Obstetrical Emergencies: PROM and PPROM

• Complications during labor and birth can pose significant risks to both the mother and the fetus, requiring prompt recognition and intervention by healthcare providers
• Obstetrical emergencies demand a coordinated team approach and adherence to established protocols to optimize outcomes

Premature Rupture of Membranes (PROM) and Preterm Premature Rupture of Membranes (PPROM)

• PROM is the rupture of the amniotic sac before the onset of true labor
• PPROM is PROM occurring before 37 weeks of gestation
• Risk factors include previous PPROM, short cervical length, infections (e.g., bacterial vaginosis), multiple gestation, and smoking
• Diagnosis is typically confirmed by visualization of amniotic fluid leakage, a positive nitrazine test (pH of vaginal fluid >6.5), or ferning pattern on microscopic examination
• Management depends on gestational age; at term, induction of labor is often initiated to prevent infection
• Preterm PROM requires a balance between the risks of prematurity and the risks of infection; expectant management with close monitoring may be appropriate in some cases
• Antibiotics are often administered to prolong latency and prevent infection
• Corticosteroids are given to the mother to promote fetal lung maturity if delivery is anticipated before 34 weeks
• Tocolytics may be used to temporarily suppress uterine contractions, allowing time for steroid administration

Preterm Labor

• Preterm labor is defined as labor that begins before 37 weeks of gestation
• Risk factors include previous preterm birth, multiple gestation, uterine abnormalities, infections, and certain maternal medical conditions
• Diagnosis is based on regular uterine contractions accompanied by cervical change or cervical dilation of ≥2 cm or effacement of ≥80%
• Fetal fibronectin (fFN) testing can help predict the likelihood of preterm labor; a negative fFN result has a high negative predictive value
• Tocolytic medications (e.g., magnesium sulfate, nifedipine, indomethacin) may be used to suppress uterine contractions and delay delivery
• Magnesium sulfate also provides neuroprotection for the fetus
• Corticosteroids are administered to enhance fetal lung maturity
• Bed rest is not routinely recommended due to lack of evidence of benefit and potential adverse effects

Post-term Pregnancy

• Post-term pregnancy is defined as a pregnancy that extends beyond 42 weeks of gestation
• Risks include macrosomia, shoulder dystocia, meconium aspiration, oligohydramnios, and placental insufficiency
• Management involves careful fetal monitoring, including non-stress tests (NSTs) and biophysical profiles (BPPs)
• Induction of labor is typically recommended between 41 and 42 weeks to reduce the risk of complications

Dystocia

• Dystocia refers to difficult or abnormal labor
• It can be caused by various factors, including problems with the power (uterine contractions), the passenger (fetal size, position, or presentation), or the passage (maternal pelvis)
• Protraction disorders involve slower than normal labor progress
• Arrest disorders involve complete cessation of progress
• Shoulder dystocia is an obstetrical emergency in which the fetal shoulders become impacted behind the maternal symphysis pubis
• McRobert's maneuver and suprapubic pressure are commonly used interventions to resolve shoulder dystocia
• The use of Zavanelli maneuver is reserved for cases where other methods have failed
• Operative vaginal delivery (forceps or vacuum extraction) may be considered in certain situations to expedite delivery
• Cesarean delivery may be necessary if vaginal delivery is not possible or safe

Induction of Labor

• Induction of labor is the stimulation of uterine contractions before the spontaneous onset of labor
• Indications include post-term pregnancy, preeclampsia, fetal growth restriction, and maternal medical conditions
• Cervical ripening methods, such as prostaglandins (e.g., misoprostol, dinoprostone) or a Foley catheter, may be used to soften and dilate the cervix
• Oxytocin is a synthetic hormone used to stimulate uterine contractions
• Amniotomy (artificial rupture of membranes) may be performed to augment labor
• Risks of induction include uterine tachysystole, fetal distress, and failed induction, potentially leading to cesarean delivery

Uterine Rupture

• Uterine rupture is a rare but catastrophic event in which the uterus tears open
• Risk factors include previous cesarean delivery, uterine surgery, and grand multiparity
• Symptoms include sudden abdominal pain, vaginal bleeding, fetal distress, and loss of uterine contractions
• Management requires immediate surgical intervention to repair the uterus and deliver the fetus

Amniotic Fluid Embolism (AFE)

• AFE is a rare but life-threatening condition in which amniotic fluid enters the maternal circulation, causing a systemic inflammatory response
• Symptoms include sudden respiratory distress, hypotension, cyanosis, and disseminated intravascular coagulation (DIC)
• Management involves supportive care, including oxygenation, ventilation, hemodynamic stabilization, and correction of coagulopathies

Prolapsed Umbilical Cord

• Prolapsed umbilical cord occurs when the umbilical cord descends through the cervix ahead of the presenting part
• It is an obstetrical emergency that requires immediate intervention to relieve pressure on the cord and restore fetal oxygenation
• Management involves elevating the presenting part off the cord, administering oxygen to the mother, and preparing for immediate delivery, usually by cesarean section

Vasa Previa

• Vasa previa is a condition in which fetal blood vessels run unprotected in the membranes over the cervix
• It is associated with a high risk of fetal exsanguination if the membranes rupture
• Diagnosis may be suspected based on ultrasound findings or vaginal bleeding with fetal heart rate changes during labor
• Management typically involves planned cesarean delivery before the onset of labor

Retained Placenta

• Retained placenta is defined as failure to deliver the placenta within 30 minutes after delivery of the infant
• It may be caused by placental adherence to the uterine wall or uterine atony
• Management may involve manual removal of the placenta, uterine massage, and administration of uterotonic medications
• In some cases, surgical removal (D&C) may be necessary

Postpartum Hemorrhage

• Postpartum hemorrhage (PPH) is defined as excessive bleeding after childbirth, usually more than 500 mL after vaginal birth or more than 1000 mL after cesarean birth
• Primary PPH occurs within the first 24 hours after delivery
• Secondary PPH occurs from 24 hours up to 12 weeks postpartum
• Causes of PPH include uterine atony, lacerations, retained placental fragments, and coagulation disorders
• Management involves uterine massage, administration of uterotonic medications (e.g., oxytocin, misoprostol, methylergonovine, carboprost), fluid resuscitation, and blood transfusion
• In severe cases, uterine tamponade, uterine artery embolization, or hysterectomy may be necessary