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MRCOG PART 2 SBAs and EMQs

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Essay 281 -PPROM

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		Posted by S D. Mon Jan 12, 2009 08:29 am
a) Detailed history of the duration of membrane rupture, if there was a gush of fluid pv followed by continuous trickling and the colour of fluid pv should be asked. Sterile speculum examination should be done to look for pooling of liquor in the posterior fornix. If present, this confirms the diagnosis. If there is no liquor but the history is suggestive, then ultrasound should be done which can show oligoamnios for confirmation of diagnosis. b) I will explain to her that there is spontaneous rupture of fetal membranes and that she is not in labour. The main aim is to prevent maternal and fetal infection and prolong the pregnancy till about 34 weeks if there are no risk factors. I will tell her that the main risks are prematurity and chorioamnionitis. Steroids are given to decrease the incidence of respiratory distress syndrome, necrotising enterocolitis, intraventricular haemorrhage and it also decreases the cost and duration of neonatal intensive care. It is given as Betamethasone 12 mg IM 24 hours apart in 2 doses. Antibiotics in the form of Erythromycin 250 mg Qds will be given for 10 days and this has been shown to decrease the incidence of infection and prolong pregnancy. I will explain to her that the special care baby unit will be informed and the neonatologist can explain about the survival figures and prognosis as well as the neonatal management for babies born prematurely. Baseline blood tests such as FBC, CRP will be done for evidence of infection as well as MSU and HVS. She will be on the antenatal ward for 48-72 hours and any change of colour of liquor, bleeding pv and abdominal pain should be promptly reported. i will expain to her that temperature and pulse will be checked 12 hourly and fetal wellbeing will be ascertained by doing a CTG daily. If after 72 hours of in-patient stay she remains well then she can be sent home after discussion with the in-charge consultant. Maternal and fetal monitoring plan should be agreed and arranged. Fetal monitoring in the form of twice weekly CTG\'s, weekly dopplers and fortnightly growth scans. Maternal monitoring should be checking of temperature daily by the patient atleast 12 hourly, Weekly FBC, CRP and HVS. This should be continued till 34 weeks if there is no sign of chorioamnionitis or fetal distress. c) Gestational age is an important factor which influences timing of delivery. Prematurity is associated with increased perinatal morbidity and mortality. It is associated with increased risks of RDS, NEC and IVH. These can be reduced by administration of steroids. Presence of fetal compromise influences the timing of delivery. Presence of chorioamnionitis mandates immediate delivery as there is increased risk of periventricular leucomalacia and cerebral palsy if delivery is delayed. Availability of neonatal cots is an important factor. In-utero transfer should be arranged if delivery is not imminent as perinatal outcome is improved in a unit with SCBU cot. Fetal presentation influences mode of delivery. If cephalic, vaginal delivery can be allowed. If breech, then the woman and partner should be counselled about the pros and cons of vaginal breech delivery as the results of term breech trial cannot be directly extrapolated to preterm breeches. Informed consent should be obtained.
		Posted by Dr Dyslexia V. Mon Jan 12, 2009 04:35 pm
a. The diagnosis could be ascertained by a detail history and clinical examination. The history of nature of her wetting her pants as it was a gush of fluid or trickling and to differentiate it from urine by was it associated with post voiding or dysuria should be taken. A pelvic examination which include a sterile speculum examination could be used to demonstrate the presence of liquor in the posterior fornix or on the lower blade of the speculum. Additional test of fluid pH, fetal fibronectin if available to be used on the fluids for confirming its origin. A ultrasound examination could be done to asses the liquor volume fetal viability and presence of an anomaly. b. The patient should be informed with the presence of the partner in regards to the diagnosis and its implication to them. The risk od delivering a fetus in prematurity which include respiratory distress syndrome, periventricular leukomalacia, sepsis, NEC and risk of developmental delay. She should be informed that corticosteroids will be given for lung maturation and antibiotic will be given in accordance to the guideline. The need for delivery in the evidence of infection should be emphasised and risk of posts partum hemorrhage and hysterectomy should be informed. If she is asymptomatic then, a conservative approach could be used and she would be delivered at 34 week of gestation. The sisgns and symptoms of chorioamnitis is informed as fever , lower abd pain, foul smelling per vaginal disharge is informed. Twice weekly monitoring of full blood count to look for leukocytosis, CRP, and initial high vaginal swab for determining the pathogen and sensitivity. The information should be provided with written leaflets c. Timing of delivery would be at 34 week of gestation if there is no presence of infection. Delivery should be done in a facility where there is a facilty for neonatal backup with ventilator avaialbity. An in utero transfer would be required in the event the re is no available ventilator in that facility. IN the event there is lekocytosis, raised CRP, fever, foul smelling discharge, fetal distress tracing on CTG then immediate delivery must be done. The mode of delivery would be preferably vaginal unless there is malpresentation such as tranverse lie or placenta previa minor, on which a lower segment caesarean section is done. The mother and partner are encouraged to informed decisin and their wishes shold be prioritised in the management of the patient
		Posted by Farzana N. Mon Jan 12, 2009 04:50 pm
a) Diagnosis in this case is confirmed by history suggestive of SROM .amount and colour of discharge should be enquired.Sterile speculum examination is performed which may demonstrate pooling of liqour in the posterior vaginal fornix.According to RCOG recommendations Nitrazine test is not necessary.In case there is doubt fetal fibronectin and insulin like growth factor binding protein-1 have been found to have high sensitivity.Digital examination is best avoided unless labor is suspected.This is to prevent ascending infection,prostaglandin release and preterm labor.Ultrasound examination is helpful only when large amount of liqour has passed. b) Patient should be told that there is high risk of infection,both for her and her baby .She may go into labor any time and have preterm delivery,in which case neonate would be at risk of prematurity and its associated complications.For these reasons she needs to be admitted and kept under close observations .Maternal pulse ,temperature and fetal heart rate auscultation would be done 4-8hrly,weekly HVS and FBC for leucocytosis, would be done.CTG monitoring would be required for fetal monitoring. Signs ,such as maternal fever,offensive vaginal discharge,uterine tenderness,fetal tachycardia would help in early detection of clinical chorioamnionitis.In this case she would require early delivery. She would receive prophylactic antibiotics,Erythromycin 250mg 6hrly or 10days.She would be given corticosteroids to reduce the risk of respiratory distress syndrome,intraventricular hemorrhage and necrotising enterocolitis.If she develops contractions .tocolysis will be given.SCBU should be informed and facilities or neonatal care should be ensured. After 48-72 hrs of in patient monitoring,if the consultant obstetrician may choose to monitor her as outpatient.she would be advised of signs and symptoms of chorioamnionitis and under what condition she should seek medical advise. c) Gestational age and presense or absence of infection are the important factors which determine the timing of delivery. If there are no signs of infection ,pregnancy may be allowed upto 34wks.If there are signs of clinical chorioamnionitis ,delivery should be expedited.If the presentation is cephalic and cervix dilated ,vaginal delivery may be allowed,under antibiotic cover. In case of noncephalic presentation at preterm gestation,caesarian section is preferred.The patient and her partner should be thoroughly counselled ,by a neonatologist regarding fetal survival ,and increased fetal morbidity regardless of mode of delivery.Their wishes are taken into account and documented.
		Posted by Osman A. Mon Jan 12, 2009 06:40 pm
a. History sudden gush of fluid associated with continuous leaking and wet her undergarment is a strong history suggestive of leaking liquor. Presence of pooling of liquor in post fornix is a positive finding. Ultrasound with oligohydramnious is good indicator of leaking liquor. The use of Nitrates test has sensitivity of 90 % but associated with high false positive rate. Fetal fibronectin has been used but not widely available. b. She should be informed that leaking liquor is associated with increased maternal and perinatal morbidity/mortality. 50% of them might go to preterm labour within 7 days. She should be admitted for observation for 48 hour to look for complication like chorioamnionitis, fetal distress and preterm labour. She should be reassured that majority of leaking liquor will have good outcome. She should be made aware that she needs undergo investigation like FBC and weekly high vaginal swab. Assessment of pad chart (change of color/foul smelly liquor and blood stained), presence of fever and contraction should be emphasized. She should be informed that injection of dexamethasone will be given to accelerate lung maturity and reduce risk of NEC and IVH. She should know that oral antibiotic (erythromycine 250mg 4 times per day for 10 days) can reduce risk of chorioamnionitis, reduce risk admission to neonatal care and prolonged the latency interval between leaking and delivery. Ultrasound will be done to her to look for placental location, presentation and fetal parameters. Weekly ultrasound for liquor and 2weekly of growth chart will be arranged. CTG should be done to her for assessment of fetal tachycardia. She and her partner should be counselled regarding the benefit (reduced risk of chorioamnionitis and fetal infection) of induction of labour (IOL) after 34 weeks or no later than 37 weeks. The risk of induction of labor (failed IOL, risk of cesarean section (CS) and future pregnancy) should be informed. She should be given written information and contact detail of hospital. c. Presence of fetal distress or fetal compromised will need to go for urgent delivery. PPROM is associated with abnormal lie thus if the fetus is not in longitudinal lie then the mode of delivery would be CS. The timing of completed steroid injection would determine the timing of delivery; tocolysis will be given to buy time for the dexamethasone to work. Presence of infection or chorioamnionitis is important fact to determine timing of delivery, delaying delivery will lead to detrimental outcome. Low lying placenta or placenta previa will make CS is the only way of delivering the fetus safely.
