Preterm Labor Flashcards
How do you define preterm labor?
Cervical length of 3cm of more in the setting of contraction
What are the risk factors for preterm labor?
-Strongest risk factor is history of preterm labor and delivery
-Short interval pregnancy
-Infection
Polyhydramnios
Short cervix
-Multiple gestation
-PPROM
How do you manage a patient with preterm labor in pregnancy?
NICHD counseling in periviable period
When viable then magnesium for neuroprotection, indocin for tocolysis, betamethasone, ampicillin or penicillin for GBS pox
What tocolytic do you use for preterm labor treatment?
- NSAIDS before 32 weeks
- Calcium channel blocker
- Terbutaline
- Magnesium
What is the role of terbutaline in the management of preterm labor?
Typically given in the intrapartum setting, works quickly
What are the potential complications of prolonged terbutaline use in a pregnant woman?
pulmonary edema
Who do you consider a candidate for tocolysis?
before steroid completion
Will you tocolyze a previable gestation?
no
How long do you continue steroid completion?
Until steroid completion
Is there a role for oral tocolysis beyond 48-72 hours?
not recommended due to risk of infection being masked
What are the risks of chronic NSAID use in pregnancy or beyond 32 weeks gestation?
Oligohydramnios
Constriction of ductus arteriosus
NEC preterm newborns
What are contraindications to tocolysis for a patient with preterm labor?
Abruption Active infection IUFD Lethal fetal anomaly Pec Pprom
Who is a candidate for corticosteroids for fetal benefit?
23-34 weeks
OR after 34 weeks before 37 weeks if no previous steroid administration
Who is a candidate for rescue steroids?
7 days from initial steroid course
OR after 34 weeks before 37 weeks if no previous steroid administration
Do you give more than 2 courses of steroids for fetal benefit?
7 days from initial steroid course
What is the earliest and latest gestational age you will give steroids for fetal benefit?
23 weeks and 36 weeks
How does magnesium provide fetal benefit?
Decreases brain activity
Neuroprotective
Dec risk of CP
Who is a candidate for magnesium for fetal neuroprotection?
Less than 32 weeks and greater than 23 weeks
Describe your regimen for magnesium for fetal neuroprotection.
4-6 grams loading and then 1-2 grams per hour
Who should receive GBS ppx?
less than 37 weeks without GBS status known Naat gbs status Arom > 18hr Fever > 100.4 Prior child affected GBS bateruria
How do you manage a patient with preterm labor and unknown GBS status?
Start antibiotics after collecting GBS
How do you manage GBS ppx in a patient with low risk allergy to PCN?
Ancef 2g, then 1g every 8hrs
How do you manage GBS pix in a patient with high risk allergy to PCN?
GBS sensitivity, if sensitive to Clinda + Erythro then give clindamycin if not give vancomycin
When is a patient a candidate for discharge from hospital following treatment of preterm labor?
Depends on gestational age and distance to hospital
What is the role of bedrest in the management of preterm labor?
it does not improve the outcome
Do you manage twin gestation with PTL differently from a singleton?
no
How do you counsel a patient about future pregnancy risk and management if she delivers prematurely due to preterm labor?
strongest risk factor for preterm delivery is history of preterm delivery
Candidates for 17OHP
- Prior delivery between 20-36 6/7 weeks
- Initiate at 16-21 6/7 but as late as 23 6/7
- Singleton pregnancy
Antenatal Betamethasone for Women at Risk for Late Preterm Delivery (ALPS trial):
Population: women at risk of preterm delivery between 34 -36 weeks (16% typically need CPAP or ventilator)
Intervention: betamethasone
Comparison: placebo
Outcome: respiratory morbidity and stillbirth/neonatal death within 72 hours
Conclusion: Administration of betamethasone to women at risk for late preterm delivery significantly reduced the rate of neonatal respiratory complications.
Beneficial Effects of Antenatal Magnesium Sulfate (BEAM study):
Population: women at imminent risk of preterm delivery at 24-31 weeks
Intervention: magnesium sulfate
Comparison: placebo
Outcome: composite cerebral palsy or IUFD/infant demise. CP was assessed at 2 years of age.
Conclusion: Fetal exposure to magnesium sulfate in women at risk for preterm delivery significantly reduces the risk of cerebral palsy without increasing the risk of death.
Progestins Role in Optimizing Neonatal Gestation (PROLONG) study:
Population: women with history of preterm birth
Intervention: progesterone injections (250mg 17OHP)
Control: placebo
Outcome: delivery at less than 35 weeks and neonatal morbidity
Conclusion: 17-OHPC did not decrease recurrent PTB and was not associated with increased fetal/early infant death.
*** women enrolled in this study have different demographics
Trial of pessary in singletons - TOPS trial is ongoing
Population: women with singleton pregnancy and short cervix (cervical length less than 2cm) between 16 weeks and 23 weeks and 6 days .
Intervention: pessary placement (arabis pessary) + vaginal progesterone
Control: vaginal progesterone
Outcome: Delivery less than 37 weeks
Pessary and progesterone for preterm prevention in twin gestation with short cervix - PROSPECT trial is ongoing
Population: twin gestation with cervical length less than 3cm less than 24 weeks
Intervention: pessary placement (arabin pessary)
Control: placebo and vaginal progesterone
Outcome: delivery before 35 weeks
Conclusion:
