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Forum >> Essay 245 - PPROM
Posted by Malar R.
Thu Aug 9, 2007 12:20 pm
A healthy 30 year old primigravida is referred with suspected ruptured membranes at 26 weeks gestation. (a) Justify your initial clinical assessment [5 marks]. (b) You confirm spontaneous rupture of the membranes. What will you tell her about the risks to her fetus? [5 marks]. (c ) Justify your subsequent investigations [5 marks]. (d) Evaluate the antenatal treatments aimed at optimising perinatal outcome [5 marks].

Assessment should start with history to check for symptoms,timing of onset , precipitating factors, fetal movements, colour of vaginal loss,dysuria and any abdominal pains.This may give an indication of the likelihood of ruptured membranes, any accompanying infections and uterine activity.

Her pulse and temperature should be checked.This may indicate an infection.She should be examined generally to see if she is flushed, which may be a sign of infection or preterm labour. Her abdomen should be examined to check for liquor volume clinically.Uterine activity and tenderness should be assesses to exclude preterm labour and infections.

The vulva must be inspected for urinary incontinence which may be misinterpreted as liquor loss.Speculum vaginal examination may confirm ruptured menbranes and show cervical dilatation.

She should be infomed about the risk of preterm labour which can follow ruptured membranes. The baby will therefore be premature and need admission to special care baby unit for support with breathing, feeding and temperature control.
There is also a risk of infections in the uterus affecting the baby with expectant management hence she will be closely monitored.
She will also be counselled about risk of breathing difficulties which may arise as a consequence of poor lung development due to lack of liquor.This may require the baby to have respiratory support after delivery.
There is also a risk of talipes due to flexion deformities due to lack of liquor.

Investigations should include an infection screen to detect preexisting infections which may have caused the ruptured menebranes.This consists of WCC,CRP,high vaginal swab,urine dipstick, microscopy and mid stream urine for culture and sensitivity.
A CTG can be attempted to check for fetal well being but this may be difficult at this gestation.An USS should be done to check for fetal growth, assess liquor volume and confirm presentation.USS should also exclude any structural abnormalities which may not have been seen on the anomaly scan.Umbilical artery dopplers may also be performed to assess fetal wellbeing.

Steroids are available to promote fetal lung maturity.They also reduce the risk of intraventricular haemorrhage and reduce perinatal mortality.They are safe if given as one course and do not cause maternal morbidity.

Erythromycin is normally given for 10-14 days after preterm ruptured membranes. It reduces morbidity and mortality due to Group B strep sepsis.It is well tolerated and has minimal side effects in the mother.

Delivery is indicated in cases of suspected chorioamnionitis to reduce perinatal mortality and morbidity. However delivery may increase the risk of operative delivery and maternal endometritis and sepsis.
Posted by Valerie T.
Thu Aug 9, 2007 11:32 pm
A healthy 30 year old primigravida is referred with suspected ruptured membranes at 26 weeks gestation. (a) Justify your initial clinical assessment [5 marks]. (b) You confirm spontaneous rupture of the membranes. What will you tell her about the risks to her fetus? [5 marks]. (c ) Justify your subsequent investigations [5 marks]. (d) Evaluate the antenatal treatments aimed at optimising perinatal outcome [5 marks].

a) An obstetric history should be taken to identify previous miscarriages or pregnancies with preterm rupture membranes or preterm labour. These women would be agreater risk of develping preterm labour. A clear history is required to determine the time that the ruptured membranes occurred, the presence of contractions and fetal movements. Vital signs should be taken. The temperature is most important in this situation to determine whether there is chorioamnionitis. Abdominal examination must include palpation for contractions and fetal presentation. Palpations would suggest threatened preterm labour. Fetal presentation is important should theis lady develop preterm labour. A speculum examination must be done in an attempt to visualise and confirm ruptured membranes. The speculum examination will also enable us to visualise the cervix and to assess whether the cervix was dilated or closed. A dilated cervix and contractions would indicate preterm labour. Speculum examination will also give us the opportunity to screen for infection with the high vaginal swab.

b) I will tell her that preterm rupture membranes could lead to chorioamniontis which is an infection in the amniotic fluid. The fetus would be at risk of developing fetal distress or neonatal sepsis. If she developed spontaneous labour at 26 weeks this would be preterm labour and the baby would be at risk of respiratory distress syndrome. The fetus will also be at risk of hypoxic encephalopathy, hypothermia and hypoglycemia.

c) Full blood count and CRP must be done. This will provide baseline investigations to screen for infection. This values can be compared to future blood results to determine whether an infection is beginning or progressing. A midstream urine specimen must be sent for microscopy, culture and sensitivity to determine if there was a urine infection. Untreated urinary tract infection may precipitate preterm rupture of membranes and preterm labour. A high vaginal swab should be sent to the lab for microscopy, culture and sensitivity. Infections such as bacterial vaginosis may precipitate preterm labour. An ultrasound scan should be done to assess the growth, liquor volume and dopplers. There may be fetal restriction or placental insufficiency that may lead to preterm labour. The liquor volume may be reduced because of the ruptured membranes. However, the value can be used to compare to future measurements, should she not develop preterm labour. Electronic fetal monitoring will be difficult because the fetus is only 26 weeks. However, intermittent monitoring with doptone should be done to indicate fetal wellbeing.