		Posted by Arun J. Mon Jan 12, 2009 08:07 pm
a-Suspected rupture of membranes can be confirmed by history(from colour and odour of the fluid),then speculum examination(to visualise the pooling of fluid in the vagina,leakage of fluid via cervix,and noting its colour and odour).If these fail to reveal ,then the patient is given a pad for a period of time and then assessed for evidence of leakage. b-I would explain the diagnosis ,the likelihood of spontaneous delivery,the risks to her(chorioamnionitis, postpartum endometritis) and her baby(like fetal and neonatal infection and its attendant risks like chronic lung disease &periventricular leucomalacia,risks of prematurity like RDS,necrotising enterocolitis,intraventricular haemorrhage,retinopathy of prematurity,feeding problems, long term neurological problems,need for prolonged scbu admission and its costs, risks of hyperbilirubinemia,hypoglycemia,hypocalcemia and the likelihood of increased perinatal morbidity &mortality).I would tell her that she needs administration of drugs like steroids(to enhance fetal lung maturity), tocolytics (for in utero transfer if needed),& antibiotics (to prevent infection), and blood tests to confirm infection if signs and symptoms are suggestive of it.Ultrsound needed to asses fetal presentation , placental position and liquor volume. She needs neonatologists consultation and a visit to the newborn unit .Options on expectent and induction of labour explained to her and encouraged to make an informed choice.I would explain the need for monitoring and the warning signs to report immediatelyif she choses for expectant course .Induction labour and the analgesia would be breifed up.The support groups their contact numbers and the need for follow up of baby would be ascertained to her. c-Timing and mode of delivery depends on maternal & fetal condition and maternal wishes.Chorioamnionitis warrants immediate delivery(to minimise maternal and fetal complications.) .Diminished fetal movements, oligohydramnios,meconium staining of liquor,and foul smelling liquor, point to fetal compromise and needs immediate delivery.Ctg and doppler of fetal vasculature do not pick up fetal infection and is of no value.Abruption and cord prolapse warrants urgent delivery(cesarian section-c.s, to salvage the baby ).Obsteteric factors (like placenta previa,malpresentation) and favourability of cervix plays a part in mode of delivery as unfavourable cervix with fetal compromise needs c.s.Amnioinfusion trans vaginal and abdominal does not influence the c.s rate and the apgar score of the baby.
		Posted by Sowmithya B. Mon Jan 12, 2009 09:52 pm
A. History of gushing of fluid, trickling or dampness should be enquired. Ask about the nature of leakage whether it is continuous or intermittent as continuous leakage is more likely to be associated with rupture of membranes. Colour and odour of the liquor has to be enquired. The exact time and date of rupture of membranes has to be noted down. Patient has to be asked about fetal movements and associated abdominal pain and vaginal bleeding. The gestational age has to be reliably assessed. Sterile speculum examination after the women has been in supine position for some time has to be done. From the heavily soaked pads the diagnosis becomes obvious avoiding the need for per speculum examination. Pooling of liquor in posterior fornix either spontaneously or on fundal pressure is suggestive of preterm prelabour rupture of membranes. Nitrazine test and ferning test are not more effective than history and per speculum examination. They both have high false positive and false negativities. The amniotic fluid volume varies widely hence ultrasound also not useful for initial diagnosis. Preweighted sterile sanitary pads can be given and the pads can be weighted after some time to confirm the diagnosis. As amniotic fluid is rich in diamine oxidase, it is employed for confirmation of diagnosis. But simple and rapid bed side test based on diamine oxidase is not available. Other tests based on beta HCG, insulin like growth factor binding protein 1 and fetal fibrnectin are available but they are not routinely used as confirmatory test. Intraamniotic dye injections can confirm but it is invasive and associated with increased incidence of infection. B. Women should told about the nature of the diagnosis and also the possible outcomes of the condition like spontaneous preterm delivery, continuation of pregnancy with delivery by 34-37 weeks of gestation by induction, continuation of pregnancy to term by resealing of membranes and unexpected delivery due to suspected infection. Women should also be counselled about the risks associated with the condition like preterm delivery, chorioamnionitis (50%), operative delivery, placental abruption (5%), cord prolapse and increased neonatal and fetal infection. And also around 50% of patients usually delivery within one week and majority of them within first 24 hours. And so she should be advised to stay in the hospital for first 48 hours. The risks and benefits of prematurity at various gestations has to told in evidence based manner based on the neonatal set up available. Neonatologist input has also to be obtained. Local neonatal set up has to checked and if unavailable need for in utero transfer has to be informed. Patient should be explained about of need for steroids to reduce the risk of respiratory distress syndrome, antibiotics(erythromycin 250mg qid for 10 days if she remains undelivered) to reduce risk of maternal infection and neonatal admission to neonatal unit and also the tocolytics which may not be useful in event of preterm delivery. C. Patient should be assessed inpatient for first 48 hours for signs of infection. Evidence of chorioamnionitis in the form raised maternal temperature and pulse rate, uterine tenderness fetal tachycardia or offensive vaginal discharge is an indication of immediate delivery. White cell count and C reactive protein should be repeated twice a week. In the absence of infection steroid therapy should be completed and erythromycin should be continued. The high and low vaginal, endocervical , perineal and urethral swab reports should be obtained and antibiotics changed accordingly. CTG to assess fetal well being should be done every day. After 48 hours if maternal and fetal condition remains optimised patient can be followed up as outpatient with written information about plan of management and the conditions when she has to approach the hospital like labour, reduced fetal movements, change in odour or colour of liquor or general unwellness. Ultrasound should be done every 2-3 weeks to assess fetal growth. If the pregnancy proceeds uneventfully labour can be induced between 34 and 37 weeks. Vaginal delivery is aimed for in absence of contraindications like cephalopelvic disproportion, malpresentation, dangerous placenta previa etc. Caesarean section is reserved for obstetric indications. Emergency termination of pregnancy is reserved for infections and fetal compromise
		Posted by Manoj Babu R. Tue Jan 13, 2009 02:30 am
The diagnosis can be confirmed in most of the cases by history and clinical examination. A history of sudden gush of fluid per vaginum, which is persistent, is highly suggestive of premature rupture of membranes. Abdominal examination may show reduced liquor. A sterile speculum examination should be done after the patient lies supine for 20-30 minutes, may show pooling of liquor in the posterior fornix or fluid leaking from the cervical canal. This confirms the diadnosis in 90% cases. Other useful tests if the speculum examination is inconclusive include, an USG to show reduced liquor, Nitrazine test to demonstrate the alkaline pH, Positive fetal fibronectin and insulin like growth factor binding protein-1 (IGFBP-1) in the cervical/ vaginal fluid. A digital examination should be avoided as it may reduce the latency before delivery. Women should be told about the diagnosis as well as the risks to the baby and the mother. She and her partner should be involved in the decision regarding further management. Risks to the baby include premature delivery and its complications like neonatal morbidity and mortalty, risk of respiratory problems like RDS, neurological problems like intraventricular haemorrhage, bowel problems like necrotizing enterocolitis. Besides this the complications due reduced liquor like lung problems, though rare after 26 weeks should be told. The risks to mother like chorioamninitis and postpartum sepsis should be told. The management may need prolonged hospitalization, need for antibiotics, and antenatal corticosteroids should be told. The management is primarly concervative till the baby matures or until she goes into spontaneous labour. She should be told to watch for adequate fetal movements, about the signs and symptoms of chorioamnionitis. She should be told about the rare possibility of management at home after 2-3 days of observation in the hospital. The aim of conservative management is to go at least till 34 weeks after which the relative risks of continuing the pregnancy may exceed the benefits. Hence delivery should be considered beyond 34 weeks. If at any point of time there is clinical and / or laboratory evidence of chorioamnionitis or she goes into spontaneous labour she should be delivered. If pregnancy is continued beyond 34 weeks she should be counseled about the advantages to the baby and the risks of sepsis. Other factors include the local avaiability of neonatal beds, and any evidence of fetal compromise. The mode of delivery depends on the gestational age, presence of any fetal compromise, presence of choriamnionitis, maternal obstertric history like presence of any uterine scars, There is no contraindication for vaginal delivery because of prematurity and cesarean section should be reserved for other obstetric indications. Cesarean section does not significantly reduce the fetal complications like intracranial hemorrhage. It may be risky especially in the presence of sepsis. Vaginal prostaglandins are preferred for induction of labour, especially if the cervix is unfavorable.
