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Premature Rupture of Membranes


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2721. 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

2722. 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

2723. 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

2724. Haemophilus Influenzae

months to 4 years. Hib causes septic arthritis and cellulitis in children younger than 2 years. Hib septic arthritis also occurs in adults. Neonatal infection: Often due to non-typeable H. influenzae , which colonises the maternal genital tract. Infection is associated with premature birth, premature rupture of membranes, low birth weight and maternal chorioamnionitis. Presentations include meningitis, pneumonia, respiratory distress, scalp abscess, conjunctivitis and vesicular eruption

2008 Mentor

2725. Gravidity and Parity Definitions (and their Implications in Risk Assessment)

should have 10 routine antenatal appointments (versus 7 in parous women) [ ] . Good antenatal and parenting education, support during labour and pain control (if desired) are especially important in a first pregnancy, as anxiety levels are likely to be high. Where there is delay in the first stage of labour in a primagravida, active management is with artificial rupture of membranes and/or oxytocin to augment labour. The second stage of labour can be allowed to continue for longer than (...) the potential lack of standardisation in our documentation [ ] . A more elaborate coding system used elsewhere, including America, is GTPAL (G = gravidity, T = term deliveries, P = preterm deliveries, A = abortions or miscarriages, L = live births). Epidemiology The current total fertility rate (the average number of children a woman would have if she experienced the fertility rate of a particular year for her entire childbearing years) stands at 1.91 (2012 figures) [ ] . Women are commencing

2008 Mentor

2726. External Eye - Lashes Eyelids and Lacrimal System

oculoplastic surgery. Poliosis [ ] This is premature, localised whitening of the lashes and eyebrows (it may involve any hairy area of the body). Microscopically there is decreased or absent melanin in the affected hair follicles. Classically, poliosis is associated with several genetic syndromes, including piebaldism, Waardenburg's syndrome and tuberous sclerosis. It may be associated with inflammation: ocular causes include chronic anterior blepharitis and sympathetic ophthalmitis. In rare cases, it has (...) is not appropriate for children. Symptoms resolve rapidly following stye rupture/drainage. Consider referral if there are symptoms/signs of associated cellulitis (preseptal or orbital) or if the patient is systemically unwell. Also, consider referring if the stye is persistent or particularly large and painful and has not responded to conservative treatment. If the stye has an atypical appearance or recurs in the same location, think of the possibility of malignancy. Cysts . Various cysts can arise around

2008 Mentor

2727. Exomphalos and Gastroschisis

cord through the umbilical ring. The viscera, which often includes the liver, is covered by a thin membrane consisting of peritoneum and amnion. Gastroschisis means 'stomach cleft'. It is a congenital defect of the abdominal wall, usually to the right of the umbilical cord insertion. Abdominal contents herniate into the amniotic sac, usually just involving the small intestine but sometimes also the stomach, colon and ovaries. Unlike exomphalos, there is no covering membrane. [ ] Epidemiology (...) are not usually present. Differential diagnosis Exomphalos and gastroschisis need to be differentiated from each other and from other causes of an abdominal wall mass. Exomphalos is more centrally placed than gastroschisis, is covered with a membrane and is more likely to be associated with other congenital defects. The hernial sac in the two conditions also feels different. An exomphalic sac feels firm and may contain liver and tightly packed bowel, whereas in gastroschisis the sac contains only free loops

2008 Mentor

2728. Genital Herpes in Pregnancy

of labour Caesarean section is recommended. Where vaginal delivery occurs: Consider intravenous aciclovir for both mother and neonate. Invasive procedures (fetal scalp monitoring, artificial rupture of membranes and instrumental delivery) should be avoided where possible as this is thought to increase risk of transmission. The neonate should be treated with intravenous aciclovir and swabs should be taken from the eyes, skin, oropharynx and rectum. Management of recurrent infection Confirm the diagnosis (...) . There is no evidence that there is any increased risk of premature labour or intrauterine growth restriction for women seropositive for HSV. If the woman has a history of recurrent genital herpes, she should be reassured that the risk of transmitting the infection to her baby is very small, even if she does have active lesions at delivery. The risk is approximately 0-3% for vaginal delivery. Maternal antibodies will give some protection to the baby but neonatal infection can still occasionally occur. Antiviral

2008 Mentor

2729. Full Blood Count

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: seen in chronic lymphocytic leukaemia (...) : 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, leukaemic blasts

2008 Mentor

2730. Fetal Distress

of antenatal fetal distress require monitoring with a view to induction of labour or planned caesarean section. Immediate delivery of a preterm fetus with suspected fetal distress may reduce the risk of intrauterine hypoxia but increases the risks associated with prematurity. Benefit may be gained by deferring delivery, especially if there is uncertainty; however, evidence is lacking to guide this decision [ ] . Continuing fetal distress during labour may indicate the need for delivery to be expedited (...) that very short 'decision-to-incision' time (<20 minutes) may be inversely proportional to neonatal outcomes, ie lower umbilical pH and Apgar scores [ ] . Amnioinfusion has been shown to be beneficial in suspected umbilical cord compression (particularly when there is oligohydramnios), with a reduced risk of caesarean section [ ] : In this process, sodium chloride or Ringer's lactate is infused transcervically or, if the membranes are still intact, via a needle inserted under ultrasound guidance through

