Sunday, September 26, 2010

Preterm Prelabour Rupture Of Membranes (PPROM)

Teaching with Dr Suhaiza =)

23 years old malay housewife G2P1 @ 34weeks POG, antenatally she is underweight, having asymptomatic anemia at 29 weeks, diagnosed to have bronchial asthma since childhood, on medication & partially controlled currently presented with leaking liquor with no other signs of labour & no symptoms of chorioamnitis

Suggestive history of leaking liquor:
ask the amount - in this patient 2 soaks sarong
With these kind of amount less likely due to urination

why u ask previous history of SI???
student would usually say it might be the cause of leaking
actually, it is not. We ask because sometimes in the morning upon waking up, a woman could have flowing out of semen from vagina due to previous SI. She mistakenly think it is leaking liquor.

Ask for signs of chorioamnitis. Need to highlight this in the history
mother - fever, contraction pain

Since we are 5th year, while asking about contraceptive methods, dont just ask about pills. Do ask about other methods as well (injection, implanon, IUCD, barrier method or natural contraception- safe period or coitus interruptus)
" This patient only used oral combine pills & did not use other methods as her mode of contraception"

Bronchial asthma - need to evaluate her asthma is well/partially/poorly controlled

In general, what is the risk factor that predispose pregnant women to PPROM??
Overdistension of uterus - polyhydramnios, multiple gestation
Infection - UTI/ asymptomatic bacteriuria, GBS, bacterial vaginosis
History of massage the abdomen
History of fall

In ward, what need to be asked to the patient??
Patient still leaking in ward
How many pads??
if patient, had stop leaking, need to ask why patient still in the ward.

What should be done with patient in the ward that presented with leaking??
Measure the AFI

How to objectively measure the AFI? Ultrasound

How can you asked the patient wether she knows the US result or not??
If patient said, she was not told of the result & doctor only said everything ok
meaning the liquor is normal. But if you dont wantto assume. Just said patient did not know of the result.
(This shows to the examiner that you are looking for evidence of oligohydramnios secondary to leaking liquor)

It is important to ask about the liquor because...
if patient severe oligo currently at 34 weeks & still leaking in the ward...
the doctor might consider early delivery & would not wait til 37weeks

What would you look for in this patient particularly in her case??
Physical examination
Toxic looking, anemic
Temperature - febrile
Pulse rate - tachycardia
Resp rate - tachypneic
Blood pressure - hypotension

Tender abdomen, irritable uterus - evidnce of chorioamnitis
Uterus smaller than date - evidence of oligohydramnios secondary to LL
Assess clinically, amniotic is adequate or not

Speculum examination:
Confirm the leaking, observe pooling of liquor at posterior fornix
If absent, ask patient to cough & observe flowing of liquor from os & pooling at post fornix
Litmus test - turn to blue (liquor is alkaline)
do HVS (high vaginal swab)

VE examination - check the integrity of membrane/already ruptured
assess the cervix:length, consistency, dilatation

How do you manage this patient??
FBC - evidence of infection
Urinalysis - evidence of asymptomatic UTI

Fetus: CTG (reactive/not) & US (AFI & fetal biometry - fetal parameters)

Bear in mind there are 2 possibilities patient could have uterus smaller than date
1) oligohydramnios secondary to Leaking liquor (LL)
2) TRO SGA/IUGR (as this patient has bronchial asthma & she is Orang Asli - small build mother, malnutrition,etc)

Start patient on antibiotic T.EES 400mg BD for 1week
Put patient on pad chart - to monitor progress of the leaking liquor
FKC (to monitor the progress of baby)
Labour progress chart
Watchout for sign & symptoms of chorioamnitis
IM dexamethasone 2 doses of 12mg 12 hours apart
Tocolysed patient if contraction 1:10

(generally there was no role of dexamethasone&tocolyse in 34weeks of pregnancy, but in this centree (HTAA), NICU is small & limited ventilator. So, the doctor's here will try to prolong the labour until term by using dexamethasone&tocolytics)

Tocolyse is use in 2 conditions:-
Not to STOP the labour but to DELAY the labour in order to
1) buy time to complete dexamethasone
2) while mother is transport to another hospital for delivery where there is ventilator

The best tocolyse being use (in transportation) - subcutaneous
(in this patient, its best to use sc terbutaline/salbutamol)

oral - is not appropriate to be used
IV infusion - hard to monitor in the ambulance

Types of tocolyse:
1) terbutaline sulphate
2) salbutamol
3) T. nifedipine
4) IV MgSO4
5) GTN - not used in HTAA
6) Atosiban - expensive but effective
7) Ritodryl - no longer use. can cause postural hypotension

For example, patient develop fever, abdominal pain, PV discharge, Tooxic looking??
suspected chorioamnitis

what should be done??
She was already started on Tablet form antibiotics...change to IV antibiotics
Plan for delivery.
Which type pf delivery?
To determine, Bishop Score need to be done
If cervix is not favourable & by palpation, head is floating --> LSCS

If cervix is favourable & head atleast 4/5 palpable & baby stable
--> sent patient to labour room for SVD
give patient pitocin & augment the labour
start intrapartum IV ampicillin

eventhough cervix is favourable + evidence of fetal distress --> LSCS
During LSCS, after open the abdomen, pack the surrounding
then incise the uterus & take out the baby (done while sucking the amniotic fluid)
Later, clean the surrounding
(this is done to prevent infection from going to the peritoneal cavity)

If patient suspected to have GBS in pregnancy,
plan for intrapartum antibiotic during SVC
but if patient undergo LSCS - no need antibiotic (no contact of baby to the vagina)
Need to screen patient for GBS during her antenatal in her next pregnancy
(take urine, vaginal culture)

Also GBS is investigated in patient with her newly delivered baby in her previous pregnancy having pneumonia & need intubation

In treating bacterial vaginosis, there was no antenatal&intrapartum antibiotics guidelines

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