OBS: Perinatal Medicine -- Abnormal Presentation and Position

Question 1

How to manage preterm labour?

Answer 1

Admission + Ascertain Gestation + Aetiology

1. Admission to labour ward
   
   • call senior & neonatologist, book NICU
   • NPO
   • ascertain gestational age by Hx & USG scan
2. Investigate aetiology of preterm labour & r/o indications for immediate delivery
   
   • Hx taking for risk factors:
     previous preterm labour, primigravida, recurrent APH, PPROM…
   • P/E:
     a. Vitals (BP/P, SaO2, temperature)
     b. Abdominal exam (lie, presentation, engagement, s/s of labour)
     c. Speculum (cervix status, liquor)
   • Ix:
     a. CBC, clotting, cross match, CRP
     b. CTG
     c. MSU, triple swab
     d. TAS for fetal wellbeing, growth parameters, liquor volume
     e. TVS for cervical length, amniotic sac funneling

Management plan
(>34w & uncomplicated) proceed to delivery
(<34w) prolong labour with tocolytics
a. dexamethasone
b. tocolytics
c. antibiotics
d. MgSO4

Question 2

How to confirm the diagnosis of PPROM?

Answer 2

• Maternal history:
  
  • sudden gush of watery clear fluid passed vaginally
  • S/S of Labour (uterine contraction)
  • S/S of infection (fever, urinary/bowel symptoms)
  • S/S of abruptio (APH, uterine pain, reduced fetal movement)
• P/E:
  
  • Vitals (BP/P)
  • Aseptic speculum exam (cervical dilation, pool of liquor, cough test)
  • Abdominal exam (fetal lie, presentation, uterine contraction, doptone)
    
    • To rule out abruptio, chorioamnionitis, scar rupture
• Specific diagnostic test:
  
  • Actim PROM test —> test IGFBP1
  • Amniostix —> from orange to blue

Question 3

Management of PPROM

Answer 3

• Inpatient management
• Clinical assessment (monitoring of maternal and fetal conditions)
  
  • Vitals (BP/P, RR, temperature)
  • Uterine tenderness
  • Vaginal discharge
  • Fetal movement
  • VTE prophylaxis
• Investigations
  
  • Maternal:
    
    • CBC, CRP, MSU C/ST
  • Fetal:
    
    • Doptone Q4H, CTG twice weekly
    • USG Q2w
• Pharmacological treatment
  
  • IM dexamethasone
  • ABx prophylaxis
    
    • (24 to 34w) Metronidazole PO, Cefuroxime IV, Erythromycin PO
    • (34 to 37w) IV Ampicillin
  • (<32w) MgSO4

Question 4

Causes of cervical incompetence

Answer 4

• Cervical trauma due to…
  
  • Previous Labour
  • Cervical procedures (D&C, LEEP, cone biopsy)
  • History of CIN
  • Previous 2nd trimester miscarriage / early preterm delivery
• Congenital
  
  • Collagen disorders
  • Uterine abnormalities

Question 5

Management of cervical incompetence

Answer 5

• Emergency cervical cerclage
• IM dexamethasone
• Antibiotic prophylaxis

Question 6

Advantages and risks of cervical cerclage

Answer 6

• Advantages:
  
  • Mechanically reinforce cervical competence to keep cervical closed
  • Prevent miscarriage or preterm delivery
• Risks:
  
  • PROM
  • Cervical tear
  • Ascending infection
  • Precipitate miscarriage/ preterm delivery

Question 7

How to describe a CTG?

Answer 7

CTG of XXX is taken on (date) at (time)
The baseline FHR is … bpm, which is normal / indicates brady-/tachycardia, with increased/moderate/decreased variability. There are … accelerations and … decelerations. There is normal/hypertonic/hypotonic uterine activity.
This CTG is abnormal/normal.

Question 8

Management of cord prolapse

Answer 8

1. Urgent delivery (CS or instrumental delivery)
2. Minimise cord compression / further prolapse
   (a) Digital elevation
   (b) Tredelenburg position
   (c) [If uterine contraction] Tocolytics: Terbutaline
   [If above ineffective] knee-chest position, bladder filling (500ml)
3. Minimise vasoconstriction
   (a) [If cord outside vagina] warm wrapping of cord
   *no cord manipulation to avoid cord spasm

Question 9

How to access fetal hypoxic status after delivery?

Answer 9

By APGAR score