Preterm Labor

Question 1

How do you define preterm labor?

Answer 1

Cervical length of 3cm of more in the setting of contraction

Question 2

What are the risk factors for preterm labor?

Answer 2

-Strongest risk factor is history of preterm labor and delivery
-Short interval pregnancy
-Infection
Polyhydramnios
Short cervix
-Multiple gestation
-PPROM

Question 3

How do you manage a patient with preterm labor in pregnancy?

Answer 3

NICHD counseling in periviable period
When viable then magnesium for neuroprotection, indocin for tocolysis, betamethasone, ampicillin or penicillin for GBS pox

Question 4

What tocolytic do you use for preterm labor treatment?

Answer 4

• NSAIDS before 32 weeks
• Calcium channel blocker
• Terbutaline
• Magnesium

Question 5

What is the role of terbutaline in the management of preterm labor?

Answer 5

Typically given in the intrapartum setting, works quickly

Question 6

What are the potential complications of prolonged terbutaline use in a pregnant woman?

Answer 6

pulmonary edema

Question 7

Who do you consider a candidate for tocolysis?

Answer 7

before steroid completion

Question 8

Will you tocolyze a previable gestation?

Answer 8

no

Question 9

How long do you continue steroid completion?

Answer 9

Until steroid completion

Question 10

Is there a role for oral tocolysis beyond 48-72 hours?

Answer 10

not recommended due to risk of infection being masked

Question 11

What are the risks of chronic NSAID use in pregnancy or beyond 32 weeks gestation?

Answer 11

Oligohydramnios
Constriction of ductus arteriosus
NEC preterm newborns

Question 12

What are contraindications to tocolysis for a patient with preterm labor?

Answer 12

Abruption 
Active infection 
IUFD
Lethal fetal anomaly
Pec
Pprom

Question 13

Who is a candidate for corticosteroids for fetal benefit?

Answer 13

23-34 weeks

OR after 34 weeks before 37 weeks if no previous steroid administration

Question 14

Who is a candidate for rescue steroids?

Answer 14

7 days from initial steroid course

OR after 34 weeks before 37 weeks if no previous steroid administration

Question 15

Do you give more than 2 courses of steroids for fetal benefit?

Answer 15

7 days from initial steroid course

Question 16

What is the earliest and latest gestational age you will give steroids for fetal benefit?

Answer 16

23 weeks and 36 weeks

Question 17

How does magnesium provide fetal benefit?

Answer 17

Decreases brain activity
Neuroprotective
Dec risk of CP

Question 18

Who is a candidate for magnesium for fetal neuroprotection?

Answer 18

Less than 32 weeks and greater than 23 weeks

Question 19

Describe your regimen for magnesium for fetal neuroprotection.

Answer 19

4-6 grams loading and then 1-2 grams per hour

Question 20

Who should receive GBS ppx?

Answer 20

less than 37 weeks without GBS status known
Naat gbs status
Arom > 18hr
Fever > 100.4
Prior child affected 
GBS bateruria

Question 21

How do you manage a patient with preterm labor and unknown GBS status?

Answer 21

Start antibiotics after collecting GBS

Question 22

How do you manage GBS ppx in a patient with low risk allergy to PCN?

Answer 22

Ancef 2g, then 1g every 8hrs

Question 23

How do you manage GBS pix in a patient with high risk allergy to PCN?

Answer 23

GBS sensitivity, if sensitive to Clinda + Erythro then give clindamycin if not give vancomycin

Question 24

When is a patient a candidate for discharge from hospital following treatment of preterm labor?

Answer 24

Depends on gestational age and distance to hospital

Question 25

What is the role of bedrest in the management of preterm labor?

Answer 25

it does not improve the outcome

Question 26

Do you manage twin gestation with PTL differently from a singleton?

Answer 26

no

Question 27

How do you counsel a patient about future pregnancy risk and management if she delivers prematurely due to preterm labor?

Answer 27

strongest risk factor for preterm delivery is history of preterm delivery

Question 28

Candidates for 17OHP

Answer 28

• Prior delivery between 20-36 6/7 weeks
• Initiate at 16-21 6/7 but as late as 23 6/7
• Singleton pregnancy

Question 29

Antenatal Betamethasone for Women at Risk for Late Preterm Delivery (ALPS trial):

Answer 29

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.

Question 30

Beneficial Effects of Antenatal Magnesium Sulfate (BEAM study):

Answer 30

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.

Question 31

Progestins Role in Optimizing Neonatal Gestation (PROLONG) study:

Answer 31

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

Question 32

Trial of pessary in singletons - TOPS trial is ongoing

Answer 32

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

Question 33

Pessary and progesterone for preterm prevention in twin gestation with short cervix - PROSPECT trial is ongoing

Answer 33

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: