A 19-year-old G2P1 woman at 30 weeks gestation presents with preterm premature rupture of membranes six hours ago.
She denies labor. She takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. Her prior
pregnancy was delivered vaginally at 41 weeks after spontaneous rupture of membranes. Her blood pressure is 110/70;
pulse 84; temperature 98.6°F (37.0°C). Pertinent sonographic findings reveal a cervical length of 34 mm and an amniotic
fluid index (AFI) of 3. What is the likelihood she will deliver within a week?
A. 80%
B. 40%
C. 20%
D. 10%
E. 5%
A
The time from premature rupture of membranes to labor is inversely related to gestational age. At term, 90% will spontaneously go into labor within 24
hours of PROM. At 28 weeks to 34 weeks, 50% will go into labor within 24 hours and 80% within 48 hours.
A 33-year-old G2P1 woman at 29 weeks gestation presents with confirmed preterm premature rupture of membranes.
She denies labor. She takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. Her prior
pregnancy was delivered vaginally at 41 weeks after spontaneous rupture of membranes. Her blood pressure is 110/70;
pulse 84; temperature 98.6°F (37.0°C). Which of the following is the best medication to delay the onset of labor?
A. Antibiotics
B. Betamethasone
C. Calcium channel blocker
D. Beta mimetics
E. Magnesium sulfate
A
Antibiotic therapy given to patients with preterm premature rupture of the membranes has been found to prolong the latency period by 5-7 days, as well as
reduce the incidence of maternal amnionitis and neonatal sepsis. Corticosteroids (betamethasone) and tocolytics may also prolong the pregnancy for
various lengths of time, but generally not seven days.
A 24-year-old G1 woman at 32 weeks gestation presents with leaking watery fluid from the vagina. On evaluation, preterm
premature rupture of membranes is confirmed. She has occasional Braxton Hicks contractions associated with fetal heart
rate accelerations. She does not have vaginal bleeding and vaginal fluid phosphatidylglycerol is absent. Her blood
pressure is 110/70; pulse 90; temperature 98.6°F (37.0°C). Fundal height is 30 cm and her fundus is tender. Amniotic fluid
index (AFI) is 4. Which of the following findings is an indication for delivery in this patient?
A. Tender uterine fundus
B. Size less than dates
C. Fetal heart rate accelerations
D. Amniotic fluid index of less than 5
E. Absence of vaginal fluid phosphatidylglycerol
A
Maternal signs of chorioamnionitis or other evidence of intra-amniotic infection are indications for delivery. This patient has ruptured membranes and a
tender fundus, which indicate chorioamnionitis. Labor at 32 weeks would be allowed to progress and prolonged non-reassuring fetal testing would prompt
delivery. There are no criteria for amniotic fluid index or degree of oligohydramnios as an indication for delivery. Most authors agree that the achievement
of fetal lung maturity (i.e. positive phosphatidylglycerol or 34 weeks gestational age) is the threshold at which the risk of morbidity and mortality of
maintaining the pregnancy in utero outweighs the benefits of prolonging the pregnancy.
,A 25-year-old G2P1 woman at 20 weeks gestation is diagnosed with preterm premature rupture of the membranes. She
denies labor. She takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. Her prior
pregnancy was delivered vaginally at 36 weeks after preterm rupture of membranes. Her blood pressure is 110/70; pulse
84; temperature 98.6°F (37.0°C). The patient's fetus is greatest risk for which of the following?
A. Pulmonary hypoplasia
B. Cardiac anamolies
C. Urinary tract anamolies
D. Microcephaly
E. Compression fractures
A
Preterm premature rupture of the membranes that occurs before viability is associated with significant risk of poor outcome. Neonatal survival when
rupture occurs between 20 and 23 weeks is approximately 25%. Complications that may be found in the developing fetus include structural abnormalities
that are primarily deformations (abnormalities that occur due to an insult after a structure has already formed) rather than malformations (abnormal
development of the structure itself). Pulmonary hypoplasia is seen when rupture of membranes occurs before 25 weeks gestation because the lack of
amniotic fluid interferes with the normal intrauterine breathing process. The result is failure of normal development and growth of the respiratory tree.
A 28-year-old G1 woman at 31 weeks gestation presents with complaints of fluid leaking from the vagina. Preterm
premature rupture of membranes is diagnosed. The patient has mild uterine tenderness concerning for early
chorioamnionitis. An amniocentesis is performed. Which of the following amniotic fluid results is indicative of an intra-
amniotic infection?
A. Presence of leukocytes
B. Low Interleukin-6
C. Amniotic glucose less than 20 mg/dl
D. Elevated level of bilirubin
E. Lecithin/sphingomyelin (L/S) ratio <2
C
In some cases of preterm rupture of the membranes, amniocentesis may be performed to detect intra-amniotic infection. The presence of amniotic
leukocytes has the lowest predictive value for the diagnosis of chorioamnionitis. Interleukin-6 would be increased in the setting of chorioamnionitis. A low
amniotic fluid glucose is an indication of intra-amniotic infection. L/S ratio is a marker for fetal lung maturity.
A 22-year-old G2P1 woman presents for prenatal care at approximately 10 weeks gestation. Her first pregnancy was
complicated by preterm premature rupture of the membranes at 28 weeks gestation. Which of the following interventions
could reduce the risk of preterm premature rupture of the membranes during this pregnancy?
A. Bedrest
B. Placement of a cerclage
C. Placement of a Tertbutaline pump
D. 17 alpha-hydroxyprogesterone
E. Nifedipine
D
Premature rupture of the membranes occurs in approximately 10-15 % of all pregnancies. Preterm premature rupture of the membranes between 16 and
26 weeks gestation is identified in 1% of pregnancies. Preterm premature rupture of the membranes occurs in 1/3 of all preterm deliveries. The reported
recurrence rate for preterm premature rupture of the membranes is approximately 32% when it occurred in the index pregnancy. Bedrest and tocolytics
have not been shown to reduce the risk for PPROM, and may have detrimental effects to the mother. A cerclage may be indicated for patients with a
history of an incompetent cervix. 17 alpha-hydroxyprogesterone has been shown to reduce the risk of premature labor.
,A 32-year-old G2P1 woman at 36 weeks gestation presents with preterm premature rupture of the membranes. She
denies labor. She takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. Her prior
pregnancy delivered vaginally at 34 weeks after spontaneous rupture of membranes. Her blood pressure is 110/70; pulse
84; temperature 98.6°F (37.0°C). The estimated fetal weight is 2700 grams. She is having one contraction per hour and
fetal heart tracing is category I. Which of the following is the most appropriate next step in the management of this
patient?
A. Observation until spontaneous onset of labor
B. Augmentation of labor
C. Magnesium sulfate
D. Nifedipine
E. Corticosteroids
B
In this patient, the benefits for delivery outweigh the risk of expectant management, so the patient should undergo augmentation of labor. Expectant
management at 36 weeks poses a large risk to the development of chorioamnionitis. The role of tocolytics in the setting of preterm premature rupture of
membranes is controversial and is contraindicated at 36 weeks gestation. Steroid administration after 32 weeks is controversial.
A 29-year-old G1P0 at 41 weeks gestation presents for a prenatal visit. Her prenatal course is complicated by tobacco
abuse and intermittent prenatal care. Her last visit was at 35 weeks. Prenatal labs are unremarkable except cervical DNA
probe positive for Chlamydia, which was treated, and a Pap smear with low-grade squamous intraepithelial lesion.
Ultrasound at 21 weeks was consistent with gestational age. Her vitals reveal a blood pressure of 128/76; pulse 74; and
temperature 98° F (36.7° C). Fundal height is 39 cm with estimated fetal weight of 2700 gm. Cervix is dilated to 1 cm, 50%
effaced, -2 station. What is the next best step in the management of this patient?
A. Non-stress test
B. Vibroacoustic stimulation test
C. Oxytocin challenge test
D. Return visit in one week
E. Cesarean section
A
The non-stress test is an assessment of fetal well-being that measures the fetal heart rate response to fetal movement. The normal or reactive non-stress
test occurs when there are two fetal heart rate accelerations of 15 beats/minute for 15 seconds within 20 minutes. Vibroacoustic stimulation is not
indicated unless the NST is non-reactive. Contraction stress test assesses uteroplacental insufficiency and looks for persistent late decelerations after
contractions (3/10 minutes); however, it is not necessary to perform, as the non-stress test will assess fetal well being, as well. Observation only would not
be proper care as the patient is post-term. In the presence of abnormal testing, labor would be induced or a Cesarean section performed.
A 29-year-old G1P0 at 41 weeks gestation presents in early labor. The prenatal course was uncomplicated. Ultrasound at
21 weeks was consistent with gestational age. Her vitals reveal a blood pressure of 128/76; pulse 74; and she is afebrile.
