Premature rupture of membrane is associated with all, except:
Correct Answer A:
Premature rupture of the membranes (PROM) near the end of pregnancy may be caused by a natural weakening of the membranes or from the force of contractions.
Other factors that may be linked to PROM include the following: multiparity, low socioeconomic conditions (as women in lower socioeconomic conditions are less likely to receive proper prenatal care), sexually transmitted infections such as chlamydia and gonorrhea, previous preterm birth, vaginal bleeding, cervical incompetence, cigarette smoking during pregnancy.
A 28-year-old G2P1001 presented to hospital at 37 5/7 weeks of gestation with painless gush of vaginal fluid that started three hours ago. Vital signs are stable, fundal height is consistent with 37 weeks of gestation, fetal presentation is cephalic, and fetal heart rate is reassuring. Sterile speculum examination confirmed rupture of membranes. The patient is admitted for expectant management and after nine hours, no signs of active labour could be detected.
Which of the following management options is the best at this time?
Correct Answer D:
Premature rupture of membranes (PROM) is rupture of membrane prior to the onset of labour irrespective of gestational age. Most women go into labour within 24 hours of ROM and when labour does not start within this time it is deemed prolonged PROM. The diagnosis is usually straight forward but if in doubt sterile speculum examination can be performed. The alkaline nature of amniotic fluid differentiates it from urine and vaginal fluid.
For at least two reasons, induction of labour (choice D) is the best management option for this patient. First, the fetus is mature (term) and there is no need to wait and second, the membranes are ruptured for 12 hours and there is a risk of infection and development of chorioamnionitis. Expectant management is recommended for only 6 to 12 hours following rupture of membrane when gestational age > 34 weeks.
→ Continuation of expectant management (choice A) would be the option if gestational age were < 34 and > 24 weeks and there were no evidence of chorioamnionitis. However, in this case antibiotics and steroids are recommended even in the absence of infection. Expectant management should be abandoned with any sign of infection.
→ Continuation of expectant management and initiation of antibiotics (choice B) and steroids (choice C) would be the option if gestational age were < 32 and > 24 weeks and there were no evidence of chorioamnionitis. Both antibiotics and steroid treatments have been shown to increase the outcome of pregnancy with premature rupture of membrane when the gestational age is < 32 and > 24 weeks.
→ Delivery by Caesarean section (choice E) is not the correct option. This should be considered only if there were an indication for Caesarean section like obstruction, herpes of the vulva, failure of labour to progress, placental abruption or any other indication. Premature rupture of membranes per se is not an indication for Caesarean section.
Key point:
With failure of onset of active labour with 12 hours of rupture of membranes beyond the 34th gestational week, labour should be induced in the absence of any indications for Caesarean section.
A 31-year-old woman has a dilation and curettage done. Some months later she comes back complaining that she has amenorrhea but pain monthly around the time she usually has her periods. No menstrual flow is seen with estrogen and progesterone challenge.
What is the most likely diagnosis?
Asherman's Syndrome is an acquired disease which is characterized by the formation of adhesions (scar tissue) in the women's uterus. Asherman's syndrome is the presence of intrauterine adhesions that typically occur as a result of scar formation after uterine surgery, especially after a dilatation and curettage. The adhesions may cause amenorrhea and/or infertility.
Asherman syndrome's patients have scanty or absent periods (amenorrhea) but some have normal periods. Some patients have no periods but feel pain at the time each month that their period would normally arrive. This pain may indicate that menstruation is occurring but the blood cannot exit the uterus because the cervix is blocked by adhesions. Recurrent miscarriage and infertility could also be considered as symptoms. Symptoms may be related to several conditions and are more likely to indicate Asherman's syndrome if they occur suddenly after a dilatation and curettage or other uterine surgery.
Asherman's syndrome should be treated if it is causing infertility or amenorrhea. Surgical treatment includes cutting and removing adhesions or scar tissue within the uterine cavity.
Alpha-fetoprotein (AFP) is increased on a triple screen test when the fetus has:
Correct Answer A: With maternal alpha-fetoprotein, elevated levels suggest neural tube defects such as (open spina bifida, meningomyelocele, anencephaly) increased risk of pregnancy complications (eg, intrauterine growth restriction, abruptio placentae), or, occasionally, twins or other multifetal pregnancy. Closed spina bifida is usually not detected.
A meningomyelocele is a defect that is large enough to allow meninges and a portion of spinal cord to protrude through the defect. Such defects can be suggested by an elevated maternal serum alpha-fetoprotein.
Increased alpha-fetoprotein measurement on a triple screen done may indicate:
Correct Answer C:
Neural tube defects such as anencephaly, spina bifida and myelomeningocele will show an increased alpha-fetoprotein on a triple screen.
In trisomies such as Edward syndrome (Trisomy 18), Down syndrome (Trisomy 21) and molar pregnancy the alpha-fetoprotein value would be low.
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