serious systemic infection.
Management of this case would aim at prolonging pregnancy to reduce the morbidity and mortality associated with prematurity, reducing the risk of infection by identifying infection as early as possible and its treatment.
Parents should be counseled at each stage regarding treatment, mode of delivery and SCBU facilities, jointly with neonatologist .Patient should be advised admission and in ?patient treatment.
History is taken regarding the duration, amount and color of liquor, any offensive smell.Meconium stained liquor will indicate a compromised fetus and prompt active management with continuous fetal monitoring. Antenatal records are checked for parity and mode of previous deliveries, any pre existing medical illnesses, such as diabetes, hyperthyroidism, anemia or heart disease. These would influence the use of beta mimetics for tocolyis.USG is checked for assessment of gestational age, presentation, congenital anomalies or IUGR.H/o contractions will indicate that she may be in labor.
General examination ?pulse and temperature noted which is raised in infection. Abdominal ex- for the size of uterus, lie and presentation, any abdominal tenderness and palpable contractions are noted to see if she is in labor.CTG should be done to detect any early fetal compromise.
Vaginal examination is avoided to prevent infection. Speculum examination is done to confirm leaking and note color of liquor. If cx is not visualized, vaginal examination may be required to check cervical dilatation.
Investigations will include FBC and CRP .some leucocytosis is normal in pregnancy, but CRP is more sensitive at detecting early infection.HVS should be taken to detect vaginal infection that may be a cause of PPROM.An USG is arranged to note presentation as malpresentation is common at this stage, with increased risk of cord prolapse.
Tocolysis is given to stop premature contraction.Although tocolysis dos not reduce fetal mortality and morbidity ,it is helpful in prolonging delivery for up to 48hrs until SCBU is arranged or in utero transfer is arranged to a tertiary centre.This gives time for .Dexamathasone to take effect. It is given in two divided doses to promote lung maturity,. according to recommendations by RCOG.It helps in reducing the incidence of RDS, IVH and NEC and duration and cost of NICU.IF the patient does not deliver in one week, multiple doses of steroid injection is a controversial issue.
Prophylactic antibiotics should be given.Erythromycin is more effective than Augmentin ,as there is reduced risk of NEC. According to ORACLE trial this helps in prevention of infection and also delivery time.
Patient should be counseled about the mode of delivery. She should be reassured that chances of survival at this stage are as high as 90%.She may go in spontaneous preterm labour.Immediate delivery should be arranged in case of signs of chorioamnionitis or any malpresentations.Ceasarian section poses problem during delivery, hence a senior obstetrician should be involved. Neonatologist should be actively involved during delivery.
If there are no signs of infection patient can b managed expectantly and delivery can be planned at 34-36wks.Patient should be closely monitored during this period for any signs of infection.Temp, pulse and uterine contractions and liquor loss is checked daily.CTG is done daily.FBC andCRP is done 2-3times /wk.Serial growth scan should be done /2wks as abdominal examination only may not be accurate.
Patient should also be counseled that risk of recurrence of PPROM is as high as 20-30%
in future pregnancies.
Posted by Shakira B.
Rupture of membranes at 28 weeks of carries risks both to mother and fetus. Fetal risks include mainly prematurity (80% chance of delivery within seven days), choriamnionitis and fetal infections. Mother is also at risk of serious systemic infection.
Management of this case would aim at prolonging pregnancy to reduce the morbidity and mortality associated with prematurity, reducing the risk of infection by identifying infection as early as possible and its treatment.
Parents should be counseled at each stage regarding treatment, mode of delivery and SCBU facilities, jointly with neonatologist .Patient should be advised admission and in ?patient treatment.
History is taken regarding the duration, amount and color of liquor, any offensive smell.Meconium stained liquor will indicate a compromised fetus and prompt active management with continuous fetal monitoring. Antenatal records are checked for parity and mode of previous deliveries, any pre existing medical illnesses, such as diabetes, hyperthyroidism, anemia or heart disease. These would influence the use of beta mimetics for tocolyis.USG is checked for assessment of gestational age, presentation, congenital anomalies or IUGR.H/o contractions will indicate that she may be in labor.
General examination ?pulse and temperature noted which is raised in infection. Abdominal ex- for the size of uterus, lie and presentation, any abdominal tenderness and palpable contractions are noted to see if she is in labor.CTG should be done to detect any early fetal compromise.
Vaginal examination is avoided to prevent infection. Speculum examination is done to confirm leaking and note color of liquor. If cx is not visualized, vaginal examination may be required to check cervical dilatation.
Investigations will include FBC and CRP .some leucocytosis is normal in pregnancy, but CRP is more sensitive at detecting early infection.HVS should be taken to detect vaginal infection that may be a cause of PPROM.An USG is arranged to note presentation as malpresentation is common at this stage, with increased risk of cord prolapse.
Tocolysis is given to stop premature contraction.Although tocolysis dos not reduce fetal mortality and morbidity ,it is helpful in prolonging delivery for up to 48hrs until SCBU is arranged or in utero transfer is arranged to a tertiary centre.This gives time for .Dexamathasone to take effect. It is given in two divided doses to promote lung maturity,. according to recommendations by RCOG.It helps in reducing the incidence of RDS, IVH and NEC and duration and cost of NICU.IF the patient does not deliver in one week, multiple doses of steroid injection is a controversial issue.
Prophylactic antibiotics should be given.Erythromycin is more effective than Augmentin ,as there is reduced risk of NEC. According to ORACLE trial this helps in prevention of infection and also delivery time.
Patient should be counseled about the mode of delivery. She should be reassured that chances of survival at this stage are as high as 90%.She may go in spontaneous preterm labour.Immediate delivery should be arranged in case of signs of chorioamnionitis or any malpresentations.Ceasarian section poses problem during delivery, hence a senior obstetrician should be involved. Neonatologist should be actively involved during delivery.
If there are no signs of infection patient can b managed expectantly and delivery can be planned at 34-36wks.Patient should be closely monitored during this period for any signs of infection.Temp, pulse and uterine contractions and liquor loss is checked daily.CTG is done daily.FBC andCRP is done 2-3times /wk.Serial growth scan should be done /2wks as abdominal examination only may not be accurate.
Patient should also be counseled that risk of recurrence of PPROM is as high as 20-30%
in future pregnancies.