Fundal height is 36 cm with estimated fetal weight of 2700 gm. Cervix is dilated to 1 cm, 50% effaced and the fetal vertex
is at -2 station. The nurse calls you to evaluate the fetal tracing. Which statement best describes the tracing seen below?
A. Normal fetal heart rate with good variability and regular contractions
B. Fetal tachycardia with good variability and regular contractions
C. Normal fetal heart rate with poor variability and regular contractions
D. Fetal tachycardia with poor variability and irregular contractions
E. Normal fetal heart rate with poor variability and irregular contractions
https://www.apgo.org/images/26-2b.jpg
A
The baseline fetal heart rate is normal with good accelerations and regular contractions. There is no tachycardia. This is a reassuring tracing.
, A 19-year-old G3P0 with spontaneous rupture of membranes for 13 hours presented to labor and delivery. She had no
prenatal care. Her vital signs are:blood pressure 120/70; pulse 72; afebrile; fundal height 36 cm; and estimated fetal
weight of 2700 gm. Cervix is dilated to 1 cm, 50% effaced, -2 station. Which statement best describes the tracing seen
below?
A. Normal fetal heart rate with good variability and regular contractions
B. Fetal tachycardia with good variability and regular contractions
C. Normal fetal heart rate with poor variability and irregular contractions
D. Fetal tachycardia with poor variability and regular contractions
E. Normal fetal heart rate with good variability and irregular contractions
D
The baseline fetal heart rate is >160 with no accelerations or variability. There are regular contractions. Prolonged periods of fetal tachycardia are
frequentlyfound with maternal fever or chorioamnionitis.
A 33-year-old G1 at 38 weeks gestation with pregnancy complicated by type 1 diabetes was admitted for induction due to
oligohydramnios. She received Cervidil (prostaglandin E2) overnight and her cervix was noted to be 3 cm dilated in the
morning so oxytocin was started. After three hours on oxytocin induction, fetal heart rate was noted to be in the 160s with
minimal variability and late decelerations despite resuscitation with oxygen, fluids and left lateral position. Thirty minutes
after discontinuing the oxytocin, she continued to have contractions every three to four minutes with late decelerations.
Her blood pressure was noted to be 138/88 and her pulse was 110. Her cervical exam was noted to be 4 cm dilated. What
is the most appropriate next step in the management of this patient?
A. Perform a biophysical profile
B. Administer morphine
C. Administer terbutaline
D. Proceed with a Cesarean section
E. Restart the oxytocin
D
This fetus is clearly not tolerating labor. Unfortunately, there is no good way to assess fetal status at this point. A biophysical profile is not of any value in
labor. The presence of late decelerations in a patient with diabetes and oligohydramnios is not reassuring and unlikely to recover. Although terbutaline may
slow down the contractions, it is not recommended in a patient whose heart rate is 110. Morphine will not resolve the late decelerations.
A 19-year-old G1P0 at 41 weeks with spontaneous rupture of membranes for 13 hours presented to labor and delivery.
She had an uncomplicated prenatal course. Her vital signs are: blood pressure 120/70; pulse 72; afebrile; fundal height 36
cm; and estimated fetal weight of 2700 gm. Cervix is dilated to 4 cm, 100% effaced, + 1 station. What does the fetal heart
rate tracing seen below show?
A. Late deceleration
B. Variable decelerations
C. Early decelerations
D. Sinusoidal rhythm
E. Normal fetal heart rate pattern
C
Early decelerations are physiologic caused by fetal head compression during uterine contractions, resulting in vagal stimulation and slowing of the heart
rate. This type of deceleration has a uniform shape, with a slow onset that coincides with the start of the contraction and a slow return to the baseline that
coincides with the end of the contraction. Thus, it has the characteristic mirror image of the contraction. A late deceleration is a symmetric fall in the fetal
heart rate, beginning at or after the peak of the uterine contraction and returning to baseline only after the contraction has ended. Late decelerations are
associated with uteroplacental insufficiency. Variable decelerations show an acute fall in the FHR with a rapid down slope and a variable recovery phase.
They are characteristically variable in duration, intensity, and timing, and may not bear a constant relationship to uterine contractions. The true sinusoidal
pattern is a regular, smooth, undulating form typical of a sine wave that occurs with a frequency of two to five cycles/minute and an amplitude range of five
to 15 beats/minute. It is also characterized by a stable baseline heart rate of 120 to 160 beats/minute and absent beat-to-beat variability.
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