A 35-year-old woman, gravida 4 para 3, at 37 weeks gestation comes to the hospital due to leakage of fluid and painful contractions. The patient has had continuous vaginal leakage of clear fluid for the past 2 days and now the fluid appears green. Her prior 3 pregnancies were uncomplicated term vaginal deliveries, and she has not received prenatal care with this pregnancy. The patient has no chronic medical conditions and no known drug allergies. Temperature is 36.1 C (97 F), blood pressure is 120/80 mm Hg, and pulse is 76/min. Speculum examination shows a pool of meconium-stained fluid in the posterior fornix of the vagina. The cervix is 6 cm dilated, 60% effaced, and the fetal vertex is at +1 station. Fetal heart tracing reveals moderate variability and early decelerations with each contraction. Contractions occur every 2-3 minutes. Which of the following is the best next step in management of this patient?

Question

A 35-year-old woman, gravida 4 para 3, at 37 weeks gestation comes to the hospital due to leakage of fluid and painful contractions.  The patient has had continuous vaginal leakage of clear fluid for the past 2 days and now the fluid appears green.  Her prior 3 pregnancies were uncomplicated term vaginal deliveries, and she has not received prenatal care with this pregnancy.  The patient has no chronic medical conditions and no known drug allergies.  Temperature is 36.1 C (97 F), blood pressure is 120/80 mm Hg, and pulse is 76/min.  Speculum examination shows a pool of meconium-stained fluid in the posterior fornix of the vagina.  The cervix is 6 cm dilated, 60% effaced, and the fetal vertex is at +1 station.  Fetal heart tracing reveals moderate variability and early decelerations with each contraction.  Contractions occur every 2-3 minutes.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_da39_c9f9_bc81_ebd34367bccb_MD0003_00 Streptococcus agalactiae, or group B Streptococcus (GBS), is a common colonizer of the maternal gastrointestinal and genital tract. Although GBS is typically asymptomatic in pregnant women, it can be vertically transmitted during vaginal delivery or after rupture of membranes, causing early-onset neonatal GBS infection (eg, sepsis, pneumonia). To prevent vertical transmission, most women are screened at 36-38 weeks gestation; those who are GBS-positive require intrapartum antibiotic prophylaxis (IAP). Women with an unknown GBS status, such as this patient, are triaged based on risk factors. Most women at ≥37 weeks gestation do not require IAP as they are at low risk for vertical transmission, and indiscriminate antibiotic use can lead to bacterial resistance. In contrast, women with the following risk factors require IAP: Rupture of membranes for ≥18 hours (as in this patient) because the extended time period allows for possible GBS proliferation, increased bacterial load, and prolonged fetal exposure to infected amniotic fluid-all of which increase the risk of vertical transmission and neonatal infection Intrapartum fever, which indicates possible intraamniotic infection involving GBS Delivery at <37 weeks gestation, as the immature fetal immune system is more susceptible to infection Women who meet criteria for IAP are typically administered intravenous penicillin (Choice C). (Choice A) Amnioinfusion is used to decrease umbilical cord compression (as evidenced by variable decelerations) after rupture of membranes. This patient's early decelerations are caused by fetal head compression; they are normal and do not require treatment. (Choices B and D) This patient has a reassuring fetal heart rate tracing and is in active labor (6 cm dilated, contractions every 2-3 minutes). Therefore, neither cesarean delivery nor labor augmentation are indicated. Educational objective: Intrapartum antibiotic prophylaxis is administered to prevent neonatal group B Streptococcus (GBS) infection in patients with an unknown GBS status and the following risk factors for vertical transmission: rupture of membranes for ≥18 hours, intrapartum fever, and fetal prematurity (<37 weeks gestation). References: Practice bulletins no. 139: premature rupture of membranes. (http://www.ncbi.nlm.nih.gov/pubmed/24084566) Prevention of perinatal group B streptococcal disease-revised guidelines from CDC, 2010. (http://www.ncbi.nlm.nih.gov/pubmed/21088663)

A 35-Year-Old Woman, Gravida 4 Para 3, at 37 Weeks