Scenario: Pregnant lady presenting with clear vaginal fluid
– History –
- CC:
- Onset: first time? When? What were you doing? Sudden\gradual? Continuous\intermittent? Getting better\worse?
- Characteristics: amount? Color? Smell? Blood streaks?
- Associated sx:
- Constitutional: fever, chills, appetite?
- Labor: abdominal cramps, lower back pain, pelvic pressure, fetal movements?
- Vagina: vaginal bleeding (if yes, ask about anemia sx), clear fluid gush\leak, discharge, itching?
- Urinary sx: dysuria, flank pain?
- Preeclampsia: headache, visual changes, epigastric pain, N\V, lower limb swelling?
- Obstetric Hx:
- Gravida? Para? Abortions? Living?
- If prev: mode of delivery? Fetal\maternal complications?
- LMP? Due date?
- Last US: when? Results? Singleton or multiple gestation?
- Screening: GBS, GDM, rubella immunization, blood type\Rh immunization?
- Gravida? Para? Abortions? Living?
- Gynecological Hx:
- Menstrual hx: regular periods? Intermenstrual bleeding?
- Contraception use, IUCD?
- Gynecological procedures, IVF\induction of ovulation?
- PMHx:
- Diseases:
- Chronic ds (HTN, DM\GDM, DLP)
- Cardiac, thyroid, SLE
- Hematological (anemia, APS)
- Gyn (PID, fibroids, uterine anomalies)
- Medications: abx, steroids, anticoagulants, folate, herbal
- Surgery, hospitalization, trauma
- Allergies
- Diseases:
- FMHx:
- Similar complaint?
- Same diseases as in PMHx?
- Social Hx:
- Occupation, living situation, support, stress?
- Smoking, alcohol, recreational drugs?
- Diet and exercise
– Physical Exam –
- WIPE, blah blah, chaperone
- Vital signs: pulse, BP, temperature
- General inspection: weight, distress, pallor
- Chest: signs of pneumonia, cardiac diseases\murmurs
- Abdomen:
- Inspection: scars, contours, fetal movements, linea nigra, striae
- Palpation: tenderness, guarding, rebound, uterus, masses, organs, contractions
- Measure fundal height, fetal lie, presentation, engagement
- Leopold’s maneuvers
- Auscultation
- Speculum:
- Cervical dilation
- Amniotic fluid leaking with fundal pressure, straining or coughing
- Signs of PROM (pooling of amniotic fluid, nitrazine paper, ferning)
– Investigations –
- US: amniotic fluid index, placenta, GA, fetal growth and presentation, maternal structural abnormalities
- Labs: CBC (WBC for infection, Hg for anemia, blood type), midstream urine sample, vaginal\cervical\rectal swabs and culture (mainly for GBS)
- Fetal wellbeing: continuous electronic fetal heart monitoring, CTG, fetal lung maturity
- For preterm labor -> consider fetal fibronectin: in women <34 weeks of gestation with cervical dilation < 3 cm and cervical length 20 to 30 mm on transvaginal ultrasound examination
– Management –
If ≥ 34 weeks:
- Admit
- Abx prophylaxis for GBS
- Deliver
- If amnnionitis, non-reassuring fetal testing, abruption, advance labor -> DELIVER!
- Otherwise, if stable -> delay delivery till 34 wks
If < 34 weeks:
- Admit to a tertiary care facility
- Continuous monitoring of the mother and fetus (esp for chorioamnionitis)
- Steroids “to accelerate lung maturity”:
- Betamethasone: 2 doses of: 12 mg, IM, 24 hrs apart
- Dexamethasone: 4 doses of: 6 mg, IM, 12 hrs apart
- Antibiotics for GBS:
- Penicillin G: 5 million units IV, followed by 2.5-3.0 million units IV every 4 hours
- Magnesium sulfate (if 24-32 wks):
- Neuroprotection against CP and other motor dysfunx
- Tocolytics: (upto 48 hrs -> to delay delivery until the steroids we’ve given take action):
- 1st line -> Indomethacin (24-32 wks): concern of premature constriction of DA
- If contraindicated -> 2nd line: nifedipine (32-34 wks)
- 3rd line -> terbutaline
- Prevent chorioamnionitis:
- Clinical findings: fever, uterine fundal tenderness, maternal \ fetal tachycardia, purulent\foul amniotic fluid
- Prevention:
- 1 dose of azithromycin upon admission, 1 g orally. Plus, a 7-day course of:
- IV ampicillin (2 g every 6 hrs for 48 hrs) -> oral amoxicillin (500 mg 3 times\d for 5 days)
- Treatment: IV Ampicillin + gentamicin until delivery (+clindamycin or metronidazole if C-section)
– Complications –
- Maternal:
- Chorioamnionitis, endometritis
- Maternal sepsis\death
- Abruptio placenta
- Fetal:
- Oligohydramnios -> Umbilical cord compression, pulmonary hypoplasia
- Prematurity -> RDS, necrotizing enterocolitis, IVH, CP
- Neonatal sepsis