Preterm birth - NICE guideline Flashcards
Re maternal steroids. What is recommended between 22+0 and 23+6?
DISCUSS with the women (&family) and MDT the use of steroids in the CONTEXT of her INDIVIDUAL circumstances.
Re maternal steroids. What is recommended between 24/40 and 33+6?
OFFER to those with suspected, diagnosed or established preterm labour, planned preterm birth or PPROM.
Re maternal steroids.
What is recommended between 34 & 35+6
CONSIDER for those with suspected, diagnosed or established PTL, planned pre-term or PPROM
What is the criteria for a single repeat course of mat steroids?
1) Less than 34 weeks,
2) last course more than 7 days ago, are at VERY HIGH risk of birth in next 48hrs.
what effect on the fetus should you take into account re repeat courses of maternal steroids in women less than 30 weeks or if FGR?
Take into account the possible impact on fetal growth.
How many courses of steroids can be given?
“do not give more than 2 course of steroids for preterm birth”,
“with multiple repeat courses the effects on birthweight may outweigh the benefits”
Maternal steroids: What was the mean difference in birthweight between women receiving repeat courses vs single course
114g
Maternal steroids repeat courses: What did sub group analysis discern regarding risks for reductions in weight.
When courses were administered <30 weeks, at intervals of less than 7 days, when total repeat course dose >24mg were administered.
maternal steroids repeat courses: what is the trending effect of increasing courses of maternal steroids?
“significant trend for reducing birthweight as the number of repeat courses increased”
What is the effect of repeat maternal steroids on chronic lung disease?
There is no evidence of benefit of repeat maternal steroids on chronic lung disease
What is the effect of repeat course of steroids on need for respiratory support in neonates?
Benefit is seen on the need for respiratory support in neonates
what is the effect of repeat courses of maternal steroids on perinatal mortality, neonatal admission, IVH, growth at 2 years and neurodevelopmental delay?
There is good evidence that repeat courses of steroids had no effect or no beneficial effect on perinatal mortality, neonatal admission, IVH, growth at 2 yrs and neurodevelopmental delay.
What are the criteria for OFFERING a CHOICE of prophylactic PV progesterone or prophylactic cercvical cerclage?
To women who have BOTH:
1) spont PTB <34/40 or loss from >16/40,
AND
2) Cervical length <25mm on TVS between 16/40 and 24/40
What are the criteria for CONSIDERING prophylactic PV progesterone?
CONSIDER if woman has EITHER
1) spont PTB <34/40 or loss from >16/40
OR
2) cervical length <25mm on TVS between 16/40 and 24/40
prophylactic PV progesterone. When is it started and stopped?
Start between 16 and 24 weeks and continue until AT LEAST 34 weeks.
What is the criteria for CONSIDERING prophylactic cervical cerclage?
CONSIDER when a woman has CL <25mm on TVS who has had EITHER:
1)PPROM in a previous pregnancy
OR
2) a history of cervical trauma.
Where prophylactic cervical cerlage is used…
ensure a plan is documented for removal of suture.
Do not consider emergency cervical cerclage for women with:
1) signs of infection, or
2) ACTIVE vaginal bleeding, or
3) uterine contractions.
between which gestations to consider emergency cervical cerclage?
between 16 and 27+6
criteria for consideration of emergency cervical cerclage
1)between 16 and 27+6 weeks
2)a dilated cervix
3)Exposed un-ruptured membranes.
Consider also gestation and extent of cervical dilation
Discuss with obs and paeds consultant.
In women 30+/40. Consider TV cervical length scan to diagnose PTL.
What is the cervical length to act on?
If more than 15mm PTL is unlikely
If less than 15mm then diagnose PTL.
Tocolysis between 24 & 25+6.
CONSIDER nifedipine for women with intact membranes and SUSPECTED PTL
Tocolysis between 26 & 33+6.
OFFER nifedipine for women with intact membranes and SUSPECTED or DIAGNOSED PTL
MgSO4 for neuroprotection between 23 - 23+6?
DISCUSS with the women in the context of individual circumstances
MgSO4 for neuroprotection between 24 -29+6
OFFER to those in established preterm labour
or
planned preterm birth within 24hrs
MgSO4 for neuroprotection between 30 -33+6
CONSIDER for those in est PTL or planned PTB within 24hrs
Monitoring in PTL between 23 and 25+6
Involve a senior obstetrician about whether or how to monitor.
A normal CTG in pre-term labour is…
reassuring and indicates that the baby is coping well with labour.
an abnormal CTG in preterm labour
does not necessarily indicate acidosis/hypoxia is present.
in PTL explain fetal monitoring options being aware that:
There is limited evidence about the usefulness of specific features to indicate acidosis or hypoxia in preterm babies.
Is there any evidence for CTG monitoring Vs IA in preterm labour
The is an absence of evidence that using CTG improves fetal or maternal outcome vs IA.
do not use FSE in PTL <34/40 unless all of the following apply:
1) It is not possible to monitor with CTG or IA.
2) it has been discussed with a senior obstetrician
3) benefits likely to outweigh the risks
4) the alternatives (immediate birth, intermittent ultrasound, no monitoring) are unacceptable to her.
Timing of DCC in preterm babies
Wait at least 60 seconds unless specific maternal or fetal conditions
