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A 17-year-old primigravid patient at 26 weeks™ gestation
comes to the emergency department because of a gush
of fluid from her vagina a few hours ago. Her pregnancy
had been uncomplicated. On physical examination,
she is afebrile with normal vital signs. Her abdomen is
nontender and appropriate size for 26 weeks. Sterile
speculum examination demonstrates clear fluid coming
from the vagina, which is Nitrazine positive. Ultrasound
demonstrates a fetus in breech presentation with severe
oligohydramnios. Which of the following is the most
appropriate management?
(A) Admission and expectant management
(B) Amnioinfusion
© Cesarean delivery
(D) Oxytocin induction of labor
(E) Prostaglandin induction of labor
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A) at 26 weeks risk of prematurity overweighs risk from anyother cause.....try to prolong the gestation??? correct me if wrong
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Ultrasound shows severe oligohydramnios. Can it be ignored with expectant management?
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I would go w/ B since there is oligohydramnios and then wait
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yup b is more app than A cause of severe..oligo.....
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The correct answer is A. Preterm premature rupture of
the membranes (PPROM) is a common cause of morbidity
and mortality in obstetrics. Preterm refers to
rupture of the membranes before 37 completed weeks
of gestation. Premature refers to rupture of the membranes
before the onset of labor.Approximately 10% of
all births in the United States are preterm and PPROM
accounts for roughly one quarter of those. Once the
membranes are ruptured there is a high likelihood that
the woman will go into labor in the next few days.
When the membranes rupture very remotely from
term, however (as in this patient™s case), the latency
period (i.e., the time from rupture of the membranes
until the onset of labor) tends to be longer. As long as
there is no evidence of infection, fetal distress, abruption,
or another indication for delivery, then the
woman with PPROM can be admitted to the hospital
and managed expectantly in hopes that she will gain
several more weeks of pregnancy and deliver a neonate
that has fewer problems of prematurity. In many institutions,
antibiotics are commonly given to women
with PPROM, as they have been shown to extend the
latency period.
To perform an amnioinfusion (choice B) on this patient
would not be correct management. Amnioinfusions are
used in obstetrics during labor and delivery to œrefill
the uterine cavity, thus helping to relieve cord compression
and to dilute thick meconium. Amnioinfusions are
not used on a patient with PPROM at 26 weeks™ gestation.
To place an amnioinfusion catheter into the uterine
cavity would risk causing an infection and forcing
delivery to happen earlier.
To perform a cesarean delivery (choice C) would not be
the correct management of this patient at this time. A
cesarean delivery now would result in the birth of a very
premature neonate (26 weeks). On the other hand, if
this patient were to go into labor now, develop
chorioamnionitis, have an abruption, develop a cord
prolapse, or have fetal distress, a cesarean delivery
would be the correct management given that this fetus
is breech.
Oxytocin induction of labor (choice D) or
prostaglandin induction of labor (choice E) would not
be the correct management strategy for this patient
given that she has a breech fetus at 26 weeks. First, most
authorities recommend that cesarean delivery should
be performed for a nonvertex preterm fetus. Second, as
explained, to deliver this fetus now, at 26 weeks, would
not be indicated and would likely lead to severe morbidity
from prematurity.
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so amnioinfusion only during labor?? Is there not a chnage of fetal distress d/t cord compression b/c of oligohy?? Or it means amnio risk overule the risk of cord compression??
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see its just a subtle fact that we lack to lose a q.......i didnt know about amnioinf...but look how they can confuse us with the word severe oligo....so basically we dont do anything for severe oligo i guess atleast in this situation...interesting
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keep them coming darri, good questions !! So I will try to remmeber that amniofusion used in obst labor compl most likley in post date preg's and RF outweighs beneftis of expectnat Mx in this case
