PROM Approach

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?

• 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

• FMHx:
  • Similar complaint?
  • Same diseases as in PMHx?

• Social Hx:
  • Occupation, living situation, support, stress?
  • Smoking, alcohol, recreational drugs?
  • Diet and exercise

 

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– 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:

1. Admit
2. Abx prophylaxis for GBS
3. Deliver
   • If amnnionitis, non-reassuring fetal testing, abruption, advance labor -> DELIVER!
   • Otherwise, if stable -> delay delivery till 34 wks

 

If < 34 weeks:

1. Admit to a tertiary care facility
2. Continuous monitoring of the mother and fetus (esp for chorioamnionitis)
3. 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

1. Antibiotics for GBS:
   • Penicillin G: 5 million units IV, followed by 2.5-3.0 million units IV every 4 hours

1. Magnesium sulfate (if 24-32 wks):
   • Neuroprotection against CP and other motor dysfunx

1. Tocolytics: (upto 48 hrs -> to delay delivery until the steroids we’ve given take action):
   • 1^st line -> Indomethacin (24-32 wks): concern of premature constriction of DA
   • If contraindicated -> 2^nd line: nifedipine (32-34 wks)
   • 3^rd line -> terbutaline

1. 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

 

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