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

 


– 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. Steroidsto 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):
    • 1st line -> Indomethacin (24-32 wks): concern of premature constriction of DA
    • If contraindicated -> 2nd line: nifedipine (32-34 wks)
    • 3rd 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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