OBS: Perinatal Medicine -- Abnormal Timing of Delivery

Question 1

How to manage preterm labour?

Answer 1

Initial Management Admit, Ascertain, Assess

1. Admit
   
   1. Inform neonatologist + book NICU
2. Ascertain gestation date
3. Assess to rule out DDx that require immediate delivery — abruptio, scar rupture, infection
   
   1. Hx taking for risk factors
   2. PE:
      
      1. Vitals
      2. Abdominal exam
      3. Speculum: ROM, cervix status
   3. Ix:
      
      1. CBC, clotting, X-match, CRP
      2. MSU ⨉ C/ST, Triple swabs
      3. TAS: growth, size, liquor, placenta, sludge
      4. TVS: cervical length
   4. Fetal:
      
      1. CTG

Further Management

*if >34w + uncomplicated -> proceed to delivery*

1. Tocolytics: Nifedipine (CCB) 1st line, Atosiban (oxytocin antagonist)
2. Steroids: IM Dexamethasone
   Indication: 24~34w
3. MgSO4Aim: neuroprotection (↓ risk of cerebral palsy)Indication: <32w, in active phase of labour
4. AntibioticsIndications:
   1. PPROM
   2. Subclinical intrauterine infection (TVS shows sludge around os)
   3. GBS protocol

Question 2

How to confirm the diagnosis of PPROM?

Answer 2

1. Hx: sudden gush of clear watery fluid passed vaginally
2. Aseptic Speculum: pool of liquor, cough test +ve
3. +/- Actim PROM test (detect IGFBP-1)

Question 3

Management of PPROM

Answer 3

1. Admit the patient for close monitoring of maternal & fetal well-being *for chorioamnionitis*Maternal:
   1. Vitals (BP/P, temperature) Q4H
   2. Observe for uterine tenderness, meconium stained liquor, PV discharge, ↓ FM
   3. CBC with differentials + CRP Q1w
   Fetal:
   1. FHR: Doptone Q4H, CTG twice weekly
   2. Fetal growth: USG Q2w
2. Steroid: IM Dexamethasone
3. Antibiotics prophylaxis: IV Cefuroxime + PO Erythromycin + PO MetronidazoleAvoid Augmentin (kill GI flora → ↑ risk of necrotizing enterocolitis)
4. VTE prophylaxis: mobilisation, elastic stocking
   - At term pre-labour ROM IOL after spontaneous ROM

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

1. Rescue surgical cerclage / PE-indicated cerclage
2. Steroids
3. Antibiotics 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