Specific Management of PPROM

Fifty percent of preterm patients go into labor within 24 hours after rupture.

Generally, one needs to balance the risks of premature birth against the risk of infection (which increases with the time that membranes are ruptured before birth). Management is aimed at assessing these risks and acting accordingly:

■ Gram stain and culture of amniotic fluid to assess for chorioamnionitis

■ If chorioamnionitis is suspected, begin ampicillin and/or erythromycin prophylaxis.

■ Amniotic fluid assessment of lecithin-sphingomyelin ratio for lung maturity

■ Perform ultrasound to assess gestational age, position of baby, and level of fluid.

■ If < 34 weeks, give steroids to decrease incidence of RDS.

■ Expectant management

■ ROM: Rupture of membranes

■ PROM: Premature rupture of membranes (ROM before the onset of labor)

■ PPROM: Preterm (< 37 weeks) premature rupture of membranes

■ Prolonged rupture of membranes: Rupture of membranes that lasts > 18 hours

If nitrazine and pooling are nonconfirmatory, ferning test is useful.

Don't get the ROMs mixed up!

THIRD-TRIMESTER BLEEDING

Incidence

Occurs in 2 to 5% of pregnancies

Workup

■ History and physical

■ Labs: CBC, coagulation profile, type and cross, urine analysis See Figure 9-2 for management algorithm.

Determine whether blood is maternal or fetal or both:

■ Apt test: Put blood from vagina in tube with KOH:

■ Turns brown for maternal

■ Turns pink for fetus

■ Kleihauer-Betke test: Take blood from mother's arm and determine percentage of fetal RBCs in maternal circulation: > 1% = fetal bleeding.

■ Wright's stain: Vaginal blood; nucleated RBCs indicate fetal bleed.

Golden rule:

Never initially do a pelvic exam in a third-trimester bleed.

Apt, Kleihauer-Betke, and Wright's stain tests determine if blood is fetal, maternal, or both.

Reposition Mother

Check blood pressure IV, tocolytics

Sucessful fetal resuscitation?

Possible Vasa Previa

Consider ruptured uterus

Terminate Pregnancy (prompt delivery)

FIGURE 9-2. Management of third -trimester bleeding.

(Redrawn, with permission, from Lindarkis NM, Lott S. Digging Up the Bones: Obstetrics and Gynecology. New York: McGraw-Hill, 1998:5Q.)

Reposition Mother

Check blood pressure IV, tocolytics

Sucessful fetal resuscitation?

Consider ruptured uterus

Possible Vasa Previa

Terminate Pregnancy (prompt delivery)

FIGURE 9-2. Management of third -trimester bleeding.

(Redrawn, with permission, from Lindarkis NM, Lott S. Digging Up the Bones: Obstetrics and Gynecology. New York: McGraw-Hill, 1998:5Q.)

Placenta previa and abruption are most common.

Most nonobstetric causes result in relatively little blood loss and minimal threat to the mother and fetus.

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