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Premature Rupture of Membranes

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2641. Deafness

health professional can look down with a torch. At the end of the canal is the eardrum. This separates the external ear from the middle ear. The eardrum is a tightly stretched membrane, a bit like the skin of a drum. Our picks for Hearing Problems Your ears do the remarkable job of allowing you to hear a huge range of sounds, from a whisper t... 4min The middle ear is an air-filled compartment. Inside it are the three smallest bones in the body, called the malleus, incus and stapes. These bones (...) If there is a problem in the ear canal or the middle ear, this causes what is known as a conductive hearing loss. In conductive hearing loss, the movement of sound (conduction) is blocked or does not pass into the inner ear. This is often as the result of earwax (cerumen) or fluid in the middle ear, although it may also be caused by a burst (ruptured) eardrum or by otosclerosis (see below). Sensorineural hearing loss If the fluid-filled chamber called the cochlea or the hearing nerve is not working properly

2008 Mentor

2642. Ehlers-Danlos Syndrome

subtypes and within subtypes. They are described in more detail below. There is some symptom overlap with and . The first presentation, at birth, may be premature rupture of the membranes. Investigations [ ] In the case of hEDS, diagnosis is normally made on the clinical presentation, by a specialist with expertise in the area. Molecular genetic testing is now recommended for the definitive diagnosis of the other subtypes, although not all patients with the specific condition will demonstrate (...) that can follow a period of over-activity. There is an increased risk of vaginal and perineal tearing in labour, and particular care is needed to slow delivery. There is an increased risk of early rupture of membranes and premature delivery if either parent has cEDS. Both mitral regurgitation and (more rarely) aortic root dilatation are sometimes seen in cEDS. Classical-like Ehlers-Danlos syndrome [ ] Also called tenascin-X deficient Ehlers-Danlos syndrome This very rare condition is similar to cEDS

2008 Mentor

2643. Diabetic Retinopathy and Diabetic Eye Problems

. Leakage results in intraretinal haemorrhages and localised or diffuse oedema. These processes result in the characteristic features seen at various stages of DR: Microaneurysms - physical weakening of the capillary walls which predisposes them to leakages. Hard exudates - precipitates of lipoproteins/other proteins leaking from retinal blood vessels. Haemorrhages - rupture of weakened capillaries, appearing as small dots/larger blots or 'flame' haemorrhages that track along nerve-fibre bundles (...) -operative PRP reduces the stimulus for neovascularisation. Complications The main complication of DR is visual loss secondary to: . Macular ischaemia. . . However, treatment modalities are also associated with risks. Complications of focal/grid photocoagulation Impaired central vision. Paracentral scotoma. Choroidal neovascularisation. Epiretinal membrane formation. Worsening of macular oedema in a minority. Complications of panretinal photocoagulation (PRP) Constriction of visual field. Nocturnal

2008 Mentor

2644. Congenital HIV Infection and its Prevention

, ventouse. Rupture of membranes (especially if delivery is more than four hours after the membranes ruptured). Vaginal delivery. Advanced maternal age. The firstborn of twins (born to an HIV-infected mother). Preterm birth. Female babies more likely to be infected early (transplacental/perinatal routes). [ ] Co-existent malaria may increase HIV transmission rates although this is not firmly established. [ ] Presentation It is to be hoped that most cases of UK-based HIV infection in pregnant mothers

2008 Mentor

2645. Congenital Infections in Neonates

to exposure to a vast array of new pathogens ex utero. Parturition also places the baby in direct contact with maternal blood or genital secretions and infections may result, especially if there was prolonged or early rupture of membranes. At birth, an infant's immune system remains immature. Some protection is provided by maternal antibodies (IgG) crossing the placenta. This process is less complete in the premature baby, especially if markedly premature. If a mother develops a new infection close (...) after delivery. Hepatitis B See separate article. Hepatitis C See separate article. Group B streptococci (GBS) GBS are found in 12-26% of pregnant women, especially in the urine. Infection has been associated with preterm delivery, and ascending infection following rupture of membranes may result in fetal infection. Maternal carriage of GBS is associated with a higher risk of chorioamnionitis and neonatal disease. Neonatal GBS disease occurs at a rate of 0.5 cases/1,000 births. The rate is increased

