Preterm birth - NICE guideline

Question 1

Re maternal steroids. What is recommended between 22+0 and 23+6?

Answer 1

DISCUSS with the women (&family) and MDT the use of steroids in the CONTEXT of her INDIVIDUAL circumstances.

Question 2

Re maternal steroids. What is recommended between 24/40 and 33+6?

Answer 2

OFFER to those with suspected, diagnosed or established preterm labour, planned preterm birth or PPROM.

Question 3

Re maternal steroids.
What is recommended between 34 & 35+6

Answer 3

CONSIDER for those with suspected, diagnosed or established PTL, planned pre-term or PPROM

Question 4

What is the criteria for a single repeat course of mat steroids?

Answer 4

1) Less than 34 weeks,
2) last course more than 7 days ago, are at VERY HIGH risk of birth in next 48hrs.

Question 5

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?

Answer 5

Take into account the possible impact on fetal growth.

Question 6

How many courses of steroids can be given?

Answer 6

“do not give more than 2 course of steroids for preterm birth”,
“with multiple repeat courses the effects on birthweight may outweigh the benefits”

Question 7

Maternal steroids: What was the mean difference in birthweight between women receiving repeat courses vs single course

Answer 7

114g

Question 8

Maternal steroids repeat courses: What did sub group analysis discern regarding risks for reductions in weight.

Answer 8

When courses were administered <30 weeks, at intervals of less than 7 days, when total repeat course dose >24mg were administered.

Question 9

maternal steroids repeat courses: what is the trending effect of increasing courses of maternal steroids?

Answer 9

“significant trend for reducing birthweight as the number of repeat courses increased”

Question 10

What is the effect of repeat maternal steroids on chronic lung disease?

Answer 10

There is no evidence of benefit of repeat maternal steroids on chronic lung disease

Question 11

What is the effect of repeat course of steroids on need for respiratory support in neonates?

Answer 11

Benefit is seen on the need for respiratory support in neonates

Question 12

what is the effect of repeat courses of maternal steroids on perinatal mortality, neonatal admission, IVH, growth at 2 years and neurodevelopmental delay?

Answer 12

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.

Question 13

What are the criteria for OFFERING a CHOICE of prophylactic PV progesterone or prophylactic cercvical cerclage?

Answer 13

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

Question 14

What are the criteria for CONSIDERING prophylactic PV progesterone?

Answer 14

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

Question 15

prophylactic PV progesterone. When is it started and stopped?

Answer 15

Start between 16 and 24 weeks and continue until AT LEAST 34 weeks.

Question 16

What is the criteria for CONSIDERING prophylactic cervical cerclage?

Answer 16

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.

Question 17

Where prophylactic cervical cerlage is used…

Answer 17

ensure a plan is documented for removal of suture.

Question 18

Do not consider emergency cervical cerclage for women with:

Answer 18

1) signs of infection, or
2) ACTIVE vaginal bleeding, or
3) uterine contractions.

Question 19

between which gestations to consider emergency cervical cerclage?

Answer 19

between 16 and 27+6

Question 20

criteria for consideration of emergency cervical cerclage

Answer 20

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.

Question 21

In women 30+/40. Consider TV cervical length scan to diagnose PTL.
What is the cervical length to act on?

Answer 21

If more than 15mm PTL is unlikely
If less than 15mm then diagnose PTL.

Question 22

Tocolysis between 24 & 25+6.

Answer 22

CONSIDER nifedipine for women with intact membranes and SUSPECTED PTL

Question 23

Tocolysis between 26 & 33+6.

Answer 23

OFFER nifedipine for women with intact membranes and SUSPECTED or DIAGNOSED PTL

Question 24

MgSO4 for neuroprotection between 23 - 23+6?

Answer 24

DISCUSS with the women in the context of individual circumstances

Question 25

MgSO4 for neuroprotection between 24 -29+6

Answer 25

OFFER to those in established preterm labour
or
planned preterm birth within 24hrs

Question 26

MgSO4 for neuroprotection between 30 -33+6

Answer 26

CONSIDER for those in est PTL or planned PTB within 24hrs

Question 27

Monitoring in PTL between 23 and 25+6

Answer 27

Involve a senior obstetrician about whether or how to monitor.

Question 28

A normal CTG in pre-term labour is…

Answer 28

reassuring and indicates that the baby is coping well with labour.

Question 29

an abnormal CTG in preterm labour

Answer 29

does not necessarily indicate acidosis/hypoxia is present.

Question 30

in PTL explain fetal monitoring options being aware that:

Answer 30

There is limited evidence about the usefulness of specific features to indicate acidosis or hypoxia in preterm babies.

Question 31

Is there any evidence for CTG monitoring Vs IA in preterm labour

Answer 31

The is an absence of evidence that using CTG improves fetal or maternal outcome vs IA.

Question 32

do not use FSE in PTL <34/40 unless all of the following apply:

Answer 32

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.

Question 33

Timing of DCC in preterm babies

Answer 33

Wait at least 60 seconds unless specific maternal or fetal conditions