management of premature rupture of membrane - djyoti

[ArchivalUser]

AND SHORT DIAGNOSIS

[ArchivalUser]

diagnosis-
fluid in posterior fornix
nitro somehting test, turns the paper blue
fern pattern on air drying on lslide

mx
check for chorioamnitis,
if very early pregnancy there is nothing you can do
start antibiotic if strep positive
if genital herpes, do CS within 4 hours
no tocolytic

[ArchivalUser]

THANKS AMYGDALA

POOLING

NITRAZINE TEST --ALKALINE

AND FERN TEST



USG TO ASSESS AMNIOTIC FLUID


CULTURE TO R/O INFECTION


NST/CST/BPP

DO NOT DO VAGINAL EXAM IF LESSTHAN 34

CBC

LOK FOR TENDERNESS IN THE ABDOMEN

ALSO TACHYCARDIA ANDFEVER TO SUSPECT CHORIOAMNITIS



RX

IF YOU DO NOT SUSPECT CHORIO- THEN

TOCOLYTICS

PROPHYLACTIC ABX

CORTICOSTEROID FOR FETAL LUNG MATURITY



IF SIGN OF INFECTION--CBC/TACHYCARDIA/TENDERNESS/ GIVE ANTIBIOTIC--AMPI GENTA

AND INDUCE

IF PT PENICILLIN ALLERGIC--GENTA AND CLINLDA

[ArchivalUser]

By PROM you said,.. if genital herpes do cs within 4 hrs, right? iF MORE THAN 4HRS VAGINAL DELIVERY,.. Why?.... the baby is already exposed why cut the mother? There was a Q of mine in that case, I will look for it.. Alibism

[ArchivalUser]

#80313
alibi - 03/23/06 19:18

A 36 y/o woman in her 37th week of gestation has a premature rupture of the membrane 12 hrs ago. It is discovered that she has a vaginal lesion of HSV. What is the recommended mode of delivery at this stage?

A. Emergent CS
B. Vaginal delivery
C. Give acyclovir + vaginal delivery




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* obgyn
#80313
alibi - 03/23/06 19:18

A 36 y/o woman in her 37th week of gestation has a premature rupture of the membrane 12 hrs ago. It is discovered that she has a vaginal lesion of HSV. What is the recommended mode of delivery at this stage?

A. Emergent CS
B. Vaginal delivery
C. Give acyclovir + vaginal delivery
D. Give acyclovir and then do a CS

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* Re:obgyn
#290852
cadavar - 03/25/06 10:08

not at all letsdoit:
I find drjyoti's postings very profissional and informative,,,and very helpful..

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* Re:obgyn
#290892
amygdala - 03/25/06 11:42

I tried to read about this. I have only read that Acyclovir is not indicated in recurrent herpes and if there is active genital lesions, to avoid vaginal delivery. I would also think, since she had a ROM for 12 hours, why not do a CS?

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* Re:obgyn
#290956
kareem76 - 03/25/06 13:24

now i think its a
the reason is not only bcz of vaginal herpes but ....rom for 12 hr how much you think of the amniotic fliud left there
whats the rick on the baby just from the delivery for get about the herpes
so i would go for a

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* Re:obgyn
#291024
kelpatel - 03/25/06 15:03

2000, the American College of Obstetricians and Gynecologists (ACOG) published a practice bulletin regarding HSV in pregnancy. Their conclusions are as follows:

Level B recommendations (based on limited or inconsistent scientific evidence)

* Women with primary HSV infection during pregnancy should be treated with antiviral therapy.

* Cesarean delivery should be performed on women with first-episode HSV infection who have active genital lesions at delivery.

* For women at or beyond 36 weeks of gestation with a first episode of HSV infection occurring during the current pregnancy, antiviral therapy should be considered.


Level C recommendations (based on consensus or expert opinion)

* Cesarean delivery should be performed on women with recurrent HSV infection who have active genital lesions or prodromal symptoms at delivery.

* Expectant management of patients with preterm labor or premature rupture of membranes and active HSV infection may be warranted.

* For women at or beyond 36 weeks of gestation who are at risk for recurrent HSV infection, antiviral therapy may be considered, although such therapy may not reduce the likelihood of cesarean delivery.

* In women with no active lesions or prodromal symptoms during labor, cesarean delivery should not be performed on the basis of a history of recurrent disease.

Despite the ACOG recommendations, recurrent HSV infections account for a small proportion of neonatal HSV infections. Whether cesarean delivery for recurrent genital lesions actually reduces vertical transmission has not been determined. Presently, however, HSV suppression with antiviral agents may suppress clinical recurrences in labor and may reduce the need for cesarean deliveries in these women.

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* Re:obgyn
#291042
amygdala - 03/25/06 15:23

"Expectant management of patients with preterm labor or premature rupture of membranes and active HSV infection may be warranted"
Does this mean the answer is B?

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* Re:obgyn
#291054
alibi - 03/25/06 15:32

I have been sitting back, and had chuckled to myself ceaselessly. No Q has ever shaken this forum more than this, moreso it is my original question. I thank all those that had contributed to this. I love this forum.
C. is the correct answer.
Kelpatel, thanks for that piece of explanation.
The fact is that CS is indicated in a case of HSV 11, if there are vaginal lesions. From the stem of the Q, the premature rupture of the membrane has occurred, moreso for the past 12 hrs. What then are you preventing by doing a CS? The deed has been done already,.. meaning that the baby is already exposed. Is it not reasonable to do a vaginal delivery at this stage? This Q was designed to test who lives through memorization. According to ericz, a good logic helps in answering usmle Qs. Ofcourse, the mother will receive Acyclovir. All these favor the option C. Thanks for your contributions. Alibism

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* Re:obgyn
#291084
djyoti - 03/25/06 16:35

NICE Q BUT

ACYCLOVIR IS GIVEN. NOW I TOTALLY AGREE/ BUT EVEN DEED IS ALREADY DONE YOU CANOT BE SO SURE THAT INFECTION HAS ALREADY OCCUR/ HOW CAN YOU BE? IT IS A RELATIVE THING

the child maynot be exposed yet virus may not be in amniotic fluid yet and while going through passage he is going to get it more of viruses/who knows acyclovir you gave did not kill the last of the virus which may be able to attack him. this way it is like you are letting a man who is spitting blood and taking tb therapy free. . but be cause he is taking therapy he canot walk to the office till 3 sputum are negative as a rule.

this guy you are giving acyclovir but the road is not clear yet there is high chance of kissing disease directly here. take him from RELATIVELY SAFER road THOUGH NOT 100% clear

WHICH IS CS not vaginal

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* Re:obgyn
#291086
djyoti - 03/25/06 16:39

so DD is the answer notC

ACYCLOVIR AND CEASEREAN SECTION--DOUBLE BOOST UP THERAPY

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* Re:obgyn
#291089
amygdala - 03/25/06 16:46

I dont agree with C. It is A or D. Why would you make it a 100% HSV infection by having a vaginal? Also it is 12 hours since ROM?

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* Re:obgyn
#291091
alibi - 03/25/06 16:50

Djyoti, I gathered from Kaplan DvD that vaginal delivery is indicated if there is vaginal lesion of HSV II in the face of PROM. Why cut the mother open when the child is already exposed?
'Expectant management of pts with preterm labor or PROM and active HSV infection will be warranted' Expectant management in this case means vaginal delivery. Alibism

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[ArchivalUser]

yes, alibi, that is what I gather from kaplan and other material. So from now on that is what I will do. >8 hours, vaginal.

[ArchivalUser]

when do you give antibiotic if culture +ve for GBS ?

[ArchivalUser]

During labor