A 34-year-old woman, gravida 3 para 2, at 33 weeks gestation comes to the emergency department due to continued leakage of fluid. The patient reports intermittent vaginal spotting but has had no contractions. Fetal movement is normal. Her prenatal course has been complicated by group B Streptococcus bacteriuria treated in the first trimester. The patient has no other chronic medical conditions or previous surgeries. Temperature is 39.2 C (102.5 F), blood pressure is 90/56 mm Hg, and pulse is 109/min. Fundal height measures 30 cm. Speculum examination shows pooled fluid in the posterior fornix that turns nitrazine paper blue; the cervix appears visibly closed. A ferning pattern is visualized on microscopy. Fetal heart monitoring shows a rate of 170/min with moderate variability. Tocometry shows no contractions. A transabdominal ultrasound reveals a fetus in transverse lie; the single deepest vertical pocket of amniotic fluid is 1 cm. Which of the following is an indication for delivery in this patient?

Question

A 34-year-old woman, gravida 3 para 2, at 33 weeks gestation comes to the emergency department due to continued leakage of fluid.  The patient reports intermittent vaginal spotting but has had no contractions.  Fetal movement is normal.  Her prenatal course has been complicated by group B Streptococcus bacteriuria treated in the first trimester.  The patient has no other chronic medical conditions or previous surgeries.  Temperature is 39.2 C (102.5 F), blood pressure is 90/56 mm Hg, and pulse is 109/min.  Fundal height measures 30 cm.  Speculum examination shows pooled fluid in the posterior fornix that turns nitrazine paper blue; the cervix appears visibly closed.  A ferning pattern is visualized on microscopy.  Fetal heart monitoring shows a rate of 170/min with moderate variability.  Tocometry shows no contractions.  A transabdominal ultrasound reveals a fetus in transverse lie; the single deepest vertical pocket of amniotic fluid is 1 cm.  Which of the following is an indication for delivery in this patient?

Quizplus · Accepted Answer

11ec25c8_da23_0e7d_bc81_390d2ad6e5a7_MD0003_00 This patient has preterm premature rupture of membranes (PPROM), defined as rupture of membranes (eg, pooling, nitrazine-positive fluid, ferning) prior to 37 weeks gestation in the absence of uterine contractions. Typically, the management of PPROM is expectant until 34 weeks gestation, followed by delivery (Choice C). At 33 weeks gestation, patients are administered corticosteroids for fetal lung maturity and a course of prophylactic broad-spectrum (ie, latency) antibiotics. Latency antibiotics prevent intraamniotic infection, prolong pregnancy, and thereby reduce the risk of maternal (eg, endometritis) and neonatal (eg, early-onset neonatal sepsis, cerebral palsy) complications. A complication of PPROM is intraamniotic infection (chorioamnionitis), which occurs due to exposure of the uterine cavity contents (eg, fetus, placenta) with ascending vaginal and enteric pathogens. Patients with intraamniotic infection present with fever, sustained fetal tachycardia >160/min, maternal leukocytosis, and/or purulent amniotic fluid. Other clinical features may include maternal tachycardia and uterine fundal tenderness. When patients exhibit signs of overt infection, the risks of infection complications outweigh the risks of prematurity, and delivery is indicated regardless of gestational age. (Choice A) Fetal malpresentation (eg, transverse lie) is not an indication for delivery in patients with intraamniotic infection. However, it does dictate the mode of delivery (ie, cesarean) once delivery is indicated. transverse lie (Choice D) Patients with group B Streptococcus (GBS) colonization (eg, rectovaginal, bacteruria) are treated with antibiotic prophylaxis during labor to reduce the risk of neonatal sepsis. GBS colonization is not an indication for delivery in this patient. (Choice E) A uterine size-dates discrepancy is a >2 cm difference in fundal height measurement from the gestational age, and may indicate abnormal fetal growth or abnormal amniotic fluid volumes (eg, oligohydramnios). This patient's uterine size-dates discrepancy and oligohydramnios are due to rupture of membranes; they are not indications for delivery. Educational objective: Management of preterm premature rupture of membranes diagnosed at <34 weeks gestation is typically expectant. However, in patients with overt signs of intraamniotic infection (eg, fever, fetal tachycardia), delivery is indicated to decrease maternal and neonatal morbidity. References: Evaluation and management of women and newborns with a maternal diagnosis of chorioamnionitis: summary of a workshop. (http://www.ncbi.nlm.nih.gov/pubmed/26855098) Neonatal respiratory morbidity following exposure to chorioamnionitis. (http://www.ncbi.nlm.nih.gov/pubmed/28514958)

A 34-Year-Old Woman, Gravida 3 Para 2, at 33 Weeks