Term PROM since 18 hrs and not in labor with 1 cm dilatation. What should be the appropriate management?
a) Wait for 6 hrs for spontaneous onset of labor and then CS
b) Induce with misoprostol for 6 hrs and CS after 6 hrs if failed induction
c) Induce with misoprostol and wait for at least 24 hrs for onset of labor
d) Perform CS directly without inducing
Correct Answer: C. In women with PROM at term, labor should be induced immediately and expectant management should is not practiced anymore (Ref: ACOG/ WHO guideline).
a) Strong evidence of rupture of the membranes.
b) Presumptive evidence of intact membranes.
c) An evidence of intact membranes.
d) Presumptive evidence of intact membranes.
Correct Answer: a) Strong evidence of rupture of the membranes. It is used to test vaginal pH during late pregnancy to determine the breakage of the amniotic sac. While vaginal pH is normally acidic, a pH above 7.0 can indicate that the amniotic sac has ruptured. (However, elevated pH can also be associated with bacterial vaginosis)
In the diagnosis of premature rupture of the membrane, all of the following are true EXCEPT:
a) History of fluid loss per vagina
b) Visualization of amniotic fluid in the vagina by sterile speculum
c) Positive Nitrazine test
d) Positive fern test
e) Positive methyline blue test
Correct Answer: e) Positive methyline blue test. A fern-like pattern can be seen on microscopic exam when estrogen and amniotic fluid mix together and cause salt crystallization.
25 yr old woman at 21 weeks of gestation with pre-term premature rupture of membranes. Delivery ensues and histopathological examination of the placenta reveals numerous polymorphs within the fetal membranes. Regarding placental pathology, match the correct response
a) Complete hydatidiform mole
c) Partial hydatidiform mole
d) Intrauterine growth restriction
f) Stem vessel thrombosis
g) Massive perivillous fibrin deposition
Correct Answer: b) Chorioamnionitis. Ascending genital tract infection with either localized inflammation overlying the cervical os or frank chorioamnionitis is the commonest cause of late second-trimester spontaneous miscarriage.
Tocolysis in women with Preterm Prelabour Rupture of Membranes (PPROM) is not recommended
Correct Answer: a) True. Tocolysis in women with PPROM is not recommended because this treatment does not significantly improve perinatal outcome. (Ref: RCOG 2010). In the absence of clear evidence that tocolysis improves neonatal outcome following leaking in pregnancy (PPROM), it is reasonable not to use it. Additionally,with leaking in pregnancy (PPROM) in the presence of uterine contractions, it is possible that tocolysis could have adverse effects, such as delaying delivery from an infected environment, since there is an association between intrauterine infection,prostaglandin and cytokine release and delivery. (Ref: RCOG)
Preterm Prelabour Rupture of Membranes (PPROM) - Weekly high vaginal swab need not be performed
Correct Answer: a) True. Weekly high vaginal swab need not be performed in women with Preterm Prelabour Rupture of Membranes (PPROM). (Ref: RCOG 2010). Although weekly culture of swabs from the vagina is often performed as part of the clinical management of women with PPROM, the data evaluating this practice do not show conclusively that it is beneficial. It has been shown that positive genital tract cultures predict 53% of positive amniotic fluid cultures with a false-positive rate of 25%.
Which of the following antibiotic is of choice in Preterm Prelabour Rupture of Membranes (PPROM)?
Correct Answer: b) Erythromycin should be given for 10 days following the diagnosis of PPROM.
Twenty-two trials involving over 6000 women with PPROM before 37 weeks of gestation were included in a meta-analysis. The use of antibiotics following PPROM is associated with a statistically
significant reduction in chorioamnionitis. There was a significant reduction in the numbers of babies born within 48 hours and 7 days (RR 0.80; 95% CI 0.71–0.90). Neonatal infection was significantly reduced in the babies whose mothers received antibiotics. Ref: RCOG 2014
The criteria for the diagnosis of clinical chorioamnionitis include EXCEPT
a) Maternal pyrexia
b) Maternal tachycardia
d) Uterine tenderness
e) Offensive vaginal discharge
f) Fetal tachycardia
g) Positive C-reactive protein
Correct Answer: g) Positive C-reactive protein and c) Leucocytosis . It is not necessary to carry out weekly maternal full blood count or C-reactive protein
because the sensitivity of these tests in the detection of intrauterine infection is low. (Ref: RCOG 2010). There is variation in the literature regarding the accuracy of raised C-reactive protein in the prediction of chorioamnionitis. The specificity of C-reactive protein is 38–55%. The sensitivities and false-positive rates for leucocytosis in the detection of clinical chorioamnionitis range from 29% to 47% and from 5% to 18%, respectively. Idea behind putting this question was that many gynecologists keep on doing CRP test for diagnosing chorioamnionitis. Leucocytosis also has less sensitivity but is part of routine CBC and it helps in monitoring infection.
The criteria for the diagnosis of clinical chorioamnionitis include maternal pyrexia, tachycardia, leucocytosis,uterine tenderness,offensive vaginal discharge and fetal tachycardia.During observation, the woman should be regularly examined for such signs of intrauterine infection and an abnormal parameter or a combination of them may indicate intrauterine infection.The frequency of maternal temperature, pulse and fetal heart rate auscultation should be between every 4 and 8 hours. Maternal pyrexia, offensive vaginal discharge and fetal tachycardia indicate clinical chorioamnionitis. There is variation in the literature regarding the accuracy of the laboratory tests of leucocytosis and raised C-reactive protein in the prediction of chorioamnionitis.
"Authored By Dr.Niraj Mahajan"
MD- Gynecologist, Laparoscopic Surgeon, Uro-gynecologist , Infertility specialist & Cosmetic Gynecologist.Read more [+]