2008 Mentor

2731. 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

2732. 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

2733. 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

2734. What is the up-to-date thinking on investigation of recurrent miscarriage and its treatment?

for recurrent miscarriage is questionable since it is associated with patient discomfort, carries a risk of pelvic infection and offers the same diagnostic sensitivity as non-invasive pelvic ultrasound assessment of the uterine cavity. Cervical incompetence is often over-diagnosed as a cause of mid-trimester miscarriage. Cervical cerclage should only be considered when the history of miscarriage is preceded by spontaneous rupture of membranes or painless cervical dilatation. The MAC/RCOG trial of the use (...) or observational studies Grade C: more limited evidence but the advice relies on expert opinion and has the endorsement of respected authorities Intervention Trial Arms Losses/Total pregnancies Percent (95% CI) None, usual care 4 30/80 37 (27 to 48) Aspirin alone 6 50/129 39 (30 to 47) Low MW heparin plus aspirin 6 36/155 23 (17 to 30) They also add that use of prednisolone was associated with higher rates of premature birth and admission to neonatal intesive care units with no evidence of preventing pregnancy

2002 TRIP Answers

2735. PROM at term and group B strep. (Abstract)

PROM at term and group B strep. 9487313 1998 03 19 2004 11 17 0094-3509 46 2 1998 Feb The Journal of family practice J Fam Pract PROM at term and group B strep. 116 Yaekle S S Oakwood Hospital Family Practice, Residency Program, Dearborn, Michigan, USA. French L L eng Clinical Trial Journal Article Randomized Controlled Trial United States J Fam Pract 7502590 0094-3509 AIM IM Female Fetal Membranes, Premature Rupture therapy Humans Infant, Newborn Labor, Induced methods Pregnancy Pregnancy

1998 The Journal of family practice Controlled trial quality: uncertain

2736. Term PROM. (Abstract)

Term PROM. 7621120 1995 08 31 2015 11 16 1355-8404 108 1285 1995 Feb Midwives : official journal of the Royal College of Midwives Midwives (1995) Term PROM. 47-8 Marshall G G eng Clinical Trial Comparative Study Journal Article Multicenter Study Randomized Controlled Trial England Midwives (1995) 9506689 1355-8404 50-56-6 Oxytocin K7Q1JQR04M Dinoprostone N Dinoprostone therapeutic use Female Fetal Membranes, Premature Rupture drug therapy Humans Labor, Induced methods Oxytocin therapeutic use

1995 Midwives : official journal of the Royal College of Midwives Controlled trial quality: uncertain

2737. Is obstetric progress dependent on rigorous randomized controlled trials? (Abstract)

-Bacterial Agents therapeutic use Bacterial Infections prevention & control Female Fetal Membranes, Premature Rupture drug therapy Humans Infant, Newborn Pregnancy Premedication Randomized Controlled Trials as Topic 1990 5 1 1990 5 1 0 1 1990 5 1 0 0 ppublish 2187362 0002-9378(90)90076-J

1990 American Journal of Obstetrics and Gynecology Controlled trial quality: predicted high

2738. Haemolytic jaundice in a neonate after intra-amniotic injection of methylene blue (Full text)

, Premature Rupture diagnosis Humans Infant, Newborn Infant, Newborn, Diseases chemically induced Methylene Blue adverse effects Pregnancy 1982 11 1 1982 11 1 0 1 1982 11 1 0 0 ppublish 6890790 PMC1628038 Am J Obstet Gynecol. 1970 Nov 15;108(6):993-4 5486493 Obstet Gynecol. 1973 Mar;41(3):476-7 4688269 Lancet. 1979 Nov 24;2(8152):1142-3 91881 N Engl J Med. 1981 Jun 4;304(23):1427 6453294 (...) Haemolytic jaundice in a neonate after intra-amniotic injection of methylene blue 6890790 1983 01 19 2018 11 13 1468-2044 57 11 1982 Nov Archives of disease in childhood Arch. Dis. Child. Haemolytic jaundice in a neonate after intra-amniotic injection of methylene blue. 872-3 Crooks J J eng Case Reports Journal Article England Arch Dis Child 0372434 0003-9888 T42P99266K Methylene Blue AIM IM Anemia, Hemolytic chemically induced therapy Exchange Transfusion, Whole Blood Female Fetal Membranes

1982 Archives of Disease in Childhood PubMed abstract

2739. Control of neonatal group B streptococcal infection. (Full text)

should be treated with intravenous penicillin or ampicillin. Risk factors include preterm labour, premature rupture of membranes, intrapartum fever, multiple births, prolonged rupture of membranes, maternal diabetes, previous sibling with invasive GBS disease, and maternal GBS bacteriuria. The latter two categories warrant chemoprophylaxis regardless of maternal colonization status.

1993 Journal of the Royal Society of Medicine PubMed abstract

2740. Role of Bacterial Vaginosis in Peripartum Infections (Full text)

correlated with the clinical diagnoses of chorioamnionitis, endometritis, and neonatal sepsis.Eighty-eight percent of patients were term and 12% were preterm. The overall prevalence of BV was 30%. The frequency of BV was similar in both term and preterm women. BV was significantly more prevalent among nonwhites than whites (37% vs. 25%, P = 0.005). Maternal characteristics such as mean age, parity, status of the membranes, mean duration of labor, mean duration of ruptured membranes, mean length of fetal

1994 Infectious diseases in obstetrics and gynecology PubMed abstract

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