Appropriate Management of PPROM at 26 Weeks Gestation

Session 19

Today, we have Dr. Karen Shackelford from Bard Vitals, joining us as we break down another question.

Meanwhile, have a look at Meded Media for more resources available to premeds and medical student.

Another podcast medical students could listen to is Specialty Stories, where I talk to different physicians about their career and their specialty. They talk about why they chose it and what they like about it. Also, learn about what you as a medical student could be doing to make yourself more competitive for this specialty.

[01:40] Question of the Week:

A young woman is 26 weeks pregnant. She’s 25 years old. Gravida 1 Para 0. 26 weeks gestation. She came into the emergency department complaining of leaking vaginal fluid for about three days, not huge, just some leaking.

She’s had some intermittent contractions but they’re fairly infrequent. A sterile speculum exam is performed. It revealed some pale, yellow, watery fluid in the vaginal valve. Her cervix is dilated 4 cm. The vaginal fluid is tested, has a pH of 7.1.

This is at an academic center where they still do the Fern test with arborization when the fluid is examined under a slide. An ultrasound is performed and it reveals oligohydramnios.

Which of the following measures is appropriate in the management of this patient? Her lab results and her pee is negative for Group B Strep.

(A) Ovarian section

(B) Flush immediate delivery

(D) Tocolysis

(E) Supplemental progesterone

[03:30] Thought Process

There is a premature rupture of membranes (PROM). If it were a placental abruption, we can take it to a C-section. But for PPROM (preterm PROM) before 37 weeks, you want to delay the delivery as long as you can. So the correct answer here is the antenatal steroid therapy to mature the lungs.

Most women who have PPROM deliver within a week. If it is within 7 days, you should initiate the steroid therapy.

The management of PPROM would depend on factors like the gestational age, the presence or absence of infection, presence or absence of labor, any sign of abruption. Fetal stability and heart monitoring should also be managed.

The American College of Obstetricians and Gynecologists (ACOG) recommends that women who have PPROM who are more than 34 weeks of gestation should deliver. But it doesn’t need to be a C-section. Normal spontaneous or induced vaginal delivery is fine.

In women less than 34 weeks, the pregnancy should be managed expectantly just until fetal maturity development. As long as the fetus is stable, the fetus will benefit by prolonging time in the uterus.

Having the antenatal steroids will improve lung maturation. But you have to balance that with the benefits like expectant management against the risks associated with like a prolonged PPROM. Placental abruption is an increased risk as well as cord prolapse or cord compression.

[06:40] Looking at the Other Answer Choices

In the lab results, the patient had a negative Group B Strep test. Antibacterial prophylaxis for Group B Strep is indicated if somebody delivers within 48 hours in an unknown status or a positive test.

But you give these patients antibiotics as it prolongs the latency of the pregnancy. It’s generally associated with better fetal results. It reduces respiratory distress syndrome and neonatal death. It reduces the risk of intraventricular hemorrhage, necrotizing enterocolitis, and all preemie problems.

It also reduces the duration of neonatal respiratory support needed. There’s no increase in maternal or neonatal infection to balance that. ACOG recommends the corticosteroids that present between 24 and 34 weeks of gestation. And if you had an earlier pregnancy, you would give antibiotics in those cases.

So Group B Strep prophylaxis is indicated. ACOG would recommend erythromycin. Some doctors will prescribe Zithromax because it’s easier to take. They also recommend IV ampicillin and oral amoxicillin. There are no data to support so it going to cover a large variety of vaginal pathogens. So the antibiotics would not be for Group B Strep but to prolong the pregnancy latency.

Tocolysis is inappropriate in this case because the patient is in active labor with cervix dilated to 4cm. With any woman who has more than 4cm of dilation or signs of chorioamnionitis or nonreassuring fetal stress test, these signs of abruption are the same thing.

The only setting for tocolysis to be indicated in this setting is to delay delivery again for 48 hours to allow the glucocorticosteroids to take effect. But this should never be given for more than 48 hours. So you’re not going to delay delivery that long given that most women deliver within a week.

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