A 36-year-old woman, gravida 3 para 2, at 29 weeks gestation comes to labor and delivery due to clear vaginal discharge. The patient has had increasing nonmalodorous discharge for the past 2 days with no associated vaginal bleeding or contractions. She has no vulvovaginal pruritus, dysuria, or hematuria. The patient has been treated multiple times during this pregnancy for symptomatic bacterial vaginosis but has had no other complications. She has no chronic medical conditions. Her prior pregnancies ended in term vaginal deliveries. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 68/min. Fetal heart rate is 130/min. The uterus is nontender and has no palpable contractions. A speculum examination shows clear fluid in the posterior fornix that increases with Valsalva. Microscopy shows ferning and squamous epithelial cells with no stippling. Ultrasound shows a cephalic fetus, an anterior placenta, and minimal amniotic fluid with an amniotic fluid index of 3 cm. This patient is at increased risk for which of the following complications?

Question

A 36-year-old woman, gravida 3 para 2, at 29 weeks gestation comes to labor and delivery due to clear vaginal discharge.  The patient has had increasing nonmalodorous discharge for the past 2 days with no associated vaginal bleeding or contractions.  She has no vulvovaginal pruritus, dysuria, or hematuria.  The patient has been treated multiple times during this pregnancy for symptomatic bacterial vaginosis but has had no other complications.  She has no chronic medical conditions.  Her prior pregnancies ended in term vaginal deliveries.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 68/min.  Fetal heart rate is 130/min.  The uterus is nontender and has no palpable contractions.  A speculum examination shows clear fluid in the posterior fornix that increases with Valsalva.  Microscopy shows ferning and squamous epithelial cells with no stippling.  Ultrasound shows a cephalic fetus, an anterior placenta, and minimal amniotic fluid with an amniotic fluid index of 3 cm.  This patient is at increased risk for which of the following complications?

Quizplus · Accepted Answer

11ec25c8_da7e_7493_bc81_5b7f577790b0_MD0003_00 This patient's vaginal pooling of nitrazine-positive fluid that causes ferning on microscopy is consistent with preterm prelabor rupture of membranes (PPROM), or rupture of membranes at <37 weeks gestation before labor onset (eg, no contractions). Risk factors include PPROM in a prior pregnancy, antepartum bleeding, and genitourinary tract infections-particularly bacterial vaginosis. ferning Patients with PPROM are at risk for both maternal and fetal complications, which may require immediate delivery. A common complication is placental abruption (abruptio placentae), a premature separation of the placenta from the uterus. Placental abruption can occur because decreased amniotic fluid volumes (eg, amniotic fluid index <5 cm) lead to uterine decompression; this causes maternal decidual vessels to shear, resulting in bleeding and separation of the placenta from the uterus. As the abruption enlarges, patients are at risk for fetal hypoxia (and possible demise) or maternal hemorrhage (and possible disseminated intravascular coagulation). Additional complications of PPROM include intraamniotic infection, preterm labor, and umbilical cord prolapse. Due to the risk of these complications, patients with PPROM require inpatient management. (Choices A, B, and E) PPROM does not affect placental attachment (eg, placenta accreta) or location (eg, placenta previa) because both are established prior to rupture of membranes. The greatest risk factor for placenta accreta (villi attachment to the uterine myometrium) is prior uterine surgery (eg, cesarean delivery). Vasa previa, the overlying of aberrant fetal blood vessels over the cervix, develops during placental attachment; it is not a complication of PPROM. In addition, this patient's placenta is anterior, making these complications unlikely. (Choice D) Uterine rupture occurs secondary to increased intrauterine pressure (eg, contractions, polyhydramnios), not due to decompression (as in PPROM). Risk factors for uterine rupture include labor after prior uterine surgery (eg, cesarean delivery) and acute trauma; neither applies to this patient. Educational objective: Preterm prelabor rupture of membranes, rupture of membranes <37 weeks gestation before the onset of labor, requires inpatient management due to the risk of placental abruption, intraamniotic infection, umbilical cord prolapse, and preterm labor. References: ACOG practice bulletin no. 188 summary: prelabor rupture of membranes. (http://www.ncbi.nlm.nih.gov/pubmed/29266069)

A 36-Year-Old Woman, Gravida 3 Para 2, at 29 Weeks