29 Year Old with Premature Rupture of Membranes Ch 27

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29 Year Old with Premature Rupture of Membranes
Ch 27

• Based upon LABORATORY MEDICINE CASEBOOK. An
  introduction to clinical reasoning
• Jana Raskova, MDProfessor of Pathology
  Laboratory MedicineUMDNJ-Robert Wood Johnson
  Medical SchoolPiscataway, NJStephen Shea, MD
  Professor of Pathology Laboratory
  MedicineUMDNJ-Robert Wood Johnson Medical
  SchoolPiscataway, NJFrederick Skvara, MD
  Associate Professor of Pathology Laboratory
  MedicineUMDNJ-Robert Wood Johnson Medical
  SchoolPiscataway, NJNagy Mikhail, MDAssistant
  Professor of Pathology Laboratory
  MedicineUMDNJ-Robert Wood Johnson Medical
  SchoolPiscataway, NJ

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CLINICAL COURSE

• MEMBRANES RUPTURE
• 12 hrs post Soap Suds Enema
• 15 hrs Oxcytocin drip
• 26 hrs
• Temperature 101 oF
• Cervix 5 cm dilated
• Caesarean Section
• Successful Delivery

Janice Saphire
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HEMATOLOGY - Admission
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HEMATOLOGY Admission 2
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CHEMISTRY - Admission
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Nutritional Needs of Pregnancy

• Proteins
• ? Calcium
• Half the calcium required by the fetus is
  deposited in the last trimester. Insufficient
  intake - then the baby will take it from your
  bones.
• ? Iron
• Calories

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Iron Deficiency in Pregnancy

• Serum iron actually increases in the first
  trimester of pregnancy due to an estrogen induced
  increase in transferrin levels
• By the third trimester- effects of estrogen are
  reversed partially by hemodilution, but also from
  iron utilization by the fetus
• Serum Iron ?, TIBC ?

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Chemistry - Admission
In pregnancy, the placenta produces ALP. ALP
begins to rise at the end of the first trimester
and can reach values up to 4 times the upper
reference limit by the third trimester A bone
derived component of ALP is also elevated and can
Remain so for 6 weeks after delivery.
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Elevated Alkaline Phosphatase

• Sources
• Placenta
• Liver
• Bone
• Intestine
• Placenta
• Cytotrophblast maturity. Peaks 3rd trimester.
  Levels up to 4x normal
• Lower in diabetics
• Normal 1 mos. Post delivery

• Disease elevations
• Hepatobiliary
• Bone
• Tumors
• Malignancies
• Ovarian, Testiculargt
• BreastgtLungs
• Heat stability in placental Alk. Phos. Suspicious
  for malignancy

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HEMATOLOGY Post-Delivery
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Hematology Post Delivery
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Shift to the Left

• Includes
• Unilobed and two lobed nucleus predominate
• Seen in
• Acute infection
• Metaboloc acidosis
• Necrosis myocardial infarct. malignant tumors
• Blood disease
• hemolytic crises,
• severe blood loss
• chronic  granulocytic leukemia,

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Toxic Granulation

• Dark blue-black granules in the cytoplasm of
  neutrophils.
• Unevenly spread throughout the cytoplasm.
• Give the neutrophil a bluish appearance..
• Stress response to acute infections.

TOXIC
NORMAL
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Dohle Bodies

• Another toxic change in WBC
• Small aggregates or RNA
• Location Periphery

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Shift to the Right

• Includes gt 5 lobe neutrophils.
• Appears in
• Pernicious anemia
• Steatorrhea
• Congenital hypersegmentation
• Chronic uremia
• Liver disease (some).

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Bacterial Culture Results

• Blood
• Positive for group B streptococci
• Placenta
• Positive for group B streptococci

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What is PROM?

• Premature Rupture of Membranes
• About 10 of all pregnancies
• 80 of these occur in term patients

• Associated with
• Polyhydramnios
• Twin pregnancies
• Amniocentesis
• Incompetent cervix

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Complications of PROM

• Premature labor
• Infections for both neonate and mother in term
  PROM
• Fetal hypoxia associated with compression or
  prolapse of the cord

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ACUTE CHORIOAMNIONITIS
Junction of Amnion and Chorion
Amnion
Chorion
Neutrophils
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Placenta - Histology

• Placental Membranes Patient
• Placental Membranes Normal

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Infections and chorioamnioitis

• Seen in 3-15 of all cases of PROM
• Infection with low virulence organisms is rare
  lactobacilli, diphtheroids, and Staphyloccus
  eipdermidis
• Infection with HIGH virulence organisms is
  frequent including Group B streptococci, Staph.
  Aureus, E. coli and clostritium

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COAGULATION STUDIES
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Alpha-Fetoprotein

• Within normal range for gestational age
• Increased open neural tube defect
• Increased fetal demise
• Decreased Down Syndrome

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AFP Distribution