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Essentials - Obstetrics > Preterm Labor > Flashcards

Preterm Labor Flashcards

1
Q

Describe the approach to PROM (4)

A
  1. Hx of fluid gush vs. continuous leakage, timing? Consistency? colour, odour
  2. Vital signs
  3. Lab studies (CBC, U/A, urine C&S + cervical culture for G&C, anovaginal swab for GBS status)
  4. Sterile speculum exam
    • a. Observe for pooling of amniotic fluid in posterior fornix, and fluid leaking from cervix during cough/valsalva
    • Nitrazine test (amniotic fluid turns nitrazine paper blue)
    • Note: do not do a cervical exam to avoid introduction of infection unless signs of labor
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2
Q

Describe the management of PROM (2)

A

Evidence of fetal distress, placenta abruption, or chorioamnionitis or labor?

  • No: < 34 wk (conservative management) vs > 34 wk
  • Yes: Urgent delivery
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3
Q

Describe the management of PROM if no evidence of fetal distress/placenta abruption/chorioamnionitis/labor and < 34 wk (5)

A

Conservative management*

  1. Limited/light activity
  2. Continuous FHR monitoring until stable then q8h
  3. Daily NST and biweekly BPP
  4. Antibiotics – GBS prophylaxis (i.e. Pen G) if in labor. If not in labor – ampicillin + erythromycin IV X 2 days then amoxicillin + erythromycin PO X 5 days
  5. Give antenatal steroids if have not already had in this pregnancy. Betamethasone12 mg IM q24h X 2.
    • *Because risk of prematurity complications (RDS, IVH etc.) outweighs the risk of neonatal sepsis at this GA
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4
Q

Describe the management of PROM if no evidence of fetal distress/placenta abruption/chorioamnionitis/labor and > 34 wk (4)

A
  • Induction of labor or C/S depending on fetal presentation. Consider transfer to different facility if <36 wk GA. Obstetrical consult if <36 wk GA
  • Must weigh the risk of prematurity vs. risk of infection/ sepsis by remaining in utero:
  • 34–36 wk GA: grey zone because risks are equal
  • >36 wk GA: risk of sepsis > risk of prematurity
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5
Q

Name causal conditions of PTL (4)

A
  • Premature activation of the maternal or fetal HPA axis
  • Inflammation/infection (chorioamnionitis, decidual)
  • Decidual hemorrhage
  • Pathologic uterine distension
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6
Q

Describe preterm labor (4)

A
  • PTL is labor (regular contractions causing a cervical D) occurring between 20 and 37 wk GA.
  • Occurs in approximately 10% of all pregnancies.
  • Very preterm birth occurs at < 32 wk, and extreme preterm birth occurs at < 28 wk GA.
  • Preterm birth is the leading cause of infant mortality.
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7
Q

Name sx: Sx of PTL (5)

A
  • Regular uterine contractions
  • Pelvic pressure,vaginal bleeding
  • D in vaginal discharge
  • Low back pain
  • Cramping
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8
Q

Name Pathogenic processes leading to preterm delivery and birth (4)

A
  • Premature activation of the maternal or fetal HPA axis
  • Inflammation/infection (chorioamnionitis, decidual)
  • Decidual hemorrhage
  • Pathologic uterine distension
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9
Q

Describe this Pathogenic process leading to preterm delivery and birth: Premature activation of the maternal or fetal HPA axis

  • RFs (5)
  • Postulated Mechanism(s) (2)
A
  • RFs:
    • Fetal stress:
      • Placenta insufficiency
      • Placental pathology
    • Maternal stress:
      • Domestic violence
      • Depression, anxiety
      • Other life events
  • Postulated Mechanism(s):
    • ↑Corticotropin-releasing hormone (CRH)→ ↑maternal and fetal adrenal cortisol → ↑ production
    • ↑ Fetal adrenal DHEAS production → ↑ placental E production
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10
Q

Describe this Pathogenic process leading to preterm delivery and birth: Inflammation/infection (chorioamnionitis, decidual)

  • RFs (6)
  • Postulated Mechanism(s) (2)
A
  • RFs:
    • GU infection (i.e., asymptomatic bacteriuria, pyelonephritis)
    • Bacterial vaginosis
    • STI
    • Pneumonia
    • Peritonitis
    • Periodontal disease
  • Postulated Mechanism(s):
    • ↑ Maternal and fetal cytokines→↑prostaglandins→↑ uterine contractions
    • Proteases and cytokines → break down fetal membranes and cervix
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11
Q

Describe this Pathogenic process leading to preterm delivery and birth: Decidual hemorrhage

  • RFs (1)
  • Postulated Mechanism(s) (2)
A
  • RFs: Placenta abruption
  • Postulated Mechanism(s):
    • Release of decidual tissue factor
    • Initiation of coagulation cascade and thrombin production →
      • Cervical ripening
      • PPROM
      • Uterine contractions
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12
Q

Describe this Pathogenic process leading to preterm delivery and birth: Pathologic uterine distension

  • RFs (3)
  • Postulated Mechanism(s) (6)
A
  • RFs:
    • Polyhydramnios (AFI>25cm)
    • Multiple gestation
    • Structural uterine abnormality (i.e., bicornuate, unicornuate)
  • Postulated Mechanism(s): Mechanical stretching →
    • ↑ Myometrial gap junctions
    • Activation of oxytocin receptors
    • ↑ PG synthesis
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13
Q

Describe the history of preterm labor (4)

A
  • Establish the age, GTPAL, gestational age, pattern of contractions, Hx of rupture of membranes, vaginal bleeding, presence of fetal movements, and Hx of preterm labor
  • Screen for the possible causes of PTL (e.g., fever, dysuria or urinary frequency, abnormal vaginal discharge, productive cough, maternal trauma or motor vehicle accident, known uterine anomaly, recent maternal stress, etc.)
  • Review current pregnancy Hx, complications during this pregnancy, and results of routine antenatal investigations (e.g., detailed anatomic ultrasound, gestational diabetes screening)
  • Review PMHx, SxHx, meds, allergies, social Hx
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14
Q

Describe physical exam of preterm labor (5)

A
  • Vital signs and continuous electronic fetal monitoring
  • Abdo exam including Leopold maneuvers
  • Focused physical exam based on positive findings on Hx
  • Sterile speculum exam if suspicion of PROM
  • Cervical exam (only if PROM and placenta previa ruled out) for dilation, effacement, and consistency
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15
Q

Describe investigations of preterm labor (6)

A
  • Urine culture and sensitivity
  • Vaginal swab for Fetal fibronectin (fFN) (between 24 and 34 wk GA)
  • Vaginal swab for bacterial vaginosis
  • Vaginal/rectal swab for GBS
  • Cervical swab for gonorrhea/chlamydia
  • U/S for cervical length, fetal presentation, amniotic fluid level, and fetal growth
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16
Q

Describe DX of preterm labor (1)

A

Regular uterine contractions leading to cervical dilation and/or effacement

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17
Q

Name Etiology/RFs of Preterm labor (5)

A
  1. Prev. PTL
  2. Maternal:
    • infection
    • chronic illness
    • Prev. surgeries (cervical)
    • stress, poor nutrition, smoking, substance/alcohol abuse
  3. Maternal-Fetal:
    • PPROM
    • placenta pathology (abruption, previa, insufficiency),
    • chorioamnionitis
    • polyhydramnios
  4. Fetal:
    • multiple gestation
    • congenital abnormality
    • hydrops
  5. Uterine:
    • incompetent cervix
    • malformations (fibroids, septae)
    • overdistension
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18
Q

Describe clinical presentation: Preterm labor (2)

A
    1. Regular painful uterine contractions
    1. Documented cervical effacement >80% or dilation >2 cm
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19
Q

Describe the initial evaluation of PTL (6)

A
  • Obstetric Hx and RF evaluation
  • Vital signs
  • Lab studies (CBC, U/A, urine R&M)
  • Continuous fetal heart and tocodynamometer monitoring
  • Sterile speculum exam—Nitrazine test (R/O PROM), GBS culture (in unknown), ± G&C cervical cultures,
  • FFN (if 24-34 GA), swab for BV
  • Cervical exam (if PROM ruled out) for dilation, effacement, station
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20
Q

Describe the management of PTL if the initial evaluation STABLE (Figure)

A
21
Q

Name criteria for Tocolysis (3)

A
  • PTL
  • Live immature fetus, no ROM, cervix < 4 cm
  • No contraindications (maternal or fetal)
22
Q

Name CI for Tocolysis (10)

A
  • A. Maternal:
    • bleeding,
    • HTN, DM
    • eclampsia, pre eclampsia
    • cardiac/renal/ pulmonary disease
    • chorioaminionitis
  • B. Fetal:
    • anencephaly,
    • fetal distress
    • IUFD
    • IUGR
    • erythroblastosis fetalis
23
Q

Describe how to Enhance fetal lung maturity (2)

A
  • a. Betamethasone (Celexone) 12 mg IM q24h × 2
  • b. Dexamethasone 6 mg IM q12h × 4
24
Q

Name etiologies for Abnormal Bleeding in T2 or T3 (4)

A
  • Abruption
  • Placenta previa
  • Vasa previa
  • Cervical pathology: (cervical polyp, ectro- pion, cervical dilation, infection)
25
Q

Describe: Abruption (1)

A

separation of placenta from uterus before delivery of fetus (after 20 wk GA)

26
Q

Name RFs of Abruption (3)

A
  • Maternal
    • Age, smoking, cocaine use, HTN, thrombophilia, trauma, Hx of abruption
  • Fetal: Multiple gestation
  • Pregnancy
    • PPROM, chorioamnionitis, polyhydramnios
27
Q

Describe clinical DX: Abruption (5)

A
  • Bleeding
  • Abdo pain
  • Regular contractions
  • Uterine hypertonus
  • Fetal distress
28
Q

Describe investigations: Abruption (4)

A
  • CBC
  • liver and renal function
  • coagulation studies including fibrinogen, type and crossmatch
  • Speculum exam if previa ruled out
29
Q