2008 Mentor

2646. Childhood AIDS

(especially if delivery is more than four hours after the membranes ruptured). Vaginal delivery. Advanced maternal age. The firstborn of twins (born to an HIV-infected mother). Preterm birth. Female babies more likely to be infected early (transplacental/perinatal routes). [ ] Co-existent malaria may increase HIV transmission rates although this is not firmly established. [ ] Presentation It is to be hoped that most cases of UK-based HIV infection in pregnant mothers will be identified before delivery, so (...) -infected children in the UK and Ireland). 44% were born in the UK or Ireland, 55% were born abroad and 2% were of unknown origin. Risk factors The following factors increase the risk of MTCT: Higher levels of maternal viraemia. HIV core antigens. Lower maternal CD4 count. Primary HIV infection occurring during pregnancy. Chorioamnionitis. Co-existing other sexually transmitted infection (STI). Invasive intrapartum procedures - eg, fetal scalp electrodes, forceps, ventouse. Rupture of membranes

2008 Mentor

2647. Viral Meningitis

infection. Neonatal meningitis [ ] See also separate general article . Neonates are at greater risk of meningitis. Risk factors for the development of meningitis include low birth weight (below 2500 g), premature delivery, premature rupture of membranes, traumatic delivery, fetal hypoxia and maternal peripartum infection. Intrapartum prophylactic antibiotics in pregnant mothers who carry, or who are at risk of colonising, group B streptococci, have been effective in reducing the risk of neonatal group B (...) by local guidelines and close liaison with a microbiologist. Initial 'blind' therapy Children 3 months and older and young people should be given intravenous ceftriaxone as empirical treatment before identification of the causative organism. If calcium-containing infusions are required at the same time, cefotaxime is preferable. Children younger than 3 months should be given intravenous cefotaxime plus either amoxicillin or ampicillin. NB : ceftriaxone should not be used in premature babies

2008 Mentor

2648. Polyhydramnios

. Serial ultrasound scans should be carried out to monitor the AFI and fetal growth. Induction of labour should be considered if fetal distress develops. Induction by artificial rupture of the membranes (ARM) should be controlled, performed by an obstetrician and with consent to proceed to lower-segment caesarean section if required. Corticosteroids should be given to the mother antenatally if preterm delivery is imminent or considered. [ ] This helps to improve lung maturity. Prostaglandin synthetase (...) There is a higher incidence of . Other complications include premature rupture of the membranes, abruptio placenta, , and . There is a higher incidence of caesarean section. For the mother, the risk of urinary tract infections is increased due to increased pressure on the urinary tract. The mother may have increased dyspnoea due to increased pressure on the diaphragm. There is also a higher risk of hypertension in pregnancy. Studies of pregnancies associated with polyhydramnios but not congenital malformation

2008 Mentor

2649. Placenta Praevia

without placenta praevia [ ] . There may be some initial pain in approximately 10% of cases with coincidental placental abruption. There is a high risk of preterm delivery; in 25% of cases, spontaneous labour appears in the subsequent few days. In a small proportion of cases, less dramatic bleeding occurs or does not start until spontaneous rupture of membranes or onset of labour. High presenting part or abnormal lie; it may be impossible to push the high presenting part into the pelvic inlet. In 15 (...) and the hazards of prophylactic anticoagulation in women at high risk of bleeding. Rare: Fetal haemorrhage, prematurity, intrauterine asphyxia or birth injury. Prognosis A prospective study of 328 European women demonstrated the high maternal and neonatal morbidity associated with placenta praevia [ ] : 42.3% antepartum haemorrhage. 7.1% postpartum haemorrhage. 30% maternal anemia. 4% co-existing placenta accreta. 5.2% hysterectomy. 54.9% preterm birth. 35.6% low birth weight <2500 g. 1.5% fetal mortality

2008 Mentor

2650. Placenta and Placental Problems

or just off-centre. Has a length not associated with length, weight or gender of the baby. Abnormalities of shape, size, surfaces and function [ , ] Circumvallate [ ] In approximately 1% of cases, there is a small central chorionic area inside a paler thick ring of membranes on the fetal side of the placenta. This is associated with an increased rate of antepartum bleeding, prematurity, abruption, multiparity and perinatal death. Succenturiate lobe [ ] These are accessory lobes that develop (...) . It is not of clinical significance. Velamentous cord insertion and vasa praevia Velamentous cord insertion is the term for where the placenta has developed away from the attachment of the cord and the vessels divide in the membrane. If the vessels cross the lower pole of the chorion, this is known as vasa praevia and there is high risk of fetal haemorrhage and death at rupture of membranes. If suspected, vasa praevia can be accurately diagnosed with transvaginal colour Doppler ultrasound. Risk of vasa praevia