d) Erythromycin is an antibiotic that is given to reduce the risk of infection. They are effective when given for 10 days. If the high vaginal swab shows bacterial vaginosis, this infection should be treated with Metronidazole. Metronidazole is effective at treating bacterial vaginosis, which is associated with preterm labour. If the patient develops preterm labour, then Erythromycin should be changed to intravenous benzylpenicillin. Betametasone is a steroid that is administered by the intramuscularly. Only two doses are given, 12 - 24 hours apart. It is effective at maturing the fetal lungs and reduces the risk and severity of fetal distress. If contractions are palpated, you may consider tocolytics to suppress the contractions to allow the steroids to be administered. Tocolytics may be atosiban or nifedipine.
Posted by Saad A.
Fri Aug 10, 2007 12:21 pm
A detailed history is obtained from the patient including her LMP, menstrual irregularity, contraceptive measures she was using before pregnancy, to ascertain her gestational age . She will be asked about vaginal discharge, bleeding P/V, urinary complaints. Her previous obstetric history is obtained including H/o painless preterm labour in previous pregnancy,about parity, MOD and gestational age and weight of previous babies. She will also be enquired about H/O cone biopsy . Her current notes are reviewed to exclude polyhydroamnios, multiple pregnancy, diabetes mellitus and APH as these are the risk factors for pre-term labour. Her BMI,BP,temperature and pulse are checked to asses her general status and to exclude chorioamnionitis. Abdominal examination is carried out to assess palpable contractions and assess size and weight of the foetus. Speculum examination is carried out to find whether membranes are ruptured or not and is done to see colour of liquor present and exclude any vaginal discharge/bleeding and also to asses cervical dilation as cervical examination will not be needed if os is closed.
b. If the membranes are ruptured then I will tell her that there is increased risk of pre-term labour and prematurity in the foetus.Due to ruptured membranes the chances of development of chorioamnioitis is increased. There is increased risk of placental abruption and bleeding. There is increased risk of cord prolapse. Then I will explain to her that all these factors increase fetal distress and there will be need of regular foetal monitoring till delivery. Due to prematurity I will tell the patient that at this gestation the risk of RDS, Intracerebral haemmorhage and necrotising endocarditis is more as compared to term baby.So there is a need of prolongation of the pregnancy in order to prevent these complications and risks in the foetus .Written information and contact details are provided.
c.The investigations which are needed are HVS to exclude infection like bacterial vaginosis and also other microorganisms. Blood FBC,CRP and ESR is required to detect raised inflammatory indices which may indicate chorioamniotis though these are not specific . MSU is done to exclude UTI. U/E will be done to assess her hydration and renal status. Fetal assessment will require detailed USG to assess fetal well being by measuring size/weight of the foetus,by excluding fetal anamoly and about liquor amount(AFI) which can show oligo/anhydroamnios. There is need of continuing monitoring of FBC,CRP/ESR throughout the pregnancy .Foetal monitoring including serial growth scan ,doppler, CTG is required throughout pregnancy.
d. The antenatal treatment required depend on the severity of symptoms. There is a need of prolongation of pregnancy because there is increased risk of prematurity and its complications like RDS,necrotising endocarditis if foetus is delivered at this gestation.Multidiscilinary care including neonatoligist is required. Corticosteroids should be given to the patient for lung maturity in order to prevent RDS. SCBU should be informed. Antibiotics like erythromycin should be given as ORACLE trial has confirmed the efficacy of erythromycin as choice of antibiotic which not only prevent perinatal/postnatal but also prolong pregnancy and improve perinatal outcome. There is a need of serial growth scan +/- doppler and CTG , BPP for foetal well being throughout pregnancy. For meternal well being there is continous need of survelliance by FBC,CRP and ESR twice weekly .There is also need to monitor BP,temperature , pulse if outpatient by community midwife daily. Patient should be given education of signs and symptoms of PTL and advise of early reporting if these symptoms develop. Written information/contact details are provided. The patient will told about the need to prolong the labour till lung maturity and term. If maternal and foetal condition remain stable vaginal delivery will be aim and C-section needed only for obstetric indication.
Posted by Shahla  K.
Fri Aug 10, 2007 06:44 pm
a)History to cofirm weather it is premature rupture of membrane by asking questions . Was it sudden gush of water per vaginum followed by off and on dampness,?what is the duration?it is associating with colicy abdominal pain,or continuous pain.Enquiry about colour of water greenish (meconium),bloody(abruption),smelly (chorioamnitis)or it has any amonical smell(mistaking for incontinence).was there any history of trauma.history of smoking or alcohol.featal movement should be enquire.Her antenatal notes seen for any risk of PROM,like UTI,multiple gestation and polyhydramnios.
Examination include ,tachycardia ,temperature to exclude chorioamnitis Per abdominal examination for fundal height .position ,presentation of fetus.Presence of uterine contraction or tenderness should be noted.Faetal heart sound be auscultated
.Serile speculum examination for confirming presence of liquor from cervical os ,Presence of posterior vaginal pooling spontaneously or after fundal pressure noted.colour of liquor noted for meconium,blood or offensive smell.Absence of cord exclude cord prolapse.cervical dilatation noted. Digital examination if labour suspected but frequent digital examination should not be done as it cause ascending infection.

b)This women is anxious ,I will tell her sympathetically and in simple language, that the water bag which surround the fetus has been open,which will not close .I will assure her that it is not her fault,it happen in 2-3 % of pregnencies
.She may deliver before time spontaneously or may need induction for safty of mother and baby.
She need admission and delivery in a hospital where SCBU available for care of newborn .
Which will not be economical,Fetus and women are at risk of ascending infection.. cord prolapse or cord compression cause reduce oxygen supply to fetus.I Will tell her that she is at risk of sudden bleeding which compromise health of fetus.Survival at 26 wek is aroud 40-50%,those who survive are at risk of many health problem .they may have poor neurological development,lugs may not work well.and intestine of neonate become abnormal.
.Admission in SCBU for long time .
c)Baseline Full blood count for Hb ,WBC and platelet .C-reactive protein for infection screening.Urine for analysis and culture as UTI may be a cause ,High and low vaginal swab ,rectal swab ,urethral swab for bacteriological examination to screen bacterial vaginosis and GBS infection..
Ultrasound to see presentation position. Presence of fetal tachycardia or absent breathing movement are indication of of infectionI
If plan is conservative, then serial scan for fetal growth every 2 weekly needed.
WBC Count and C-reactive protein twice a week TO monitor for infection.
d)To improve perinatal outcome ,two doses of Betamethasone 12mg im given .it reduce incidence of respiratory distress syndrome,intraventricular haemorhage and necrotizing enterocolitis therby reduce hospital stay and reduce cost.its effect is best seen if delivery occur in 24 hour to 7 days of does not exacerbate infection at this dose. However Repeat dose should not be given .In multiple gestation it does not show its effect.
If she goes into labour then Tocolysis has to be given for short duration. Aim is to give time for steroid to work and in utero transfer to unit where SCBU available .Atociban is oxytocin receptor inhibitor is better then beta agonist for its unwanted effect profile.
Oral erythromycin is similar to amoxicillin in preventing fetal infection morbidity But peri ventricular leukomalacia is lower with erythromycin

Posted by Sabahat S.
Fri Aug 10, 2007 09:31 pm
a) History of duration of leaking, colour of discharge, any associated pain, fetal movements, any fever is taken. History of any urinary symptoms is important, as it could just be urinary leakage on straining. History of any previous / present vulval itching / unhealthy discharge is important.
Maternal pulse rate & temperature is checked. The fundal height and fetal heart activity is checked. By a sterile speculum, the cervix is examined & any evidence of leaking is noted. The colour, smell of liquor is noted which may indicate infection. Any other associated vaginal infections are noted & swab taken for culture. FBC, CRP and mid stream urine for microscopy & culture is sent. . Ultrasound to confirm gestational age, amount of liquor is done.
b) The patient should be told that the gestational age is very preterm & at the margin of viability. If the fetus remains in utero long term, with depleted liquor, it has the risk of developing lung hypoplasia, facial ( potters facies / flat facies) and postural defects. Amniotic bands may be formed which may result in auto limb amputation. There is a risk of intrauterine infection (chorioamnionitis) which will further increase the fetal morbidity & mortality.
If in case the fetus delivers it will be at the margins of viability & require prolonged NICU admission. I will tell her the department specific survival rate for this gestational age & that the baby will be at high risk of mortality and neuro developmental handicap, severe developmental problems, cerebral palsy.
c) Ultrasound will be done to confirm the gestational age, amount of liquor, any congenital anomalies. A reduced amount of liquor on scan confirms the diagnosis of PPROM. High vaginal swab is sent for culture.
Biophysical profile is unhelpful at this gestational age but presence of fetal breathing movements, indicates absence of infection. A twice-daily temperature chart is kept, to show any evidence of infection by rising temperature. FBC is repeated daily / twice weekly ? any increase in WBC indicates infection. PS examination is done every 1 ?2 weeks to send repeat swabs & check for any unhealthy or foul smelling discharge.
d) Erythromycin 250 mgm orally QID for 2 weeks helps in reducing the incidence of infection. Betamethasone IM 12 mgm 2 such doses at 24 hour interval helps in reducing morbidity from IUH, NEC, neonatal RDS & significantly reduced the length of NICU stay. Tocolysis ( nefidipine, atosibian ) may be used to complete the course of corticosteroids or to facilitate in ? utero transfer to a hospital suitably equipped to deal with such extreme preterm baby ? to optimize survival chances. Clindamycin is helpful in cases with bacterial vaginosis.Amnioinfusion has no role in the management of PPROM.

Posted by Natalie P C.
Fri Aug 10, 2007 09:32 pm
I would start with a clear history. After review of her antenatal notes I would clarify what exactly happened and assess if it is a convincing story of SROM example a large gush, liquid ran down legs or wet clothes as apposed to just feeling a bit wet, felt wet after bath or after passing urine though those cold still be SROM. I will look for other symptoms that may suggest a differential diagnosis like dysuria and frequency for a urinary tract infection. I would check to see if she is a group B streptococcus carrier or any other vaginal infections detected in pregnancy.

I would exam her. I would check her pulse, blood pressure and temperature for signs of sepsis (tachycardia, pyrexa) as she may already have a chorioamnionitis which is associated with preterm prelabour rupture of membranes (PPROM) and which will lead me to consider expediting delivery and which may be the cause of the PPROM.
Would palpate her abdomen looking for tenderness which may suggest chorioamninitis. I would then do a sterile speculum examination looking for evidence of PPROM. I would look for pooling of liquor in the posterior fornix and if not a cough may demonstrate loss of liquor form the cervix. If vernix is present this will help identify the fluid as liquor. I would look at the colour (clear, meconium, blood stained) as these can suggest the cause example preterm meconium in listeriosis or blood stained in an abruption. I would check the fetal heart rate as tachycardia may also suggest infection.

I will explain that the most immediate risk of that or preterm delivery and prematurity. I will request a Paediatrician to discuss further details of morbidity and mortality. I will explain that survival will depend on the gestation but also any associated morbidities. Survival is 70-80% but there is increased risk of morbidity which can be neurological, physical or respiratory. I will explain that there is risk of respiratory distress syndrome in premature infant requiring assistance with ventilation and oxygenation.

I will explain that there is a risk of ascending infection already present (even if asymptomatic) or developing causing sepsis in the baby.premature babies also have a risk of necrotising enterocolitis which can furthr decrease survival and which will delay feeding.

Longer term risks if the pregnancy continues will be fetal growth restriction and lung hypoplasia and limb contractures which are related to the degree of oligohydramnios.

The main intent of investigation is to assess fetal ad maternal well being to decide when to intervene and induce labour. I would admit at least for the first 3 days as this is when there is the greatest risk of spontaneous labour and allows time to start therapy to improve outcome. I would do a twice daily temperature charting to detect sepsis if it develops. Full blood count looking specifically at the white cell count and CRP which will also help detect chorioamnionitis will be done weekly. Vaginal swabs weekly will detect if there is a vaginal infection.

Weekly ultrasound scan will monitor liquor volume as anhydramnios has a worse prognosis. Every 2nd scan will also be used to assess fetal growth (2 weekly) as subclinical infection can cause fetal growth restriction. CTG will be done twice weekly.

The woman will be advised ad given a written information leaflet about signs to look out for like offensive discharge and abdominal pain.

Corticosteroid injection (usually betamethasone 12 mg im every 24 hr for 2 days) has been shown to reduce the incidence of RDS, intraventricular haemorrhage, neonatal death and necrotising enterocolitis. RDS is decreased significantly at gestations below 34 weeks (OR 0.36) with the number needed to treat to prevent 1 case of RDS of 5.

Erythromycin was shown in the ORACLE study to prolong pregnancy in cases of PPROM. This was equally efficacious to co-amoxiclav but without the increased risk of necrotising enterocolitic seen with co-amoxiclav. There is also a significant reduction in fetal infection and abnormal cranial ultrasound scans.

Tocolytics are only recommended for use when arranging in utero transfer for an infant as when labour starts there is a high incidence of infection present and mortality is not redced by delaying labour in these cases.
Posted by Zarkoth A.
Sat Aug 11, 2007 01:42 pm
a) PPROM at 26/40 is associated with increased fetal/neonatal morbidity and mortality. I would start by taking a thorough history to assess the nature of PV loss (?clear fluid,?urine / trickling or \'gush\') and any signs of infection. I would also check antenatal notes for any predisposing factors (like Hx of BV). I would then proceed to examination; first by checking maternal temperature and pulse and then by assessing the abdomen (?tender, fundal height, presentation). A portable scan would give more information about liquor volume and presentation. I would then proceed to a sterile speculum examination (and not VE in order to avoid introducing infection) following bed rest for 1-2h; I would look for a pool of liquor in the vagina and also assess cervical effacement and dilatation (triple swabs would also need to be performed to check for infection). If speculum examination is inconclusive, a fibronectin swab might help as it has a very high negative predictive value.
b) I would explain that there is a risk that she would go into preterm labour in the next few days. At 26/40, the risk of prematurity is a severe one as it is associated with neonatal morbidity and mortality. The main concern is the immaturity of the fetal lungs and their inability to function effectively once baby is born. There is also a risk of ascending infection which would increase morbidity. The increased incidence of intracranial haemorrhage and stay in SCBU should also be mentioned and a neonatologist should discuss those issues with the patient in more detail.
c) After taking vaginal swabs (as mentioned above), I would check maternal temperature and pulse every 4 hours initially to detect any signs of infection. I would also perform FBC and CRP for the same reason. A urine dipstick and MSU would help confirm/rule out the possibility of UTI (predisposing factor of PPROM/preterm labour). A departmental scan would also be useful in order to assess growth and liquor volume and look for any congenital anomalies (since they are associated with PPROM). I would then enquire about the availability of cots in the SCBU and consider intrauterine transfer is that was not the case.
d) Steroids (betamethasone 12mg IM 24h apart) have been shown to reduce respiratory distress syndrome, intracranial haemorrhage and stay in SCBU. Erythromycin 250mg po for 10 days (or until delivery) should be given as according to the ORACLE trial they decrease the incidence of infections and reduce neonatal morbidity and mortality. Tocolysis can be considered in the case of intrauterine transfer or if contractions commence; they have not been shown to alter fetal outcome, but they do prolong gestation and may be useful in order to give time for steroids to work. Amnioinfusion has been used in research context only to decrease morbidity from the respiratory and musculoskeletal system.
Posted by Mohammad H.
Sat Aug 11, 2007 11:28 pm
healthy 30 year old primigravida is referred with

suspected ruptured membranes at 26 weeks gestation. (a)

Justify your initial clinical assessment [5 marks]. (b)

You confirm spontaneous rupture of the membranes. What

will you tell her about the risks to her fetus? [5 marks].

(c ) Justify your subsequent investigations [5 marks]. (d)

Evaluate the antenatal treatments aimed at optimising

perinatal outcome [5 marks].

a-Iwill ask about her symptopms and its duration and if there is uterine contractions , blood stained vaginal discharge as the patient may be in preterm delivery (PTD). The presence of fever ,abdominal tenderness or loss of fetal movement increeas the suseptibility of chorioamnionitis.
Temprature may be elevated in cases of chorioamnionitis.
Speculum examination to detect the flow of amniotic fluid with nitrazine paper test if in doubt.Vaginal swabs may be needed for culture .

b-I will tell her that her fetus is at increased risk of pre-term delivery that can be spontaneous or induced if maternal or fetal complications occured. The fetus is at increased risk of respiratory distress and this can be reduced with the use of antenatal corticosteroids.There is also increased risk of intrauterine growth
restriction(IUGR) so, serial growth scans are needed and there is increased risk of intrauterine fetal death(IUFD).

c-Follow up of the patient\'s temprature ,abdominal tenderness ,fetal movement and foul vaginal discharge to
detect chorioamninitis and uterine contractions for PTD.
Serial Blood tests including FBC &CRP as WBCs and CRP may be elevated in cases of chorioamnionitis.
Serial growth scans to assess fetal growth.Assessment of fetal well being using Doppler umblical studis .Biophysical profile is not of value if amniotic fluid is one of the parametres used as it is already reduced but other parameters can be of value .

d- Prophylactic antibiotics with erythromycin being drug of choice & treatment of vaginal of infection as this will reduce the risk of PTD.
Corticosteroids antenataly as it reduces RDS ,ventricular
haemorhage and perinatal mortality.

amnioinfusion injection of saline in the amniotic sac will increase the fluid around the fetus.
Follow up for symptoms & signs of chorioamnionitis,fetal distress and PTD.
Induction of labour in cases of chorioamnionitis &fetal distress.
Provide information leaflets .