		Posted by S M. Tue Jan 13, 2009 02:44 am
a) I would like to take a thorough history of any gush of fluid vaginally ,which is suggestive of ruptured membranes . I would confirm rupture of membranes with a sterile speculum exam to visualize the cervix and the amniotic fluid leak through the os .If obvious leaking is not observed , I would do a Nitrazine test , which may be positive in other conditions too.Ferning test is positive with ruptured membranes .Fetal fibronectin test may be utilized , if available .Ultrasound can be done to check for amniotic fluid index. b) I would like to inform the woman about the clinical situation , explain what PPROM ( preterm premature rupture of membranes) is.I would like to explain about the risks to the woman and her baby with PPROM .The woman could develop chorioamnionitis , which is the infection of the inside of the womb .This could lead to spread of infection in the woman and excessive bleeding after delivery(PPH) .The risks to the baby are of a preterm delivery, difficulty in breathing ( RDS) and an increased chance of illness and death .I would arrange for her to meet the neonatal team , who can counsel her about the prognosis and care for the preterm baby .This would change with her gestational age and clinical circumstance.I will offer hospital admission for atleast 72 hrs for basic investigations to prove maternal and fetal well- being.4 hourly check for temperature above 37.8 C and tachycardia will be done .Any uterine tenderness / contractions , foul smelling vaginal discharge and fetal compromise like , fetal tachycardia on CTG will be looked for .These are suggestive of chorioamnionitis.Full blood count will be checked for leucocytosis.CRP , High vaginal swab and MSU for culture and sensitivity will be done .She will be started on oral erythromycin as prophylaxis for 10 days.She will be offered steroid prophylaxis – betamethasone 12mg IM , 2 doses. With PPROM , there is a possibility of cord prolapse and spontaneous preterm labour.If all is well, the woman may be discharged , with Consultant advice and weekly follow up will be planned for her .She will be advised to do a 12 hourly check for fever at home and advised to report immediately to the hospital if fever or foul smelling discharge is noticed. Serial scans- 2 weekly, for liquor amount and baby growth will be arranged for.I will counsel her about circumstances that would prompt an induction of labour or operative delivery .Aim is to carry the pregnancy to 34 - 37 weeks , if mother and baby are well.I would give her written information on PPROM and care of preterm babies. I would like to involve the specialist midwife and GP in her care and give her hospital telephone numbers , for prompt advice. I would like to document the details of our session in her notes, after informing her. c) Clinical signs of chorioamnionitis like maternal fever, feeling of unwell, tachycardia, uterine tenderness, foul smelling liqour associated with leucocytosis , rise in CRP are an indication for delivery. Fetal compromise seen on CTG as fetal tachycardia also indicates need for prompt delivery.Availability of SCBU bed must be ensured before delivery . Cautious use of tocolytics in individualized cases may be considered till SCBU bed is arranged for .Abnormal scan findings of severe oligiohydramnios and abnormal dopplers would necessitate prompt delivery.I would aim for vaginal birth for cephalic presentations and cesarean section for fetal/maternal indications .If non – cephalic presentation, cesarean section may be offered as there is insufficient data regarding safety of vaginal birth in preterm breech presentations.Forceps maybe used while ventouse should be avoided till 34 completed weeks gestation.
		Posted by Neelam A. Tue Jan 13, 2009 02:56 am
A.A detailed history should be taken to know duration frequency and severity of leaking including any symptoms of preterm labour in form of uterine contractions or bleeding, urinary symptoms or vaginal discharge. Obstetric history is also important to know any previous preterm labour or rupture membrane in previous pregnancy. Any operative interventions in form of Shirodhkar suture for incompetent cervix, amniocentesis as an invasive procedure or associated polyhydramnios or any fetal congenital anomalies in current pregnancy should also be taken under consideration. Pulse, blood pressure and pulse should be checked to rule out any signs of infection. Urine should also be checked as a routine test and also to rule out urinary tract infection. Sterile speculum examination should be done to see any pool of liquor in vagina or any leak on coughing suggestive of rupture membrane. Nitrazine test to confirm the diagnosis is not very sensitive test that why this test is not recommended. A vaginal swab should be taken to check any thrush or bacterial vaginosis or group B streptococcus. An attempt should also be made to check cervical dilatation to rule out preterm labour. No vaginal examination should be done until unless she is in labour as it would introduce ascending infection. An Abdominal examination for fundal height, presentation, uterine tenderness and uterine contraction should be done. A fetal monitoring should be commenced. A scan should be organized to confirm the diagnosis if there is doubt of ruptured membranes on speculum examination as it would show reduced liquor in cases of ruptured membranes. B.I would tell the diagnosis and its implications in form of risks of preterm labour, abruption and chorioamnionitis. I would tell we need to balance the risks of prematurity against infection. She should be explained that preterm babies will have difficulty in breathing, feeding problems, temperature control and they are at increased risks of infection. She should be aware that preterm baby needs admission in special care. It is a good idea to arrange a meeting with pediatricians. She should be given the 2 doses of steroids at 24 hours interval after explaining its advantages per RCOG guidelines. She should also be started on antibiotics erythromycin 250 mg four times a day as ORACLE trial has shown its advantages after doing FBC and CRP to check any evidence of infections. She should be in hospital initially for 48 hours to regularly monitor BP, pulse, temperature and abdominal examination for uterine tenderness. She should be advised to check temperature twice a day and to report to hospital if any smelly discharge or any symptoms of infection in form of raised temperature, abdominal pain or diminished fetal movements. She should also be assessed in Day Assessment unit twice a week to check bloods, vaginal swab weekly, growth scan 2 weekly and liquor volume and Doppler weekly. She should also be aware that active intervention would be advisable if there will be any symptoms or signs of infections. She should not be offered tocolysis if she goes in to preterm labour. She should also be counseled for in-utero transfer in cases of unavailability of cot in the hospital if she goes in to preterm labour. She should be informed of recurrence of this condition in subsequent pregnancy. Smoking is one of the precipitating factors for ruptured membranes. Treating vaginal infections would reduce her risk of having recurrence in subsequent pregnancy. C.Parity of the woman, fetal presentation, fetal health on monitoring, presence of major congenital anomalies, presence of chorioamnionitis and whether spontaneous or induced labour would determine the timing and mode of delivery. Expectant management should be continued until 34 weeks of gestation provided there is no evidence of infections and fetus is not compromised. Delivery prior to 34 weeks is associated with respiratory distress, intraventricular haemorrhage, hypothermia and increased risk in the neonate. Leave fore-water intact as long as possible in cases of hind-water ruptured membranes if they go into preterm labour. Paediatricians should be available at the time of delivery. Expectant management should be switched to active management in presence of chorioamnionitis, abruption or fetal compromise as all these scenarios are associated with increased perinatal morbidity and mortality. Continued expectant management in presence of infection would result septicaemia, DIC, postpartum haemorrhage and renal failure. There is no evidence to deliver preterm breech by elective caesarean section. Increased risks of caesarean sections should be balance against preterm breech and woman’s wishes should be taken under consideration in decision making Elective caesarean section should be offered if there are any obstetric indications such previous 2 caesarean sections, placenta praevia or compromised baby. If women goes into labour spontaneously following ruptured membranes, they progresses very quickly. However these women should be monitored by continuous external fetal monitoring. Fetal blood sampling should be avoided in presence of infection if the trace is abnormal. As it is not a sensitive test to indicate fetal compromise. On the other hand she should be delivered by caesarean section if imminent delivery is not expected.
		Posted by Mark D. Tue Jan 13, 2009 03:04 am
mark a) I will take a detail history of episode . A history of gush of watery fluid wetting her clothes is highly suggestive of leak. I would do a sterile speculum examination to note pooling of amniotic fluid in the speculum.Since nitrazine test has a high false positive rate it is not recomended in the diagnosis of PPROM. I would avOid a digital examination unless she is in labour.Ultrasound can be useful to diagnose oligohydramnios. However it may not be useful in small leak where amniotic fluid may be normal. b) I will inform her about the diagnosis and convince her for admission.I will tell her that there is a 40% chance that she will go into labour.She has a risk of chorioamnionitis,sepsis and abruption. Fetus is at risk of prematurity and its associated risks , sepsis and postural abnormalities.Baby will need care is SCBU. I will explain these in a way she understands it.I will tell her that at admission i will do a few tests like FBc, CRP to check for infection, HVS for culture to detect the organism responsible for infection and a urine for wbc and nitrites and culture. HVS and FBc would be repeated weekly. She will receive an antibiotic(erythromicin 250 mg bd) orally which she should continue taking for 10 days.she would also receive one course of steriods to enhance fetal lung maturity.In ward she will be monitered for signs of onset of labour and signs of infection like taccycardia, uterine tenderness,foulsmelling vaginal discharge,fever and fetal taccycardia at 12 hourly intervals. CTG would be done daily.An ultrasound scan would be arranged to check babies weight,amniotic fluid volume,placenta and general well being(biophysical profile). I will tell her that she may need to be delivered if any signs of infection arise and this may end in an operative delivery at this gestation.our consultant may consider an outpatient managenment aftyer complete assesment after 48-72 hours. howvere at home she has to check temperature 6 hourly when awake and report to hospital if any signs of pn in abdomen,foul smelling vaginal discharge, pv bleeding or fever occurs. A 24 hour contact number and written information will be provided. I will tell her that she will also have to come for followup at weekly intervals at day assesment unit even if alls well till 34 weeks .At 34 weeks a plan of delivery will be made as conservative management after this gestation dosent improve fetal maturition and increases infective morbidity. c) Delivery should be considered if any signs of chorioamnionitis develop. Abnormalities in ctg would also necessitate delivery urgently. If there is any obstetric indication like placenta previa,previous classical ceserrean section,CPD, then delivery will be by ceserrean section. Breech presentation is not an absolute indication for ceserean section (CS)in preterm cases. Urgency of delivery like abruption or ctg abnormaliteies may need delivery by CS. Failed induction of labour, very poor bishops score(less than 6) will need CS. maternal wishes should be taken into account when deciding mode of delivery. in absence of any complications induction should be done at 34 completed weeks.
		Posted by Sandhya P. Tue Jan 13, 2009 04:36 am
a) A detailed history would be taken to know if it was leaking - if she felt a sudden gush of fluid &if it caused wetting of her undergarments . The colour of the fluid would also be asked . Any history of urinary incontinence or mucoid discharge p/v is also asked as it may be confused with leaking . Given that she indeed has leaking it should be confirmed with a sterile speculum examination to see pooling of liqour in the posterior fornix and the cervix may also be visualised . Nitrazine test may help but is not used routinely . Recently tests for fetal fibronectin and ILGFBP are studied and have high specificity to confirm leaking. A per vaginal exam is not advisable due to risk of infection being introduced into the cervical canal but may have to be done if cervix cannot be visualised or she has uterine activity . A USS may help to diagnose pprom by showing oligoamnios and also helps to know the gestational age & presentation. If still in doubt a pad study can be done to confirm tha leaking. b)Once the diagnosis is confirmed the woman and her partner will be told about the implications of the diagnosis in a comprehensive &sensitive manner without undue alarm. They will be informed that the main problems are prematurity &infectious morbidity . the risk of going into preterm labour is 80%. However the EPICURE study has shown an overall survival of 80% at this GA . Theywould be told that she needs inpatient admisssion and monitoring to optimise the outcome .She would be educated about the symptoms of chorioamnionitis .I would tell her to inform if she has fever ,feeling of malaise ,foul smelling discharge P/V , rigors or abdominl pain. I will tell her that her pulse ,temp will be recorded 4 -6 hrly , blood would be drawn for tests (tbc ,crp ,)twice a week , urine forc/s , vaginal swabs would be taken to screen for infections like GBS, Bacterial vaginosis treatment of which can improve the chances of a haealthy baby . She will also be told about the need for growth scans to asess the fetal growth as abdominal palpation is unreliable . The advantages of having steroid injections two doses betamethasone to decrease risks of prematurity like Respiratory distress , Intraventricular bleed &NEC. will be explained . she will also be told that in the event of her developing infection or going into labour a decision on mode of delivery would have to be planned and thae baby will need SCBU care may be for prolonged periods . This should be in laison with neonatologist who should brief her about preterm baby care . Possibility of postural deformity in fetus should be explained at the same time reassuring her that it can be treated with splinting . The need for long hospitalisation should be informed so she can make arrangements at home. Domiciliary management may be possible in selected cases. Risk of recurrence 20 -30% will be told. c) The factors that determine the timing & mode of delivery are the development of clinical or subclinical chorioamnionitis or the onset of spontaneous labour or reaching a satisfactory GA for planned delivery . The onset of infection necessitates prompt delivery . The wishes of the mother should also be taken into account . The presence of malpresentation ,cord prolapse or fetal distress would warrant caesarean delivery . Problems with C/S in preterm should be borne in mind & senior obstetrician should do the surgery . The illformed lower segment can make delivery difficult needing extension of incision to upper segment with its implications for future pregnancies . If vaginal delivery is opted the ease of induction is assessed by bishop score . Ctg interpretation can be misleading . Intermittent auscultation should be done . An experienced neonatologist should attend the delivery . In cases where the PPROM progresses to 34 to 36 weeks the delivery should be planned as the risks of prolongation out the benefits of delivery . in cases where PPROM threatens to go into labour tocolytics may be given for a short period to alow the steroid to act as the risks of prematurity can be greatly decreased with steroid Or to facilitate transfer to tertiary centre. The previous obstetric history would also help in determining mode of delivery.
		Posted by H H. Tue Jan 13, 2009 04:52 am
A healthy 27 year old woman presents with suspected rupture of the membranes at 28 weeks gestation. (a) How would you confirm the diagnosis? [4 marks] I will ask the patient about the time of suspected breaking of her water, was it a gush of fluid ,its colour and if it has an offensive odour(queery infection) or smell of urine.I would ask if it was associated with labour pains and wether these are frequent.I would ask if she had previous urinary infection and if she feels feverish. To help me confirm , abdominaly I would feel fundal level and if corresponding to gestational age or not but this is not conclusive, Do sterile speculum examination and see if pool of fluid collects in vagina or actually see tickling of fluid from the external cervical os.If no fluid seen this is not conclusive so I would put for her a dressing over her vulva and see if becomes wet.I might do tests to confirm that the fluid is amniotic fluid as measuring PH by nitrazine paper or doing fern test (not conclusive). b) You have confirmed the diagnosis and she is not in labour. What would you tell the woman? [10 marks I would tell her that there is risk of ascending infection to her and her baby and also risk of baby being born preterm should delivery be decided or spontaneous labour take place.I would tell her that measures will be taken to prevent infection such as giving her antibiotics which the college recommends and avoid vaginal examination,and also measures to early detect the occurance of infection(FBC,CRP 2-3 times weekly,vaginal swabs weekly ,CTG daily) at which time delivery of the baby is adviced.I would tell her that intramuscular dexamethasone will be given to her as it is associated with improved perinatal outcome should the baby be born premature.I will tell her that the baby if born might need special care and neonatologist will be available. I will discuss with her the timing of delivery and that it depends on the follow up results and also the mode of delivery which might be a cesarean depending on the favourability of the neck of the womb.If cesarean section is needed at such gestation it might be an upper segment cesarean section ,so I would discuss its effects on future pregnancy I will tell that she can be admitted for investigations and follow up ,but that she can also be followed up as outpatient provided there is no fetal or maternal compromise. If no evidence of infection or fetal compromise ,fetal growth scan will be done every 2 weeks.Usually will go into spontaneous labour by then. c) Evaluate the factors that would determine the timing and mode of delivery [6 marks]. If there is evidence of infection as maternal pyrexia, abdominal tenderness, offensive amniotic fluid or fetal tachycardia, or raised CRP , delivery is justified.If she is being followed up for evidence of infection we do not wait for the whole blown picture but might act if raise CRP and fetal tachycardia. In presence of fetal malpresentations there is risk of cord prolapse and we might act early. At 28wk the cervix might not be favourale for induction and cesarean section would be needed at which time the lower segment is not yet formed and an upper segment cesarean is done.If patient goes into spontaneous labour vaginal delivry is allowed but for breech there is risk of cord prolapse. The results of the term breech trial can not be applied here and neonatal outcome is not improved by doing a cesarean section. Maternal wishes are taken into account but note that maternal anxiety about her baby may favour doing a cesarean section. {0} Mark as read Mark as unread Delete Junk Not junk Print View message source © 2009 Microsoft Privacy Legal Help Central Account Feedback
		Posted by A S. Tue Jan 13, 2009 05:13 am
Am a- Confirmation of the diagnosis entails taking history of time and nature of the fluid passed per vagina ( gush of fluid) and history of urinary incontinence . Digital vaginal examination is contraindicated as it icreases the risk of infection . Checking the patient pad may help . Sterile speculum examination will show pooling of fluid in the vagina . Nature and colour of the fluid will be noted . Amnioindicator swabs has high false positive results . U/S will help only if amount of liquor lost is considerable . b- Counseling about implications of the diagnosis , possible complications and the management plan will be discussed with the women and her partner and will be documented in her notes . She will be told that most probably she will have preterm labour and this will carry high risk of neonatal morbidity and mortality because the systems in the fetal body are still immature especially the lungs , cns and the GIT. Antibiotics will be given (erythromycin) because it is proved to prolong pregnancy and protect against infection . I will explain the benefits of corticosteroids in reducing intracranial hemorrhage and necrotizing enterocolitis and helping lung maturation .No need to give prophylactic tocolytics unless she will have labour pains before steroid therapy or to transfer her to a secondary center with NICU services. There is a risk of developing chorio amniitis and endometritis which will increase morbidity and mortality to mother and baby ,that is why she is better be admitted to the hospital under observation for 72 hours . Labour may be associated with placental abruption and there is increased rate of cesarean section rates .Base line investigations in the form of FBC , MSSU for culture and sensitivity vaginal swabs for c&s will be done for her . U/S for checking placental site and number of fetuses she is carrying and fetal lie will be done if not in her notes . During her hospitalization she will be checked regularly for temperature changes ,pulse rate , abdominal pain , fetal heart rate and sign of going into labour . Arrangement for discussing her condition with neonatologist and consultant obstetrician will be done .After the 72 hours the decision to discharge her or deliver her will be taken by the treating team in her and her baby best interest according to results of tests and her clinical condition. I will tell her that prolongation of pregnancy ideally till 34 ws is the aim and that this carries a risk of abnormal positions of fetal limbs if the liquor is scanty . Small risk of lung hypoplasia exists . If outpatient management will be eventually taken a detailed written information about how and when to check her temperature , sign of infection or labour and 24 hrs contact numbers . c- I f the woman develops chorioamniitis , delivery is a must . The route of delivery depends on number of fetuses , placental location, lie and presentation of the fetus . Transverse lie or breech presentation will need cesarean section after counseling . Twin pregnancy with PPROM is a challenge and unless both are cephalic CS is preferred because vaginal delivery carries more risk of short term morbidity . This will balanced with operative risk to the mother . If she has a history of previous CS delivery , she will be counseled about chances of successful vaginal delivery rates ( 60-70%) and possible risks including rupture uterus. U/S detection of fetal anomalies will affect mode of delivery . Availability of neonatal intensive care services is important in determining timing of delivery . Ventouse delivery is better avoided because of increased risk of intracranial and retinal hemorrhage .
		Posted by G. K. Tue Jan 13, 2009 09:28 am
to confirm preterm prelabour rupture of membranes (PPROM), a thorough history should be taken with regards to the timing of the suspected rupture of membranes. Patient should be asked whether the fluid passed was in a \"gush\" or is trickling.Inquire about the nature of the discharge, whether itis watery or mucousy and stringy, since watery discharge is more predictive of PPROM. If there is still doubt, then a sterile speculum exam should be performed to see the pooling of fluid in the posterior fornix of vagina. If pooling of fluid is seen, nitrazine swab is not necessary, but can be performed if in doubt.It has sensitivity of 90% and positive predictive value of 17% When PPROM is confirmed, the woman should be councelled regarding the risk of premature labour and preterm delivery and adverse neonatal outcomes in terms of respiratory distress syndrome,necrotizing enterocolitis and intraventricular haemorhage alongwith the risk of infection i.e chorioamnionitis. She should be explained the benefits of steroid administration in reducing the above mentoned complications and the use of erythromycin in the prevention of infection, therefore minmizing the morbidity asociated with PPROM bt not abolishing it completely. She needs to know that she would be kept under observation in hospital for atleast 48hours and monitored for impending labour or signs of infection by regular recording of temperature and full blood count and a high vaginal swab to culture the amniotic fluid for pathogens.If cnsiderd appropriate , she can be monitored from home after though councelling about regular self recording of temperature and the signs and symptoms of infection such as abdminal pain and foul smelling vaginal discharge. She should be advised to come straight to the hospital if anyof these signs or symptoms are noticed by her. The factors that infuence the timing of delivery depend upon period of gestation. If the patient has gone up to 34 weeks and above, delivery is recommended. Also the presence of infection should prompt delivery since prolonged exposure of the fetus to hostile uterine enviroment is associated with adverse perinatal outcome.Prior to delivery , it is important that the patient has completed a course of steriods for fetal lung maturity. The mode of delivery should be vaginal unless indicated otherwise, i.e fetal distress in early labour.
		Posted by Ahmad A. Tue Jan 13, 2009 09:56 am
Detailed history of the condition should be obtained from this lady asking about the leaking of gush of water, this may prove the condition with the specific character of pure watery discharge wetting her underwear and drippling vaginally. Local pelvic examination should be carried out by local inspection of the vulva, sterile aseptic technique for the vagina. Notice of the leaking of clear fluid from the cervix and presence of the pole of water in posterior fornix. Testing of the leaking fluid by specific amniocator for PH evaluation characterized the amniotic fluid, or using Nitrazine paper. Also we may detect it by using ferning test, under microscope with exposing thin film of the fluid over a slide. I would tell this lady about the case that she had pre mature rupture of membrane (PROM) and this condition may initiate the labour pain and may ended soon by preterm delivery. I would tell her there is high incidence of ascending infection and this could have side effect over her and the fetus. So, we have to overcome these two main possible complications. So, how to delay her delivery till the possible advanced gestational age about 34 weeks or more. Also how to avoid the possibility of chrioamniitis. I would advise her, that she needs for closer follow up and the hospital is the best place to stay under close follow up observation. I would discuss with her the condition in case of early delivery and the complications that we may encountered regarding the prematurity. I would advise her to be seen by neonatology specialist for more and accurate discussion and probabilities. I would discuss with her the available options that may give best outcome for her and the fetus. These may includes, the steroid to prevent respiratory distress syndrome, preventing necrotizing enterocolitis and reducing inter ventricular haemorrhage. Also, antibiotics in form of Erythrocin ot prevent chorioamniitis. Use of tocolytic in case of starting uterine contraction till the effect of steroids can take place. The mode of follow up inpatient, daily check of the vital signs, specially temperature, tenderness, abdominal pain, bad smell discharge, foetal monitoring of heart rate and uterine activity. High vaginal swab as initial investigation and could be repeated later on in case of suspicious infection. Urine test for culture and sensitivity should be obtained as with pretem delivery with PROM is highly related to urinary tract infection. Weeky FBC and CRP and biweekly ultrasound examination of foetal growth, liquor amount and foetal presenting part. Patients\' information leaflet should be provided to the patient discussing the variable options and recommended advise. Timing of the deilvery can be determined by some factors, firstly the aim of delay the delivery till the gestational age of 34 weeks or more. Unless, if there is inevitable delivery with progressive cervical dilatation and regular uterine contraction despite of tocolysis. Also, the symptoms and signs of possible chorioamnitis with high tempreture, smelly vaginal discharges, abdominal pain, tenderness, high WBCs, high CRP and/or foetal comprise detected by monitoring, biophysical profile, ultrasound Doppler study. Mode of delivery will depend upon some factors, these includes, fetal maturity, weight and baby position and presentation. Breech vaginal delivery of premature baby is an issue of controvery. Also, these will depend the cervical status,ripening, dilatation, and position. Induction of albour and vaginal delivery is the preferable option in case of chorioamnitis. Previous mode of delivery may also play a role in deciding for this delivery. Patient\'s choice should be considered in the mde of delivery.
		Posted by J P. Tue Jan 13, 2009 10:08 am
a.I will ask for a detailed history like onset and time elapse since membranes ruptured..History of sudden gush of water or vaginal dampness will suggest the diagnosis. Continuous leaking per vagina and the color of the fluid[white flakes] also adds up to the diagnosis. Speculum examination will be done to confirm rupture of membranes by noting pooling of water in posterior fornix and also to assess the nature of cervix.USS [oligo hydramnios] may be suggestive in presence of positive history. b.I will explain the diagnosis to the women as spontaneous rupture of membranes before term and tell her that she is not in labour.This situation will be dealt carefully as it is likely to cause significant anxiety to the woman.The main risks of chrioamnionitis and prematurity will be informed to the patient. Hence conservative management can be done in the absence of infection or fetal compromise.The risks f prematurity and chrioamnionits has to be balanced before arriving at the decision. Delivery may be delayed till 34 weeks. However 60% of women deliver within 1 week or ruptured membranes.I will tell her the need for in patient assessment. Investigations like FBC,CRP,high vaginal swab to rule out infection will be done as in-patient.Fetal monitoring in the form of CTG and USS for liquor volume and fetal presentation will be done.I will tell her pulse and temperature will be monitored every 4-8 hrs to identify any sign of infection.Betamethasone 12 mg im 12 th hourly 2 doses will be given to decrease the incidence of RDS and intra ventricular haemorrhage.Antibiotics like erythromycin will be given 250 mg 6 th hourly to decrease perinatal mortality and infection.I will explain to her that drugs to prolong pregnancy [tocolytics] are used only in case of in-utero transfer and for the steroid effect. I will tell her she will be discharged after 48-72 hrs if everything is well with written information regarding follow up and further tests like weekly vaginal swabs and FBC.She will be adviced to take temperatures twice and daily and taught about warning signs like fever,chills,abnormal colour of liquor ,decreased fetal movements foe which she has to report immediately.Fetal monitoring will be by CTG and USS weekly till 34 weeks.The survival and prognosis of baby at this gestation will be explained and also an appointment with neonatologist for the same will be arranged. c.Maternal and fetal factors influence the mode and timing of delivery. Gestational age is important since prematurity is associated with RDS,intraventricular haemorrhage and morbidity ,hence delivery delayed upto 34 weeks.But at any time in evidence of fetal compromise or evidence of infection needs urgent delivery. Fetal presentation decides the mode of delivery.In cephalic presentation vaginal delivery is the aim.In non vertex prentation mode of delivery is controversial and has to be decided after discussing the pros and cons.Nature of cervix[bishop score] also decides the respone to induction and also the mode of delivery. Availability of neonatal cots is important in deciding the timing since in –utero transfer has to be arranged in case of non availability if delivery is not imminent.
		Posted by Ron C. Tue Jan 13, 2009 08:20 pm
A. Detailed history taking is essential; I’d enquire about day and time of leaking and exact nature (amount, colour, smell, vernix), whether it was a sudden gush and whether leaking still ongoing. Inspection of pads, underwear may aid in diagnosis. On vulval inspection leaking or vernix may be seen. Speculum examination with pooling of liquor (make patient strain or cough) is very conclusive. A fern test can be done in doubt. Finally sonographic assessment of amount of liquor may be helpful. If despite suggestive history examination is inconclusive, patient can be admitted for a short time and her pad is checked regularly. B. Premature ruptured membranes will cause anxiety which must be acknowledged and addressed. The multidisciplinary management means the neonatologist will be involved in information giving as well. The main problems with PPROM are development of infection and/or contractions/premature delivery. I’d explain to her that we give antibiotics (erythromycin) to reduce infection risk but that if she goes in labour this will be allowed, as it is often accompanied by infection and then the baby is better off delivered. Contractions will only be surpressed by medication if she needs to be transferred out to another hospital due to absence or lack of neonatal intensive care facilities in our hospital or to gain time to obtain full effect of 2 injections of corticosteroids over 48 hours to promote maturation of fetal lungs. She must be aware that though most babies (>90%) survive, there can be up to 50% short- or long term problems. They require special care for a longer time, as short term problems are common (difficulties in breathing/RDS, feeding problems/NEC, infections/sepsis, difficulty to maintain body temperature). She must also be advised on possible long term outcome which will often only become clear after several years, such as retinal blindness, developmental problems (motorical, speech etc), behavioural problems, learning difficulties, childhood astma. I will finally give her some written information as well as contact numbers for patient support groups. C. If contractions develop, delivery will be accepted provided full corticosteroid cover is obtained and neonatal care facilities are present. As long as clinical monitoring and regular blood results don’t show any signs of infection and fetal condition (CTG) and growth (ultrasound) are satisfying I’d allow the pregnancy to continue. By 37 weeks though I will deliver her as further prolonging probably won’t improve outcome whilst likelihood of infection is still there. If infection develops I will arrange delivery earlier. In all cases with spontaneous onset of labour I’ll allow vaginal delivery provided fetal condition and progress are good. In all other cases where fetal condition doesn’t require immediate delivery and induction of labour is not contra-indicated (previous caesarean), I will try for a vaginal delivery, unless gestational age, favorability of cervix and parity of the mother make successful induction unlikely.
		Posted by Priti T. Tue Jan 13, 2009 11:08 pm
prt a]The diagnosis of preterm prelabour rupture of membranes[PPROM]is confirmed mainly by hx and examination.The exact time of the sudden gush of fluid wetting the pants/underwear of the patient should be asked.Constant trickling or dampness of fluid is asked for in the history.The colour,odour of the fluid and the presence of white bits indicating vernix suggests amniotic fluid.At the same time urinary incontinence and the vaginal discharge is ruled out.Enquiry about the vaginal bleeding,foetal movement and uterine contraction is made. Patient is examined physically for pulse,temperature and B.P,to rule out infection.The dating scan is checked in the records .The uterine size,tenderness and the presence of contraction is noted.FHS is checked by CTG.Women\'s clothes ,pads should be checked for liquor.Speculum examination is carried out only if there is uncertainty in the diagnosis.Digital vaginal examination is not performed.In an event of uncertainty speculum examination is repeated after the women is supine for some time;to identify the pooling of liquor in the vagina.Alternatively the women is given preweighed pads ,which are reweighed after some time. b]The diagnosis should be explained to the patient.I would like to tell the patient in a sympathetic manner regarding the likely outcome of PPROM.These may be spontaneous preterm delivery,continuation of pregnancy with planned induction at 34 weeks or continuation of pregnancy with unplanned delivery because of suspected infection. Patient should be expalined in written regarding the foetal/neonatal risks associated with prematurity and infection.Patient may need inpatient admission for the 48 hours in view of preterm labour.She is asked to report if she feels unwell or the vaginal loss becomes green,offensive or blood stained.She will need FBC ,CRP 2-3 times a week to identify the evidence of sepsis.She should have endocervical swab,urethral swab,HVS and low vaginal and perineal swab also to identify GB streptococcal infection.Foetal growth scan is done 2weekly as the clinical assessment is unreliable. Patient shouls liase with the neonatologist and the balanced prognosis should be provided according to her gestation on the data form by the local neonatal unit.She should be told that she needs 2 injections of betamethasone 12 mg in 24 hours as it reduces the incidence of RDS,IVH,NEC in the preterm baby.She aso should be told that she needs to take antibiotics like erythrmycin 250mg 4times a day fo 10 days to prevent the infection associated with PPROM as per ORACLE study.Tocolytics do not have much role unless patient develops preternm labour and needs time for in utero transfer for the steroids to act. c]The main risks to the patient are prematurity and maternal/foetal&neonatal infection.Prolonging the pregnancy reduces the risks associated with prematurity,but increases the risk of infection.After discussing these risks with the patient,the joint decision is taken on the timing and the mode of delivery.It is accepted that before 34weeks ,the balance of risk is in favour of prolonging pregnancy.Any evidence of chorioamnionitis at 28 weeks or before 34 weeks is justification of delivery;especially if corticosteroids have already been given.Foetal compromise in the form of abnormal CTG is also the indication of delivery.PPROM comprises of 3% of pregnancies.50%of women will deliver with in 24 hours of rupture of membranes and another 50%every subsequent week.At 34 weeks planned induction can be carried out/or CS if the cervix is unfavourable.
		Posted by Manoj M. Wed Jan 14, 2009 06:20 am
A healthy 27 year old woman presents with suspected rupture of the membranes at 28 weeks gestation. (a) How would you confirm the diagnosis? [4 marks] (b) You have confirmed the diagnosis and she is not in labour. What would you tell the woman? [10 marks] (c) Evaluate the factors that would determine the timing and mode of delivery [6 marks]. a) A detailed history which includes a significant rupture of membranes like large gush of fluid may suggest a definite rupture of membranes. The timing and persistance of leaking fluid, color of fluid and offensive or not may suggest presence of underlying infection. A history of underlying urinary tract infection or smell of urine may distinguish from rupture of membranes. A sterile speculum examination with finding of pool of liquor in posterior fornix will confirm rupture of membranes. If speculum examination is inconclusive an ultrasound scan with suggesion of reduced/absent liquor volumewill help in the diagnosis. b)Explain the diagnosis of preterm prelabour rupture of membranes(PPROM) to the patient that she is only 28 weeks and confirmed rupture of membranes in simple understanding words. Explain to her the significance of preterm gestation and PPROM is associated with increased perinatal morbidity and mortality as increased risk of prematurity, chorioamnionitis and fetal lung hypoplasia. With confirmed PPROM there is increased likelihood she may go into preterm labour and her baby may require long term neonatal care and arrange opportunity for her to speak with the paediatritian. She may require inutero transfer depending on neonatal cot availability especially if she she goes into preterm labour and may need to consider tocolysis for transfer. She should be recommended to stay in the hospital for first 48-72 hour for monitoring of infection and as risk of peterm labour. She will have CTG monitoring, vaginal swabs done when speculum examination to look for any signs suggestive of infection. She should be offered steroid treatment to reduce the incidence of respiratory distress syndrome, intraventricular haemorrhage and necrotising enterocolitis. She should be offered antibiotics (Erythromicin 250mg QID for 10 days) to reduce the incidence of infection associated with PPROM She should be explained if she she does not labour in 48-72 hours out patient management with increased surveillence will be organised. She should be explained regarding symptoms and signs of chorioamninitis like fever, raised temperature, offensive discharge vaginally which if she suspects should return to hospital immediately and if possible to record her temperature daily twice. With outpatient management she will be seen every week in day assessment unit for monitoring her baby and to monitor infection untill delivery. c)Maternal factors affecting delivery will depend on her previous obstetric history associated with scars on uterus and may need caesarean delivery Infection status which is suggestive of chorioamnionitis may warrant urgent delivery irrespective of her gestation. Fetal factors includes viability of pregnancy at presentation, with fetal demise may need delivery straight away or with signs of fetal distress on CTG may warrant urgent delivery and may need caesarean section at 28 weeks gestation. If pregnancy continues with expectant management the current recommendation is to delivery at 34weeks, she should be counselled with increase risk of chorioamnionitis and consequence vs decreased risk of serious neonatal respiratory problems. She should also be counselled regarding increase risk of neonatal intensive care of her baby and increased risk of caesarean section at 34 weeks gestation. Fetal presentation at 34 weeks will also guide regarding mode of delivery as incresed risk of malpresentation at 34 weeks gestation and may warrant a caesarean section. Presence of underlying obstetric conditions like placenta previa may also necissitate the need for caesarean section.
		Posted by Nero N. Wed Jan 14, 2009 07:23 am
A= Careful history is taken including feeling of sudden gush of watery vaginal discharge variable in amount. Abdominal examination can reveal fundal level less than that expected for gestational age with or without uterine contraction. Pelvic speculum examination can show liquor coming through the cervix. A sample is take from vaginal fornixs and put on a slide and allowed to dry, if liquor present , it can give a crystallization phenomena. Fetal fibronectin can be detected also. B= We inform her that she has preterm prelabour rupture of membrane and this can be attributed to many causes like sub clinical infection of amniotic fluid, cervical weakness or local vaginal infection. However, many cases occur due to unknown causes. The woman informed that she will need close observation to monitor her general condition and her fetus wellbeing. Also she will need a corticosteroid injections to enhance fetal lung maturity and reducing incidence of RDS in case she has preterm labour, these injections can also reduce incidence of fetal intracranial haemorrhage. Broad spectrum antibiotic that cover anaerobes will be prescribed also to reduce risk of chorioamnionitis. We inform her that a Multidisplanary team will be involved in her management including senior obstetrician, anesthetist and neonatologist and she may require to be transferred to tertiary centre for more advanced facilities. We explain to her that she will have daily CTG test which can give signs of fetal distress. Doppler US will be done weekly to see blood flow in umbilical vessels to detect utero-placental insufficiency and impending fetal demise. She will need also blood tests to detect signs of infection. High vaginal swap will be taken also to detect and treat infection if present. Further USS will be done two weeks later on to detect fetal growth and amount of liquor. The mother informed that there is no single fetal surveillance test that can ascertain fetal wellbeing for sure. We inform her that pregnancy will be allowed to continue as far as she and her baby are in acceptable condition. If she develop premature uterine contraction, tocolytics drugs can be given to her. Sometimes she may progress to have preterm labour. Iatrogenic preterm delivery can be employed if her condition or fetal condition deteriorate, her doctor or the medical staff will select the favorable time and mode for her delivery after balancing risk of continuing pregnancy against risk of prematurity. C= Time and mode of delivery will be decided according to fetal gestational age, lie and presentation. If the foetus reach 34 weeks gestation, the risk of developing RDS after delivery will be less. Foetus with longitudinal lie and cephalic presentation can be allowed for vaginal delivery if there is no contraindications. Maternal general condition and fetal wellbeing can affect the decision also as abdominal delivery by caesarian section will be selected when there is signs of impending fetal demise. Maternal parity and cervical bishop score can affect mode of delivery, primigravida with unfavorable cervix may indicate that vaginal delivery will take long time with high incidence of failure and this will be on account of both; the mother and foetus so caesarean section will be favorable.
		Posted by syeda sajida M. Wed Jan 14, 2009 08:13 am
(a) History from patient regarding rupture of membranes to confirm diagnosis is of crucial importance .I will ask her whether there was gush of water and about colour of liquour.I will do the sterile Speculum examination,to confirm the presence of liquour in the vagina and to take HVS.VE is not recommended if patient is not in labour .ultrasound can confrim PPROM in some cases but not all. b. Incidence of pretem rupture of membranes is 2-3 %. Pretem rupture of membranes is associated with the increase Risk of perinatal morbidity and mortality as well as maternal morbidity.I will inform my pt. that there is risk of infection for her as well as for her boby.she can suffer from Chorioamnionitis which requires hospitalization and I/V Antibiotics.PPROM is associated with increase risk of preterm delivery approximately 75% of women at 28 weeks with PROM go into establish labour in 7 days.So her baby is at risk of prematurity as well as infection.I will offer her admission in the hospital.I will give her steroids (Betamethasone) 24 mg 1/m in 24 hours for fetal lung maturity.I will assure her that Single course of steroids will not be harmful for her and her baby.i will tell her that she needs Antibiotics (Erythomyin) 250 mg 6 hourly for 10 days to prevent infection.She will need close monitoring with temperature,pulse 4 hourly.Abdominal palpation for tenderness which is one of the sign of chorioamnionites.daily monitoring for colour of liquour.she needs twice weekly FBC for leucocytosis ,weekly CRP and HVS to diagnose any infection.She will need close fetal monitoring by daily cardiotocograph,weekly ultrasound for dopller and Amniotic fluid volume and 2 weekly growth scan.tocolytics are not needed unless she is in labour as they are not proven to improve fetal outcome.their value is only to gain some days for intrauterine Transfer or for Corticosteroids to work.I will inform the NICU and infrom my patient that in case of Preterm delivery her baby will need admission to NICU.and may need to stay there for long time. I will inform her if she remains asymptomatic for 48 -72 hours she may be discharged home after discussing with consultant.In that case she need close monitoring at home with temperature,pulse 2 times a day and watch for color of liquour.she should know the signs and symptoms of chorioamnionitis such as pyrexia,palpitations abdominal pain tachycardia and foul smelling discharge then needs to report immediately to the hospital.she will be given appointment to Day assesment unit fro regular monitoring for her and her baby.so her complaince with this scenario is of great importance.I will give her written information. (c) Timing of delivery in PROM is influenced by gestational age maternal and fetal condition.If no sign of maternal and fetal infection then delivery should be planned at 34 weeks.But delivery beyond 34 weeks will be associated with increase risk of chorioamnionitis but reduces risk of Neonatal respiratory Distress syndrome,admission to SCUBU and risk of caesarean section.premature delivery in case of fetal compromise or maternal chorioamnionitis associated with increase risk of neonatal respiratory distress syndrome,intra cerebral hammorage and Necrotising enterocolitis.Timing of delivery is influenced by availability of incubator in NICU.in case of unavailability ,arrangements of inutro transfer should be done.Mode of delivery is influenced by fetal presentation as in case of Cephalic presentation Vaginal delivery should be considered. In case of preterm Breech presentation Couple should be councelled for risk and benefits of vaginal breech delivery V/S ceaserian section and their wishes should be taken into account.
		Posted by Maayka .. Wed Jan 14, 2009 10:49 am
) A history of a gush of fluid per vaginam with continuous trickling and not associated with urgency or urge incontinence will suggest PPROM. The time and duration of event should be taken into consideration because if it was one episode or few hours later there may be no visible evidence on examination. Examination of the pad for soiling with clear fluid, which does not resemble urine, suggest liquor. If uncertain still, a sterile speculum exam to check for pooling of fluid in posterior and rule out cord prolapse should be done. If these still not definitive, an ultrasound can be done to rule out possible oligohydramios. b) I will tell her that at 28 weeks gestation there is a 50% risk of these cases going into labour, most within 48hrs, if not by 7 days. She should be advised of the risks of infection i.e. associated chorioamnionitis and subsequent endometritis and puerperal sepsis. In patient monitoring, will be advised for most cases, at least for 48- 72 hrs and only the consultant can decide thereafter if there is a possibility of outpatient monitoring. The maternal vital signs will be checked for signs/ symptoms of infection, looking for increased temperature, pulse, uterine tenderness. Also fetal heart rate will be checked every 8 hrs to detect any fetal tachycardia subsequent to infection. She will be advised to wear a pad at all times and assessment of the colour of fluid draining done. Prophylaxis vs. infection will be given in the form of Erythromycin for 7 days and any swabs done on vagina / urethra followed up and any identified infections treated. The risks should be explained of prematurity i.e. delivery before 37 gestation, of sepsis in the neonate, intraventricular haemorrhage and respiratory distress syndrome. The latter can be prevented by the use of corticosteroids which the mother is likely to be offered in the form of Bethamethasone for 2 doses. There will also be checks on a blood test done weekly, a CBC, to look for leucocytosis, again another sign of infecetion. If she goes into labour and allowed a vaginal delivery, she would be kept in close proximity to a neonatal ICU. This is to afford the infant best care from birth. The fetus antenatally would be monitored every 2 weeks with ultrasound. Prolongation of the pregnancy till 34-37 wks will be individualized depending on the findings of all the reports of CBC, swab and ultrasounds, with the maternal vital signs and fetal heart rate. There is further risk of infection occurring the longer the pregnancy is prolonged vs. the risks associated with prematurity. c) Her gestation if multiple like twins vs. singleton is likely to make her go into labour soon and before 37 weeks gestation. The presence of signs of infection with increasing gestation age is going to warrant a planned induction of labour. The earlier the gestation, the evidence of infection must be unequivocal to avoid the risks of prematurity but if more than for instance 32 weeks there will be less hesitation because the neonatal morbidity/ mortality is significantly reduced then as opposed to delivery at 28 weeks. If there is any sign of fetal distress or severe oligohydramnios then delivery will be justified immediately. The presentation of fetus and favourability of cervix will determine the mode of delivery. If breech, likely that C/ Section will be advised because the evidence of the term breech trial is only applicable to term pregnancies. There is insufficient data otherwise for preterm babies.
		Posted by shree D. Wed Jan 14, 2009 12:19 pm
A healthy 27 year old woman presents with suspected rupture of the membranes at 28 weeks gestation. (a) How would you confirm the diagnosis? [4 marks] ( In the history, the presence of constant leaking with a sudden onset with or without abdominal pain should be checked. On examination, the fetal limbs may be markedly palpable in the presence of SROM, the symphysio fundal height may be less than expected at 28 weeks gestation. On performing a speculum examination, the presence of liquor may well be seen in the vagina on coughing. A fetal fibronectin test can also be performed to confirm SROM, or nitrazine stick test. An ultrasound can confirm the presence of reduced amiotic fluid volume. b) You have confirmed the diagnosis and she is not in labour. What would you tell the woman? [10 marks] The main risks of premature pre-labour rupture of membranes are chorioamnionitis and pre-term labour. 40% of pre-term labours present with PPROM. Admission would be warrented in case she should go into labour within the next 48 hours. She should have 8 hourly temperature and heart rate monitoring, to exclude an infection developing. A high vaginal swab should be taken at the time of examination and MSU sent for analysis to exclude a potential source of infection. A CTG should be performed to check the fetal heart is reassuring, and exclude tachycardia-a marker of infection. As she is 28 weeks\' gestation, the administration of steroids to assist the development of lung maturity should be considered. Blood should be taken for FBC and CRP every other day to check for infection. She should also receive antibiotics to reduce the risk of chorioamnionitis for 10 days. A multi-disciplinary approach should be taken with the neonatologists, who should counsel the woman on the problems associated with premature delivery at 28 weeks. An ultrasound should be performed to identify presentation, should the patient go into pre-term labour. Discharge should be considered after at least 3 days\' admission as an inpatient. After this, she should be reviewed int he day assessment unit once weekly for HVS and bloods. At home, she should check her temperature daily. If any of these parameters change, or she feels abdominal pains, she should come in. (c) Evaluate the factors that would determine the timing and mode of delivery [6 marks]. The presence of maternal pyrexia, feeling unwell and tachtycardia would suggest the presence of underlying infection, which would trigger induction of labour or delivery. In addition, raised white cell count and CRP would also be indicators used to consider delivery. If the patient goes into spontaneous labour, she should be allowed to do so (depending on presentation and fetal heart). Presentation and lie will also determine the mode of delivery. If the patient is over 34 weeks\' gestation, an induction of labour can be considered, depending on the presenation, lie and findings on vaginal examination. The risks of delivery at 34 weeks and the risks of possible chorioamnionitis should be discussed with the patient in full.