Describe management: Abruption (3)

A
  • Maternal stabilization (large-bore IVs, IV fluids ± blood transfusion) If mother Rh–, give Rh immunoglobulin
  • Delivery if fetal distress or term infant
  • Expectant management if mother and premature infant stable (steroids if < 34 wk, no Tocolysis, consider transfer to higher level facility)
30
Q

Describe: Placenta previa (1)

A

placenta covers or is close to (< 2 cm) cervical os

31
Q

Name RFs: Placenta previa (6)

A
  • Maternal
    • Previous previa
    • age > 35 y
    • parity >3
    • previous C/S or uterine surgery
    • smoking
  • Fetal: Multiple gestation
32
Q

Describe clinical DX: Placenta previa (3)

A
  • Bleeding
  • Painless
  • Digital cervical examination contraindicated due to high risk of severe hemorrhage
33
Q

Describe investigations: Placenta previa (2)

A
  • U/S to confirm previa
  • CBC, type and crossmatch
34
Q

Describe management: Placenta previa (5)

A
  • Maternal stabilization as above
  • If mother Rh–, give Rh immunoglobulin
  • Expectant management if GA 24–36 wk and mother/fetus stable
  • Delivery via C/S at 36–37 wk
  • Note: Delivery should occur at center with adult ICU, blood transfusion. Pt should be consented for hyster- ectomy and blood transfusion.
35
Q

Describe: Vasa previa (1)

A

velamentous insertion of umbilical cord vessels into placenta, so vessels traverse the cervical os before entering the placenta

36
Q

Name RFs: Vasa previa (5)

A
  • Fetal
    • Multiple gestation
  • Pregnancy
    • Previa
    • bilobed placenta
    • velamentous cord insertion
    • IVF pregnancy
37
Q

Describe clinical DX: Vasa previa (2)

A
  • Bleeding
  • Painless
38
Q

Describe investigations: Vasa previa (3)

A
  • CBC, type and crossmatch
  • Speculum exam and Apt test
  • U/S with color Doppler if vasa previa suspected (before bleed)
39
Q

Describe management: Vasa previa (4)

A
  • Steroids at 28–30 wk GA
  • Manage as inpt from 30–32 wk GA
  • Elective delivery at 34–36 wk GA
  • Emergent delivery if bleeding (50% fetal mortality)
40
Q

Name RFs for Cervical pathology (2)

A

Maternal

  • Previous cervical polyp, RF for STD
  • Recent internal exam, intercourse
41
Q

Describe clinical DX: Cervical pathology (2)

A
  • Bleeding
  • Painless or associated with cramping
42
Q

Describe investigations: Cervical pathology (4)

A
  • Speculum exam
  • Pap smear
  • Swab for C and G
  • ± U/S for cervical length if cervix appears short or associated with cramping/contractions
43
Q

Describe management: Cervical pathology (3)

A
  • Dependent on etiology
  • Treat cervicitis
  • Do not remove cervical polyp—refer to colposcopy if AbN appearing/AbN pap smear
44
Q

RhD isoimmunization leads to what? (2)

A
  • a. Fetal/neonatal hemolytic anemia ± hyperbilirubinemia 25% to 30% and/or
  • b. Hydrops fetalis 25%
45
Q

The amount of RhD+ blood required to cause isoimmunization is how much? (1)

A

small (< 0.1 mL).

46
Q

Name Causes of Isoimmunization (3)

A
  • Fetomaternal hemorrhage at delivery, Prev.ectopic pregnancy (EP), or prev. abortion
  • Spontaneous antenatal fetomaternal hemorrhage
  • Invasive procedures during pregnancy (i.e., cerclage, amniocentesis)
47
Q

Describe: Prophylaxis for All Rh− Women

A

Administration of one prophylactic dose (300 mg) of RhoGAM (↓ rate of developing antibodies to Rh Ag)

  • At 28 wk unless the father of the baby is known to be Rh−
  • Within 72 h of delivery of an Rh+ infant
  • Following T1 miscarriage, threatened miscarriage, induced abortion, ectopic pregnancy, or molar pregnancy
  • Post invasive procedures (i.e.,CVS, amniocentesis, fetal blood sampling)
  • Any T2/T3 bleeding, external cephalic version, blunt abdo trauma
48
Q

Describe: Legal Liability for Negligence (2)

A
  • Failure to act on abnormal prenatal screening results may be considered a cause of harm.
  • Failure to recognize Rh isoimmunization in a pregnant woman may be considered a cause of harm→ due to failure to meet the standard of care.
49
Q

Name: Risk Factors for Antepartum and Postpartum Depression (9)

A
  • Social Hx
    • Experience of life stress/adverse life event during pregnancy
    • Lack of social support
    • Domestic violence
    • Unplanned pregnancy
    • Low socioeconomic status
  • Maternal Hx
    • Hx of depression or anxiety
    • Hx of postpartum depression
    • Discontinuing antidepressant prepregnancy or during pregnancy
  • Family Hx
    • Depression or post partum depression

Essentials - Obstetrics (4 decks)

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