Posted by Mahmud  K.
Sun Aug 12, 2007 12:59 am
History of sudden gush of fluid followed by leaking of liquor may indicate spontaneous rupture of membrane. The potential duration of PROM and the events surrounding this {eg. abdominal pain, uterine contraction,)also give important clue for prediction of complications of PROM .Review her note for history of B streptococcus infection. Woman should be examined for sign?s of chorioamnionitis . These are pyrexia (above 37.8 C), tachycardia, abdominal palpation for uterine tenderness , uterine contraction , offensive vaginal discharge. Sterile speculum examination should be considered. Pooling of liquor in the posterior vaginal fornix or dribbling of liquor from cervical os spontaneously or on stress (cough) confirm PROM. Colour of liquor ( blood stained or meconium) ,cervical dilation should be noted. As digital vaginal examination prone to cause ascending infection to the mother and foetus , it should be avoided in suspected PROM. Monitoring of foetal heart by cardiotocograph may helpful to exclude foetal tachycardia

As 26 weeks gestation she should be advised regarding the potential fetal risks relate to prematurity , choriamnionitis and pulmonary hypoplasia. Foetal pulmonary hypoplasia leading to respiratory distress syndrome .This risk is highest in preterm delivery before 30 weeks. Foetal brain is especially susectable to injury between 20 and 32 weeks post conception. Therefore her foetus may have higher risk of cerebral damage like periventricular haemorrhage ,post haemorrhagic hydrocephalus. In utero foetal infection may lead to sepsis and increase mobidity and mortality. Less liquor volume may increase risk of postural deformity of foetus.

High vaginal swab for culture sensitivity should be considered. It is useful in determining causative organism once chorioamnionitis develops and in directing antibiotic therapy for mother and the preterm neonate. Full blood count and C-reactive should be sent because leucocytosis and raised C-reactive protein may indicate infection. Mid stream urine should be sent for culture sensitivity .Asymptomatic B streptococcus urine infection or infection by other pathogens may precipitate preterm labour . Ultrasonogram for liquor volume , foetal growth may helpful for further management. If IUGR suspected Doppler of umbilical artery may suggested.
Erythromycin should be given for 10 days following diagnosis of PROM. Co-amoxiclav is not recommended for women with PROM because concerns about necrotizing enterocolitis .Treatment of bacterial vaginosis with metronidazole or clindamycin and of beta haemolytic streptococcus with penicillin is beneficial .Antibiotic treatment helps in increasing the interval to delivery and decreasing the risk of infection .However there is no evidence to date that their use improves neonatal outcome. Antenatal coticosteroids should be administered to induce fetal lung maturation .The data on repeated use of corticosteroids are controversial. Prophylactic tocolysis in women with PROM without uterine activity is not recommended. Women with PROM and uterine activity who require in-utero transfer or antenatal corticosteroids should be consider for tocolysis. At present there is insufficient evidence for to recommend amnioinfusion for prevention of pulmonary hypoplasia.
Posted by Idris O.
Sun Aug 12, 2007 01:14 pm
I submitted my answer yesterday night but can\'t find it. I\'m sending another one now.

a) My initial assessment would include history of sudden leakage of clear fluid per vaginam which stains the underwear is suggestive of PROM. I would need to exclude leucorrhoea of pregnancy and urinary incontinence. I would examine the patient looking for pyrexia which may suggest chorioamnionitis, uterine contractions which may suggest preterm labour. I would assess the fetal heart for fetal wellbeing. Her speculum examination showing a pool of clear fluid in the posterior vaginal fornix or demonstrated on coughing or on fundal pressure confirms PROM. In doubtful cases, positive ferning test or the finding of fetal fibronectin in the fluid confirms the diagnosis. Nitrazine PH test may also be used but less sensitive.

b) I would inform her the risk to the fetus include prematurity from preterm labour. At this stage of pregnancy, the chances of fetal survival is up to 83% and long term morbidity is found in about 15%( best discussed by the paediatrician). Another risk to the fetus is fetal infection from chorioamnionitis. This increases the mortality by 4x. Others include pulmonary hypoplasia from oligohydramnios, chronic lung disease, respiratory distress syndrome, intraventricular hemorrhage and periventricular leucomalacia. Overall there is an increase in perinatal mortality and morbidity.

c) Her investigations would include FBC, WCC and CRP and this would be repeated twice weekly. Serial rise in WCC and CRP suggest intrauterine infection more than a single reading. I would obtain Hvs for m/c/s and this would be repeated weekly. The finding of GBS would inform the use of antibiotic prophylaxis in labour but Hvs is not very sensitive in diagnosing intrauterine infection. I would perform CTG daily and the finding of fetal tachycardia is a late signof intrauterine infection. I would perform a msu to exclude UTI which may cause preterm labour. I would arrange for an USS assessment of liquor volume once weekly and growth scan forthnightly including EFW. I would also arrange for a twice weekly biophysical profile and doppler of the umbilical artery. This has a sensitivity of up to 80% in diagnosing intrauterine infection with a false positive rate of about 10%. Obtaining amniotic fluid for gram stain and culture is the goal standard in diagnosing intrauterine infection but this is only performed in specialised units.