2008 Mentor

2651. Ovarian Tumours and Fibroids in Pregnancy

growth restriction, premature labour and premature rupture of the membranes. Etoposide, used in the treatment of germ cell tumours, has been specifically associated with myelosuppression in the newborn. [ ] Uterine fibroids Most fibroids cause no problems during pregnancy and observation is all that is required. [ ] Diffuse uterine fibroids can be successfully treated conservatively to achieve a successful pregnancy outcome. [ ] Intractable fibroid pain unresponsive to medical treatments (...) , a Cochrane review failed to find evidence to confirm that myomectomy improves subsequent fertility, which is the usual indication for myomectomy at the time of caesarean section. [ ] Bilateral uterine artery embolisation (UAE) immediately after caesarean delivery may be effective in decreasing postpartum blood loss and minimising the risk of myomectomy or hysterectomy. [ ] Complications Ovarian masses [ ] Torsion presenting as acute abdomen. Rupture presenting as acute abdomen. Obstruction of labour

2008 Mentor

2652. Perinatal and Neonatal Infections

to exposure to a vast array of new pathogens ex utero. Parturition also places the baby in direct contact with maternal blood or genital secretions and infections may result, especially if there was prolonged or early rupture of membranes. At birth, an infant's immune system remains immature. Some protection is provided by maternal antibodies (IgG) crossing the placenta. This process is less complete in the premature baby, especially if markedly premature. If a mother develops a new infection close (...) after delivery. Hepatitis B See separate article. Hepatitis C See separate article. Group B streptococci (GBS) GBS are found in 12-26% of pregnant women, especially in the urine. Infection has been associated with preterm delivery, and ascending infection following rupture of membranes may result in fetal infection. Maternal carriage of GBS is associated with a higher risk of chorioamnionitis and neonatal disease. Neonatal GBS disease occurs at a rate of 0.5 cases/1,000 births. The rate is increased

2008 Mentor

2653. Peripheral Blood Film

or prolonged hypoxia. Pelger-Huet anomaly describes bilobed neutrophils which may be hereditary (when the neutrophils are functionally normal) or acquired - eg, myelodysplastic syndrome. Reactive lymphocytes seen in infectious mononucleosis. Right shift is characterised by the presence of hypersegmented polymorphonucleocytes (>5 lobes to their nucleus), seen in liver disease, uraemia and megaloblastic anaemia. Smear cells are lymphocytes whose cell membranes have ruptured in preparation of the blood film (...) on the following: The erythrocytes (RBCs): a note will be made of their size, shape, any membrane changes, colour and stippling. Any inclusion bodies (eg, Howell-Jolly bodies or malarial parasites) will also be noted. Other abnormalities include red cell rouleaux, red cell nucleation and the presence of reticulocytes. The leukocytes (WBCs): the number and morphology of these cells are noted, as well as abnormalities such as toxic granulation or dysplastic changes. Presence of abnormal cells is important (eg

2008 Mentor

2654. Oligohydramnios

does not recommend this for women with preterm rupture of membranes. Vesico-amniotic shunts Vesico-amniotic shunts may be used to divert fetal urine to the amniotic fluid cavity in women in whom a fetal obstructive uropathy is determined to be the cause of oligohydramnios. Although it is effective in reversing oligohydramnios, its ability to achieve sustainable good renal function in infancy is variable. [ ] Pulmonary function cannot be guaranteed with restoration of the AFV. Although (...) (and also therefore the fetus') has a major effect on the AFV. Increased maternal fluid intake has been shown to increase the AFV in women with oligohydramnios. [ ] Pathology Oligohydramnios is secondary to either an excess loss of fluid, or a decrease in fetal urine production or excretion. Oligohydramnios is usually associated with one of the following conditions: Rupture of amniotic membranes (ROM). Congenital absence of functional renal tissue or obstructive uropathy: Conditions that prevent

2008 Mentor

2655. Patent Ductus Arteriosus

weeks of gestation will have persistent patency of the ductus arteriosus and will be assigned the diagnosis of PDA at some time during the early neonatal period. [ ] In a preterm infant, PDA should be suspected if the respiratory distress because of hyaline membrane disease does not improve or worsens after initial improvement and the baby cannot be weaned off the ventilator. In the premature infant of low birth weight, the classical signs are usually absent. The continuous murmur is rarely heard (...) and European Guidelines. You may find one of our more useful. In this article In This Article Patent Ductus Arteriosus In this article Patent ductus arteriosus (PDA) occurs in 5-10% of all congenital heart defects, excluding premature infants. PDAs are very common in preterm babies and can have significant physiological effects. It is important to recognise that PDA in the preterm infant and PDA in term babies and older children are two very distinct conditions with different implications and management

