Lecture 16: Obstetrical Complications

Question 1

1. Preterm Birth/ Pre-term Labor

Question 2

Preterm birth (PTL) is defined at what point in the gestational timeline?

Answer 2

- 20-36 weeks gestational birth

Birth that occurs after 20 weeks but before 37 weeks of gestation

Question 3

The diagnosis of preterm labor is defined as what 2 events?

Answer 3

1) Uterine contractions w/ CERVICAL CHANGE

- “You don’t know someone is in PTL, unless you see cervix is changing!”- Wootton (slide 14)

and/or

2) Cervical DILATION of 2cm, 80% effaced

Question 4

What are 5 symptoms of PTL (Pre-term Labor)?

Answer 4

1) “Menstrual like-cramping”
2) Dull backache
3) Pelvic Pressure
4) Bloody Discharge
5) Uterine Contractions*** (WITH CERVICAL CHANGE)

Question 5

Which ethnicity is 2x more likely to experience pre-term labor?

Answer 5

African Americans 2x more likely than Caucasians

Question 6

There is a link between infection and progressive changes in cervical length.

How is this related to preterm labor?

Answer 6

as cervical length ↓ (decreases)**

Risk of PTL ↑ (increases)

From Slide: Infection-Cervical Pathway

Question 7

Which 2 cervical length screening tools can predict relative risk of PTL birth?

Answer 7

1) Ultrasound
* Especially important if hx of PTL or LEEP or Cold Knife Colonization*
2) Fetal fibronectin (FFN)
- Must be obtained before cervical evaluation
- Must be delayed if sex within past 24 hrs)
* released from BM’s of fetal membranes in response to disruption of the membranes as w/ uterine activity, cervical shortening or infection*
* From Slide: CERVIX and PTL*

Question 8

Which tocolytic used for PTL is only used on a short-term basis (mostly for extreme prematurity)?

Answer 8

Indomethacin

Question 9

Whic

Question 10

What is 1 reason Ibuprofen (NSAID) is USED for in PTL?

What is Ibuprofen NOT USED FOR in PTL?

Answer 10

1) Used to ↓ uterine activity (sign of PTL)
2) BUT IBUPROFEN IS NOT used for primary treatment of preterm labor

Question 11

Glucocorticoids are given between what weeks, in regards to fetal lung maturation ?

Answer 11

Between 24-** **34 weeks gestation

Question 12

A single course of betamethasone is recommended for pregnant women between which weeks of gestation if at risk of PTL within 7 days and who have no received a previous corse of antenatal corticosteroids?

Answer 12

Between 34 0/7 week and 36 6/7 weeks of gestation

Question 13

What are some of the preventative measures being used for PTL?

Answer 13

• IM progesterone (Makena) given weekly from 16-36 weeks in women w/ prior hx of spontaneous PTL/PPROM
• Vaginal progesterone used in women w/ shortened cervix (<2.5 cm)
• Pessary (Arabin pessary) used in women w/ shortened cervix

Question 14

Diagnosis of premature rupture of membranes (PROM) is based on what; confirmed how?

Answer 14

• History! —> loss of fluid + confirmation of amniotic fluid in vagina
• Rupture is confirmed using a sterile speculum

Question 15

What should you never do when assessing a presumed ruptured preterm patient?

Answer 15

Do NOT check the cervix —> ↑ risk of infection especially w/ prolonged latency before delivery

Question 16

What are 3 tests that can be done to confirm PROM?

Answer 16

• Pooling
• Nitrazine paper (turns blue)
• Ferning

Question 17

Management of PPROM depends on what 4 factors?

Answer 17

1. Gestational age at time of rupture: if <24 wks may lead to pulmonary hypoplasia
2. Amniotic fluid index: any value <5cm is considered oligohydramnios
3. Fetal status
4. Maternal status

Question 18

What is the goal of management for PPROM?

Answer 18

Continue the pregnancy until lung profile is mature

Question 19

Regardless of fetal lung maturity, most women with PPROM will deliver at how many weeks gestation?

Answer 19

34 weeks

Question 20

While managing woman with PPROM you must monitor for signs/sx’s of chorioamnionitis, which include what?

Answer 20

• Maternal temp >100.4 °F
• Fetal or maternal tachycardia
• Tender uterus
• Foul smelling amniotic fluid/purulent discharge

Question 21

ACOG recommends using what drugs to attempt to prolong latency period of woman with PPROM?

Answer 21

• 48 hour course of IV Ampicillin and Erythromycin/Azithromycin
• Followed by 5 days of Amoxil and Erythromycin

Question 22

What is the ACOG recommendation for use of steroids in patient with PPROM?

Answer 22

Use up to 34 weeks of gestation to ↓ risk of RDS

Question 23

1) What is the definition of IUGR (Intrauterine Growth Restriction)?
2) What are 3 causes of IUGR?

Answer 23

1) When newborn’s birthweight < 10%

2)

2a. Cigarettes (babies will weigh ~200 grams) <– maternal
2b. Velamentous Cord Insertion <– placental
2c. TORCH Infection <– fetal
* (Toxplasmosis, Other, Rubella, CMV, Herpes)*

Question 24

1) Primary screening tool for dx of IUGR?

2) Fundal height LAGS MORE THAN 3 cm behind gestational age, in newborn suspected for IUGR. Mom has hypertension, diabetes. What is next best step?

Answer 24

1) Serial Fundal Height Measurement

2) Ultrasound

Ultrasound is routinely used for high risk conditions that predispose to IUGR such as Hypertension, Diabetes, Renal Disease, Drug abuse, Antiphospholipid Syndrome, Lupus

Question 25

If suspect fetal IUGR…

1) No intervention, if……?
2) Deliver, if….?
3) Antenatal testing, if….? (NST 2x weekly, Biophysical Profile, Doppler studies of Umbilical Artery)

Answer 25

1) Normal Ultrasound
2) IUGR on Ultrasound and GREATER than 38 weeks
3) IUGR on Ultrasound and LESS than 38 weeks

Question 26

PTP (Post Partum Pregnancy)