		Posted by Seema B. Thu Jan 15, 2009 03:50 am
a) History of sudden gush of liquor associated with continuous leaking is highly suggestive. Further confirmation is done on speculum examination showing fluid coming through os or collection in posterior fornix. In cases of doubt ultrasound scan is done to look for oligohydramnios. If diagnosis is still doubtful admission and pad charts for leaking may help to confirm the diagnosis. Nitrazine test and Fern test have false positive rates. Fetal fibronectin and raised insulin like growth factor binding protein -1 in vaginal secretion are new modalities for diagnosing ruptured membranes.not available everywhere. b) I will explain the diagnosis to the woman that the membranes have ruptured.The risks of prematurity and its associated complications and maternal risk of chorioamnionitis will also be explained to her.There is a small risk of lung hypoplasia and postural deformities although more common before 26 weeks gestation.The aim of management is to reduce these risks and keep her under surveillance for early detection and treatment of chorioamnionitis. SCBU will be informed and if neonatal facilities are not available an in utero transfer will be arranged as she is not in labour. Steroid in the form of inj Betamethasone12 mg IM 2 doses 24 hrs apart will be given to accelerate fetal lung maturity.It will help to reduce the risks of respiratory distress syndrome,intraventricular haemorrhage and necrotising enterocolitis. Antibiotic tablet Erytromycin 250 mg qid orally will be given for 10 days to reduce the risk of infection and help prolongation of pregnancy. She will be admitted as inpatient for regular maternal and fetal surveillance.The inpatient monitoring will include daily clinical assess ment by an obstetrician. Pulse and temperature will be checked 4-6 hourlyDaily examination willbe done to look for uterine tenderness,liquor loss and colour and daily ctg for fetal tachycardia and uterine contractions if any. FBC and CRP will be done twice weekly and HVS weekly to detect infection.LVS and urethral and rectal swab for group B streptococcal infection will also be done. FEtal growth will be monitored by growth scans done fortnightly as clinical assess ment is unreliable in presence of ruptured membranes. She along with her husband will be couselled by a neonatal team regarding prognosis of baby. There may be a small place for outpatient management in absence of infection and labour.This will be a consultant decision after atleast 48-72 hours of inpatient monitoring.The monitoring for signs and symptoms of chorioamnionitis will be explained to her and an outpatient follow up arrangement organised. If pregnancy progresses uneventfully the aim of management will be to prolong pregnancy to 34 weeks. I will provide her with written information and contact details c) Gestational age is an important determinant regarding timing of delivery.Aim is to prolong pregnancy to 34 weeks.If continuing pregnancy beyond 34 weeks the incresed risk of chorioamnionitis has to be balanced against reduced risk of respiratory morbidity and SCBU admission. Evidence of fetal compromise or chorioamnionitis will dictate an urgent delivery irrespective of gestational age. If labour starts pregnancy has to be terminated.There is no proven evidence for benefit of tocolytics in prolonging pregnancy in presence of ruptured membranes except for administration of corticosteroids or in utero transfer. Timing of delivery will also depend on the neonatal facilities available for resuscitation of preterm babies. Vaginal delivery will be aimed for unless there are obstetric indications for cesarean sections like placenta praevia.cord prolapse Fetal presentation and previous scars should also be taken into consideration before deciding on mode of delivery. Induction of labour has to be undertaken at 34 weeks.Chances of failed induction are high at this early gestation which may necessitate a cesarean section. Womans wishes should be taken into account.
		Posted by Mark D. Thu Jan 15, 2009 05:57 am
c) Delivery should be considered if any signs of chorioamnionitis develop. Abnormalities in ctg would also necessitate delivery urgently. If there is any obstetric indication like placenta previa,previous classical ceserrean section,CPD, then delivery will be by ceserrean section. Breech presentation is not an absolute indication for ceserean section (CS)in preterm cases. Urgency of delivery like abruption or ctg abnormaliteies may need delivery by CS. Failed induction of labour, very poor bishops score(less than 6) will need CS. maternal wishes (1) should be taken into account when deciding mode of delivery. in absence of any complications induction should be done at 34 completed weeks. timing of delivery: Spontaneous labour could occur; pregnancy advances to 34 weeks, evidence of sepsis, membranes re-seal and pregnancy progresses to term (rare). You were not expected to present a list of obstetric reasons that prompt delivery Mode of delivery: Spont labour – aim for vaginal delivery even if breech and CS for obstetric indications. IOL required – then only if cephalic and CS if breech dear dr paul, i did not get your point. i have covered all the points which you have highlighted, in my answer to the section \'c\'. how should i have written it? pl specify.
		Posted by M M. Thu Jan 15, 2009 08:57 pm
a) History of sudden leakage of fluid from vagina running down the legs or wetting her clothes is suggestive of spontaneous rupture of membranes. The colour and odour of the fluid will be enquired to exclude urinary incontinence. Abdominal palpation may reveal symphysial-fundal height smaller than date. Vulva or pad may be damp or vernix noted during vulval inspection. Sterile speculum examination demonstrating leaking of liquor from cervical os or pooling of liquor in posterior fornix confirms the diagnosis. Ultrasound scan may show oligohydramnios that can further support the diagnosis. b) The woman will be informed of her preterm prelabour rupture of membranes diagnosis(PPROM). She will be counselled that PPROM is associated with risk of chorioamnionitis and premature delivery. She will need to be admitted for observation for symptoms and signs of premature labour and also chorioamnionitis. She will be observed at least 12hrly for symptoms of chorioamnionitis such as maternal pyrexia, offensive vaginal discharge, uterine tenderness and foetal tachycardia. She will have high vaginal swab taken weekly to detect any infection. Blood test(FBC) will be taken at least weekly to detect leucocytosis that may be indicative of infection. She will be prescribed with antibiotics (erythromycin 250mg 6hrly orally) to reduce risk of infection. She will also receive corticosteroid intramuscular injection to reduce risk of neonatal respiratory distress syndrome, intraventricular haemorrhage and necrotising enterocolitis in case she delivers prematurely. She will be seen by the neonatologist to further discuss the prognosis of the baby. After 48-72hrs of in-patient observation, she may be suitable for outpatient monitoring after assessment by consultant obstetrician.She will need to monitor her temperature and asked to attend immediately if she has any symptoms of fever, abdominal pain, offensive vaginal loss or reduced foetal movements. She will be given a written information leaflet and also appointment for follow up. In cases where she doesn\'t labour spontaneously and there are no signs and symptoms of chorioamnionitis or foetal distress, she will be managed expectantly until at least 34weeks. c) Delivery should be considered at 34weeks gestation. However, if there are symptoms or signs of chorioamnionitis or foetal compromise, delivery should be expedited. If the mother declines induction of labour after 34weeks, she should be counselled regarding high risk of chorioamnionitis. The neonatologist should be informed of planned delivery to ensure bed availability in neonatal care. In cases where it is not available, in-utero transfer should be considered. Tocolysis may be given in this case. The fetal presentation and lie will influence the mode of delivery. In cephalic presentation, induction of labour is indicated. In preterm breech presentation, vaginal delivery is associated with perinatal morbidity. However, there are limited evidence to suggest caesarean delivery is safer. Therefore the mode of delivery should be discussed with the woman. Caesarean delivery is indicated if the fetus is in transverse lie or in the presence of placenta praevia. It is also indicated in cases where delivery is urgent such as in foetal distress.
		Posted by Atashi S. Fri Jan 16, 2009 04:32 pm
(A)For confirmation of diagnosis proper history and clinical examination is important. Nature of event should be noted whether it was gush of fluid or trickling or dampness. Examination of women under wear or pad for inspection of colour and odour of the fluid. Identification of continuing loss of fluid is important, a single episode with no further leakage for several hour makes membrane rupture unlikely while continuous leakage is highly suggestive. If uncertainity arises then sterile examination is to be done to detect pooling of fluid in the posterior vaginal fornix. (B) Explanation of the diagnosis is to be done at first. I will explain her regarding the risk of maternal and foetal infection associated with premature rupture of membrane. She should be informed about the likely outcomes including spontaneous pre-term delivery,continuation of pregnancy with planned induction at 34 to37 weeks of gestation , continuation of pregnancy with unplanned delivery because of suspected infection, rarely sealing of leaking of membrane with continuation of pregnancy up to term. There is a 50% chance to go into spontaneous labour within 7days. Majority of them within first 24 hour that\'s why she need inpatient care for atleast for first 48 hour. Explanation is to be given to her regarding prolonging of pregnancy is in favour against the risk of infection at this gestational age. She should be informed regarding the risk of prematurity including including necrotizing enterocolities, respiratory distress syndrome and intraventicular hemorrhage. She should be informed regarding the need of corticosteroid. Explanation is to be given to her regarding the need of erythromycin in preventing infection and prolonging pregnancy.Discuss should be done about use of tocolysis.She should be award regarding sign of infection including filling unwell, offensive vaginal discharge, onset of vaginal bleeding and rise of temperature. I will discuss with the women regarding the timing and mode of delivery .she need counseling with neonatologist.If local neonatal unit unable to manage the premature baby then I will discuss with her regarding the need of in-utero transfer in a unit with available intensive neonatal facilities.Information should be provided to her that should be balanced and stress the positive as well as the adverse outcome of delivery at this specific gestational age based on data available for local neonatal unit. (c) If uterine contraction developed spontaneously and there is no evidence of maternal and fetal infection then I will allow for vaginal delivery.If Women developed fever ,tachycardia, uterine tenderness, vaginal bleeding it need urgent delivery and if there is a possibility of prolong induction delivery interval then caesarian section would be the preferred mode of delivery.Full blood count & CRP monitoring should be done 2-3 time per week and if there is evidence of sepsis it need urgent delivery.CTG abnormality also indicates need for urgent delivery. If all maternal and foetal observations are satisfactory then I will consider delivery with planned induction at 34-37 week gestation.
		Posted by Mark D. Thu Jan 22, 2009 04:59 am
THANK YOU SIR, I APPRICIATE YOUR VALUABLE FEEDBACK.