d) The aim of antenatal treatment of PROM is to delay delivery untill about 34 weeks GA if there is no evidence of fetal distress or chorioamninitis. This is to improve fetal survival and reduce the perinatal mortality and morbidity associated with PROM.
Two doses of betamethasone are usually administered to promote fetal lung maturation. This has being shown to be cost effective and is associated with a reduction in the risk of RDS,IVH and NEC. It is associated with a reduction in admission to NICU.
The oracle trial showed that when erythromycin (not co amoxiclav) is administered for about 10 days after PROM, it reduces the risk of choriamnionitis and fetal infection. It is also associated with an increase in the latency period from about 48h to up to 7days. Tocolysis is not usually used in PROM except to allow for administration of steroids if there is uterine contractions or in utero transfer to a tertiary centre with neonatal care facilities. The use of amnioinfusion or fibin glue to prevent pulmonary hypoplasia is not effective and is not recommended.
Posted by Jancy V.
Sun Aug 12, 2007 09:31 pm

(a) I would ask her the duration of leaking, whether associated with labour pains or not, because PPROM is commonly associated with preterm labour. I would ask her if she had fever, foul smelling discharge, malaise to rule out symptoms of infection and chorioamnionitis. I would ask her menstrual history for confirming gestational age and go through her antenatal records to confirm dates and anomaly scan. I would examine the pulse , BP , temperature as tachycardia and pyrexia indicates chorioamnionitis. Abdominal examination for fundal height , presentation and to assess if there are contractions. Sterile speculum examination to confirm leaking and to visualize the cervix to know if she is in active labour. Digital examination is better avoided , but may be needed is cervix is not visualized. I would do an ultrasound to assess fetal biometry, liquor volume and presentation of the fetus. CTG may be unreliable at this gestational age.
(b) I would inform her that the condition carries a risk of preterm labour (80% get into labour in 7 days after PPROM) and preterm delivery. I will quote the statistics from our neonatal unit to get a realistic picture of what to expect about fetal survival at this early gestational age and use multidisciplinary counseling involving the neonatologist and specialist nurse. The preterm neonate carries a high risk of respiratory distress syndrome due to lack of surfactant in the alveoli. Preterem babies are also at risk of necrotizing enterocolitis, intraventricular hemorrhage and retrolental fibroplasia. Long term effects include poor brain development and risk of permanent neurological sequalae. Even if she doesn?t get into labour, PPROM predisposes to ascending infection leading to chorioamnionitis which also leads to fetal morbidity. Preterm babies need to be in special care unit for several days and have poor feeding and high risk of infections. I will supplement the information with leaflets, arrange for contact with supprt groups of parents of preterm infants.
(c) I would do full blood count as leucocytosis is an indicator for infection and chorioamnionitis. I would do serum C reactive protein which also indicates infection. CRP is more sensitive than WBC in chorioamnionitis but both the tests are non specific and should be weighed along with clinical signs. I would do a high vaginal swab for culture and sensitivity and midstream urine culture , as infection is the most common casue of PPROM. I would do a detailed ultrasound scan for fetal assessment, biometry , liquor volume, presentation. CTG may be unreliable at this gestational age. If the patient is for conservative management, the FBC and CRP should be repeated at regular intervals.
(d) The patient should be admitted as inpatient. If there are no signs of chorioamnionitis and she is not in active labour, corticosteroids should be given for fetal lung maturity , 2 doses, 24 hour apart. It considerably reduces the incidence of RDS in babies after 24 hrs to 7 days and shortens NICU stay and saves cost. If there is evidence of preterm labour, tocolytics are given to buy time for action of steroids and to transfer the fetus in utero to a tertiary neonatal center if needed. She should be started on erythromycin 500 mg QID , as it reduces the incidence of infections without adverse effect on the fetus. If vaginal swab culture shows infecton, antibiotics should be given accordingly.
Posted by Natalia  N.
Mon Aug 13, 2007 03:21 am
A. I will start my clinical assessment with taking the history, and clarifying what has exactly happenned. If will ask if she had a big gush of fluid or if it has been leaking small amount of fluid. I will ask when she thinks she ruptured membranes, what color the fluid was, and if she had any asociated symptoms, e.g. abdominal pain, fever, urinary symptoms. I will enquire about fetal movements. I will also find out her antenatal history, and in particular if she had antenatal screening test of fetal anomalies. I will aslo enquire if she has recently had any infections or bacterial vaginosis. I will enquire about smoking, alcohol and illicit drug use as well as about her family situation and work.
I will perform clinical examination. I will check her temperature and heart rate, which could elevated in case of chorioamninitis. I will examine her abdomen to confirm gestation, fetal lie, and any tenderness, which is another sign of chorioamnionitis. I will then proceed to speculum examination to confirm RPOM, and check the color of amniotic fluid.

B. I will tell her that main risk to the baby is prematurity. Premature labour has more complication in comparison to labour in term. In particular, there is higher risk of cord prolapse, fetal distress, difficulties monitoring fetal heart during labour, malpresentations. About 75% of babies born at 26 weeks will survive. However, baby is at risk of infection, lung hypoplasia, respiratory distress syndrome, nectrotising enterocolitis, intraventricular heamorrhage, and have higher perinatal mortality and morbidity. I will explain that perinatal outcome will be better if delivers her baby in tertuary centre will neonatal intensive care unit. I will ask neonatologist to counsell her regarding perinatal outcomes as well. I will aslo provide her with written information.

