Preterm Labor and PPROM

Question 1

A 25 year old G4P3 27wks presents with contractions. She has had 3 prior preterm deliveries.

-How would you evaluate this patient?

Answer 1

I would perform a history and physical exam to assess for fetal well-being, evidence of chorioamnionitis, abruption or ruptured membranes.

Question 2

A 25 year old G4P3 27wks presents with contractions. She has had 3 prior preterm deliveries.

• Your speculum exam is negative for nitrizine, ferning, and pooling.
• She is a febrile and FHT is reassuring. She is contracting painfully q7 minutes.
• afebrile, no uterine tenderness, no maternal tachychardia.
• cervical exam 2/50/high

-What is your next step?

Answer 2

Without evidence of chorioamnionitis, ruptured membranes, or abruption, I would treat for preterm labor with magnesium sulfate 4-6gram IV bolus, followed by 2g/hr infusion. I would give betamethasone 12mg IM q24 hours x 2 doses and stop the magnesium 48 hours after the first dose of BMZ.

-If she is GBS unknown, I treat with PCN 5 million units IV then 2.5 million units IV.

Question 3

A 25 year old G4P3 27wks presents with contractions. She has had 3 prior preterm deliveries. She is febrile and membranes are intact. There is maternal and fetal tachycardia.

How would you manage this patient?

Answer 3

I suspect chorioamnionitis in this patient. I would counsel the patient on amniocentesis. I am looking for glucose <15 or the presence of bacteria.

Question 4

A 25 year old G4P3 27wks presents with leakage of fluid. She has had 3 prior preterm deliveries.

How would you manage this patient?

Answer 4

I would perform a history and physical exam to evaluate for ruptured membranes, labor and chorioamnionitis.

If rupture of membranes is confirmed, Instead of PCN for GBS ppx, I would give amp 500mg IV q6hr and erythromycin for 7 days to prolong the latency period. I would limit vaginal exams and admit until delivery at 34wks or sooner if indicated.

Question 5

Define preterm birth and name risk factors.

Answer 5

• birth at <37 weeks following PTL, PPROM, cervical insufficiency
• 12% of US births

RF:

• history of PTB carries an increased risk of PTB by 1.5 to 2.
• cervical length <25mm prior to 24-28 wks
• BMI <19.8
• short interval pregnancy <18-23 months between live birth and conception of the next pregnancy
• multiple gestation
• polyhydraminios (AFI 24cm+ MVP 8cm+