A 32 year old multigravid woman was transferred from a regional hospital at 23+1 weeks of gestation with a history of spontaneous rupture of membranes. Her past history included a normal vaginal delivery complicated by manual removal of the placenta and postpartum curettage for retained products. She had later undergone further curettages for miscarriage. Subsequently, she developed Asherman's Syndrome requiring hysteroscopic division of adhesions for secondary infertility.
The presenting complaint was of a painless watery vaginal discharge over the preceding 10 days with associated bloody mucous loss. At the regional hospital, hourglassing of the membranes through the cervix was observed. During transfer her membranes spontaneously ruptured. On admission to our tertiary hospital 3½ hours later, sterile speculum examination revealed umbilical cord in the vagina. The fetal heart was present and normal in rate. Nifedipine administered at the regional hospital was ceased. Intravenous antibiotic therapy was commenced and two doses of Celestone were given (11.4 mg, 12 hours apart). Ultrasound examination demonstrated a live, well-grown fetus in a footling breech presentation and severe oligohydramnios consistent with ruptured membranes. The umbilical cord was seen to be prolapsing through a partially dilated cervix. The placenta was normally situated. There was a small area of very thin (3 mm) myometrium suggestive of placenta accreta.
The woman and her husband were advised of the poor prognosis for the pregnancy, fetal survival and risk of long term disability if delivered at this gestation, and potential maternal complications. The risks of classical caesarean section, the significance of placenta accreta and the potential for hysterectomy were fully discussed. Conservative management was recommended as the best option both to reduce maternal morbidity and prolong the pregnancy to a gestation that may improve fetal outcome.
Intravenous antibiotics were changed to oral erythromycin (250 mg QID). The woman was monitored for signs of chorioamnionitis and ordered bed rest. One week later, repeat ultrasound demonstrated normal fetal growth and biophysical parameters. Fetal presentation was unchanged and no amniotic fluid was seen. The umbilical cord filled the cervix and the vagina, with no cord seen in the uterus. The cervix remained 2–3 cm dilated. Cord flow Dopplers were normal with a S/D ratio of 2.5. Myometrium remained thin but normal vascularity was demonstrated confounding definitive diagnosis of placenta accreta.
During admission, the cord prolapsed outside of the vagina on a number of occasions, mainly when the patient passed a bowel motion. It was digitally replaced into the vagina each time. Thereafter, the woman was instructed to place a tampon into the vagina prior to each bowel motion and remove it immediately afterwards. The woman remained clinically well with no signs of chorioamnionitis. Clear vaginal loss continued. Regular full blood examination confirmed normal white cell count, however, C-reactive protein was raised up to 48 mg/L. Each day the fetal heart was auscultated using a sonacaid. Cardiotocography was not performed because the decision had been made to deliver only on maternal indications (i.e. bleeding complications, sepsis or if labour ensued) prior to 26 weeks of gestation.
Classical caesarean section was performed at 26+1 weeks of gestation with patient consent for hysterectomy if needed. The placenta was anterofundal, removed manually and good haemostasis was achieved. Estimated fetal blood loss was 500 mL. A live male baby was born weighing 658 g with Apgar scores of six at 5 minutes and seven at 10 minutes.
The infant was intubated, ventilated and exogenous surfactant administered in the operating theatre. He was transferred to the Neonatal Intensive Care Unit and commenced on empiric antibiotic therapy after blood culture was obtained. Initial haematological markers of sepsis were benign and blood culture did not isolate any organisms. Airway pressure support was finally ceased at 35+6 weeks postmenstrual age. Continuous low flow nasal oxygen was required for chronic neonatal lung disease. He was exclusively fed on his mother's own breastmilk. Routine cranial ultrasounds on days 5, 14 and 42 were all normal.
Histopathological examination of the cord and placenta was consistent with premature rupture of membranes. Placental culture revealed a light growth of candida (Torulopsis) glabrata and mixed anaerobic organisms.