C. I will perform FBC and CRP to monitor inflammatory response. WCC and CRP are not specific markers, but will help in early diagnosis of chorioamnionitis. These tests should be performed twice weekly if pregnance progresses. I will also take vaginal swab for microscopy, culture and sensitivity to exclude vaginal infection, especially bacterial vaginosis which is associated with PROM and GBS which is associated with increased rate of perinatal infections. I will also send midstream urine for microscopy, culture and sensitivity as UTI is also associated with PROM. I will also perform daily CTG to monitor fetal condition and to watch for early signs of chorioamnionitis (fetal tachycardia). I will perform fetal US to assure absense of fetal anomalies, check fetal growth, and uteroplacental function with Doppler studies.

D. Antenatal treatment should include steroids (dexametasone 12 mg, 2 doses 24 hours apart). Steroids decrease rate of RDS, necrotising enterocolitis. Repeated doses are not currently recommended. Tocolysis should be used with caution in cases of preterm rupture of membranes and only is infection has been excluded. Tocolysis can be used to allow transfer of woman to a hospital with neonatal intensive care unit, and to allow steroids cover. Tocolytics drugs have similar effecacy, but differ in side effects. Atosiban and nifedipine have less side effects than beta-mimetics. Prophylactic antibiotics should be used. Erythromycin has been shown (in ORACLE trial) to decrease clinical intrauterine infection and neonatal infection, and prolong pregnancy and has less side-effectes in comparison to amoxiclav, which increases rate of necrotising enterocolitis. Metronidazole should be given if bacterial vaginosis is diagnosed. Intrapartum IV antibiotics should be used for GBS prophylaxis and in suspected cases of chorioamnionitis to decrease neonatal infection and maternal infective complications (e.g. endometritis). Active management (IDL) has no advantages in cases of PPROM.
Posted by Parveen  Q.
Mon Aug 13, 2007 03:34 am
Preterm premature rupture of membranes are associated with increase maternal morbidity, perinatal morbidity and mortality.Clinical assessment begins with establishing the right diagnosis of PPROM, as leakage of urine is quite common in pregnancy.I will ask her about the duration of membrane rupture, if it was like a gush of water or just a trickle. i will also ask about the colour , and odour of the dishcarge and associated pain in the lower abdomen or back and bleeding pv if any. This will help to determine if there is evidence of chorioamnionitis, or abruption which are the complications of PPROM. Her gestational age will be confirmed from her early USS report, and review of her records for any evidence of infection in the past .I will her check her pulse, B.P, note down if there is tachycardia. abdominal examination for the fundal height, presenting part, and any signs of tenderness will be noted. ctg, though unreliable at this gestational age, will be done to know if FHS is there and for normal pattern. Sterile speculam examination to see if there is pooling of liquor in the vaginal fornix, and see if there is no prolapsed cord. Digital examination is avoided for fear of introducing infection. The discharge will be sent for culture and sensitivity, and endocervical and vaginal swab for clamydia, Group b hemolytic streptococcus and bacterial vaginosis.
(b)The risk to the foetus is mainly due to prematurity, either iatrogenic (if devlivered in the event of maternal or foetal compromise)or spontaneous delivery, sepsis, and pulmonary hypoplasia. I will tell her if baby is delivered at this time, it may need admission in the neonatal care unit, and need ventilatory support and surfactant therapy. If there is evidence of infection , needs iv antibiotics and monitoring. If associated with group b hemolytic streptococcus infection, there are early sequale of pneumonia , which can occur within 72hours and late infection in the form of meningitis which can occur upto 7days , so needs monitoring and appropriate anitibiotics. In the event of infection, with PPROM can lead to damge of the white matter of the brain, leading to cerebral palsy in 60 to 90% of affected infants. I will arrange for them to meet the paediatrician to explain the survival rate in the unit.
(c) Basic FBC , WBC, CRP , as raised wbc count and crp will point towards infection. USS for amount of liquor, biometry, and to rule out any congenital anamalies. Biophysical profile for foetal wellbeing, and doppler for evidence of any decreased or reversed enddiastolic flow and umblical artery doppler to see if there is increase sysolic ,diastolic ratio, as the later will be increased as markers for intrauterine infection. This will help in deciding the time of delivery , though frequent doppler and BPP donot improve the pregnancy outcome. MSU for culture and sensitivity. CTG can done daily , and if there is tachycardia , it will point towards infection. HVS repeated weekly and weekly full blood count can be considered. She is observed for clinical signs of chrioamnionitis at least 12hourly. Nitrazine test which detects the ph change is not necessary due to high false positive rate. recently tests like fibronectin and raised insulin like growth factor binding protein-1 in the cervical and vagial secretions show high ensitivity and specificity.
(d)The aim of the management is to prolong pregnancy in the absence of maternal or foetal infection. erythoromycin 250mg 6hourly given for 10days following the diagnosis. later, antibiotics changed as per the sensitivity report, if group b streptococcus is isolated, iv pencillin is given and clindamycin for those allergic to penicillin. If chrioamnionitis is suspected, broad spectrum antibiotic including an agent active against GBS should replace should replace GBS-specific antibiotic prophylaxis. steriods in the form of betamethsone given 12.5mgm 12hourly 2doses. It reduces the rate of RDS significantly, reduces neonatal death, intraventricular haemorrhage and neonatal enterocolitis, without increasing maternal or foeatl infection. The role of repeated steriod injection is controversial. The role of fibrin glue is not recommended routinely, and further studies are needed about the role of amniopatch which has shown increase in amnitic fluid volume in some cases. Tocolytics are not given routinely except till the time for striod to work and also when faciltating inutero tranfer.
Posted by Sangeetha S.
Mon Aug 13, 2007 12:01 pm
A healthy 30 year old primigravida is referred with suspected ruptured membranes at 26 weeks gestation. (a) Justify your initial clinical assessment [5 marks]. (b) You confirm spontaneous rupture of the membranes. What will you tell her about the risks to her fetus? [5 marks]. (c ) Justify your subsequent investigations [5 marks]. (d) Evaluate the antenatal treatments aimed at optimising perinatal outcome [5.
I will take history regarding the onset of vaginal loss that is sudden gush of fluid followed by recurrent dampness (which is more suggestive of ruptured membranes) or increased gradual vaginal loss (may be
increased vaginal discharge); colour of the loss, any assosciated pinkinsh PV loss or PV bleeding(may be in preterm labour, associated abruption); any associated history of abdominal pain or contractions (might suggest preterm labour);regarding fetal movements; or any bladder disturbances (may be UTI).
I will check her temperature, pulse and blood pressure. Increased temperature and pulse may suggest associated infection. On abdominal examination feel for any contractions, any tenderness, measure symphysiofundal height, lie and presentation,and listen to the fetal heart. Then I will do sterile speculum examination, if pool of liquor in the posterior fornix or on coughing a gush of clear fluid coming through cervix suggests ruptured membranes and at the same time will also look for length and dilatation of the cervix and take a high vaginal swab, will also rule out any urinary incontinence. If no liquor seen on examination there is no reliable tests to confirm PPROM even though some bed side tests are available.
Therefore diagnosis of ruptured membranes is mainly by history and clinical examination.
Once the diagnosis is confirmed I will tell the patient that baby is at increased risk of preterm labour , cord prolapse , abruption , chorioamnionitis there by causing neonatal sepsis. Overall there is increased risk of perinatal mortality and morbidity.At the same time I will reassure her that exectant management with antibiotics, steroids for lung maturity and regular assessment can minimise these complications.
Subsequent investigations are blood tests for baseline fullblood count, c-reacive protein and urine for dipstick and microscopy and culture to rule out any urinary infection or asymtomaic bacteruria. High vaginal swab at the time of speculum examination. I will do a bedside scan to cofirm lie and presentation. Departmental ultrasound can be done later to assess the liquor volume.
This patient needs antenatal steroids either dexamethasone15mg IM 2 doses 12hrs apart or betamethasone 12gIM 12hrs apart, which helps in the lung maturity and also reduces the risk of intraventricular haemorrhage and necrotising enterocolitis(NEC). There is no need to repeat another course of steroids as repeated doses of steroids have not proven beneficial instead can be harmful. She is given antibiotics erythromycin 250mg 4 times a day for 10 days to reduce the risk of infection. Augmentin should not be given as it associated with increased risk of NEC. She should be admitted in the hospital for observation
for 48 to 72 hrs, if particular unit do not have the neonatal facility for less than 28 weeks , needs an intrauterine transfer with tocolysis if associated with threatened preerm labour. Neonatologist review is needed to discuss regarding the baby. If is no signs of preterm labour in 72 hr then can be managed as outpatient with follow up in day assessment unit once a week with repeat bloods and vaginal swab.Weekly utrasound for liquor and Umbilical artery Doppler and growth scans once in two weeks. Mother is instructed to check her temperature once in 12 hrs, to come in immediately if feeling unwell, change in the colour of discharge or offensive discharge, or associated abdominal pain.
There is a controversy regarding the delivery at 34wks or to continue until term.