2008 Mentor

2656. Antenatal Care

rupture of membranes or if there is placenta praevia, although evidence is limited. [ ] Alcohol [ ] High levels of alcohol consumption during pregnancy may result in the fetal alcohol syndrome (FAS). There are various components including growth restriction, general learning disability, facial anomalies and behavioural problems. Not all women who drink heavily in pregnancy have babies with FAS, so there are other components, which are as yet poorly understood. It is not known how much alcohol is safe (...) start a gentle programme of regular exercise. Moderate exercise has not been shown to cause any harm but the patient should be warned of the dangers of highly energetic and contact sports that would risk damage to the abdomen, falls or excessive joint stress. Scuba diving should be avoided, as it can cause fetal birth defects and fetal decompression disease. Sexual intercourse This has not been shown to cause any harm during pregnancy. It may be advisable to avoid it if there is risk of preterm

2008 Mentor

2657. Antenatal Infections and their Consequences

in the event of rupture of membranes or onset of labour. Caesarean section should be recommended, as the risk of HSV transmission is very high (41%). If HSV antibody tests subsequently confirm a recurrent infection, when initially it had been thought to be a primary infection, caesarean may no longer be indicated. In recurrent HSV infection, risk of neonatal herpes is low, even if lesions are present at time of delivery (0-3% for vaginal delivery). Aciclovir may not be needed but daily suppression (...) with oral aciclovir may be used from 36 weeks of gestation. Delivery by caesarean section should be offered but the final choice should be made by the woman. If a primary episode of genital herpes simplex occurs at the onset of labour, caesarean section should be recommended. If vaginal delivery cannot be prevented, application of fetal scalp electrodes, fetal blood sampling, artificial rupture of membranes and/or instrumental deliveries should all be avoided. Human immunodeficiency virus [ ] affects T

2008 Mentor

2658. Abdominal Pain In Pregnancy

: Constant pain, profound shock, fetal distress and vaginal bleeding; usually presents during labour and with history of uterine scar. Rarely, occurs without labour and without uterine scar. Chorioamnionitis: This usually follows premature rupture of membranes but can occur with membranes intact. Acute fatty liver of pregnancy: Presents in the second half of pregnancy with abdominal pain, nausea/vomiting, jaundice, malaise and headache. Acute polyhydramnios. Rupture of utero-ovarian vessels. [ ] Severe (...) causes, see separate . Obstetric causes [ , ] Labour pain - premature labour or term. Pre-eclampsia or HELLP syndrome - epigastric or right upper quadrant pain. Placental abruption: Typically, sudden severe pain and a 'woody' hard, tender uterus; fetal distress ± vaginal bleeding. With posterior placenta, pain and shock may be less severe, with pain felt in the back; diagnose by pattern of fetal contractions (excessive and frequent) with fetal heart pattern suggesting hypoxia. Uterine rupture

2008 Mentor

2659. Breech Presentations

reduces the risk of a breech presentation at term but may be more likely to lead to a late preterm birth [ ] . Contra-indications (such as having another indication for caesarean delivery, antepartum haemorrhage in the last week, abnormal cardiotocography (CTG) trace, major uterine anomaly, ruptured membranes) occur in only 4% of women with breech presentation at term. Spontaneous reversion to breech presentation after a successful ECV occurs in fewer than 5%. It should only be carried out (...) , irrespective of the outcome of ECV [ ] . Complications associated with ECV are uncommon but include placental abruption, uterine rupture and fetomaternal haemorrhage. ECV is offered from 36 weeks in nulliparous women and 37 weeks in multiparous women. ECV can be attempted in post-date women and can even be performed in early labour provided membranes are intact. Attempting ECV between 34 and 36 weeks of gestation compared with after 37 weeks of gestation is more likely to be successful and considerably

2008 Mentor

2660. Abbreviations

-gamma peroxisome proliferator-activated gamma PPROM preterm, prelabour rupture of membranes PPV pneumococcal polysaccharide vaccine PR progesterone receptor PRA preoperative risk assessment PRL prolactin prn pro re nata (when required) PRNP PR ioN P rotein PRP polyribosyl ribitol phosphate PS polysomnography PSA prostate specific antigen PSVT paroxysmal supraventricular tachycardia PT prothrombin time PTA polymyxin/tobramycin/amphotericin PTBD percutaneous transhepatic biliary drainage PTCA (...) Ambulance Incident Officer AJ ankle jerk ALF acute liver failure ALS amyotrophic lateral sclerosis AMAs anti-mitochondrial antibodies AMH anti-Müllerian hormone AMHP Approved Mental Health Professional ANA antinuclear antibody ANCA antineutrophil cytoplasmic antibody Anti-GBM antiglomerular basement membrane antibody anti-RNP antibodies to ribonucleoprotein anti-U1-RNP anti-U1-ribonucleoprotein a-NVH asymptomatic non-visible haematuria AP anteroposterior aPL antiphospholipid aPPT activated partial

2008 Mentor

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