Posted by Misbah W.
Wed Aug 15, 2007 04:56 pm

A- Initial clinical assessment should include a history of duration and amount ,a sudden gush of fluid favor PROM and a slow discharge may be due to vaginal discharge or urinary incontinenc. A history of associated abdominal pain if intermittent may be due to uterine contractions or constant lower abdominal due to infection. Her physical examination should include checking of temperature, pulse and abdominal palpation for tenderness to predict any infection. A abdominal girth record will help for follow up .A sterile speculum examination with a pool of fluid in posterior fornix will help to diagnose PROM and condition of cervical os. Moreover, a bed side nitrazine will detect PH change to differentiate between urine, amniotic fluid and vaginal discharge. Digital examination should be avoided as it may transport organism from vagina into cervix. A bed side USG may help to diagnose PROM by demonstrating oligohydramnios as well as help to assess fetal heart rate.
B-Around 70-80% of women deliver within week,50% within 4 days. At this stage of gestation a survival is possible in around 75-80% of cases but in the absence of infection or evidence of fetal distress, so delaying of delivery is management of choice .As prematurity is associated with increase in prenatal morbidity and mortality due to RSD, IVH ,EC ,prolong neonatal ICU admission and neonatal death. But delay in delivery has to be vigorously monitor for chorioamnionitis and fetal distress to achieve expected neonatal outcome .There is a risk of postural deformities due to reduced liquor.
C- Subsequent investigation should help infection screening like maternal full blood count ,CRP ,urine dipstick and culture and high vaginal swab for culture and sensivity.Results will help to decide about delivery time and appropriate antibiotics.
Cardiotocographi is useful because fetal tachycardia, if present, represent late sign of infection .BPP and Doppler assessment has not been fully assessed. Role of amniocentesis in improving outcome remains to be determined.
D?Antenatal corticosteroids should be offered to the patient with a risk of preterm delivery as it is associated with significant reduction in rates of RDS,neonatal death and IVH. Prophylactic tocolysis is only consider in woman with uterine activity to buy time for intrauterine transfer or antenatal steroids to be effective. Prophylactic antibiotic like erythromycin should be recommended as it is associated with significant reduction of chorioamnionits ,neonatal sepsis, neonatal ICU admission time, Prolong pregnancy time but no significant reduction in perinatal mortality. Amnioinfusion is not fully assessed in women with early second trimester PPROM.. fibrin sealants are not recommended as routine for treatment of second trimester oligohydramnios caused by PPROM , may lead to postural deformity.