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Obstetrics > Preterm labor and PPROM > Flashcards

Preterm labor and PPROM Flashcards

1
Q

Spontaneous preterm birth is a direct result of:

A

Preterm labor (myometrium), PPROM (membranes) and Cervical Insufficiency (Cervix)

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2
Q

Preterm delivery affects how many pregnancies in the US per year?

A

1/10 per year

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3
Q

What percent of preterm birth occurs in women without any risk factors?

A

50%

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4
Q

What are the 3 main risk factors for spontaneous preterm birth?

A

Multiple fetal gestation, history of prior PTD , history of bleeding in pregnancy

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5
Q

What is the definition of preterm labor?

A

Persistent uterine contractions that cause the cervix to dilate to 2 cm and efface to 80%

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6
Q

What percentage of patients diagnosed with PTL will deliver at term?

A

50%

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7
Q

True or false: Activity restriction increases the risk for preterm delivery?

A

True

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8
Q

What cervical length is reassuring that the likelihood of PTL is low?

A

CL > 3.0 CM

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9
Q

What cervical length is worrisome for increased likelihood of PTL?

A

CL < 2.0 CM

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10
Q

When should you send an FFN in the work up for PTL?

A

When the cervical length is between 2.0 - 3.0

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11
Q

How long is an FFN predictive of PTB

A

Predictive for the next 14 days

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12
Q

FFN has a _____ negative predictive value and a _____positive predictive value

A

High, Low

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13
Q

How long do tocolytics usually delay delivery?

A

Up to 48 hrs

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14
Q

True or false: Tocolytics improve the survival and mortality associated with

A

False

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15
Q

When should Tocolysis be used and for how long?

A

Used to get through steroid window for up to 48 hrs

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16
Q

When you use Magnesium with Nifedipine what complication should you be aware of?

A

hypocalcemia

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17
Q

Should magnesium sulfate be used as a tocolytic?

A

No

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18
Q

What is the best tocolytic agent to use prior to 32 wga?

A

Indomethacin

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19
Q

What is the dosing of Indomethacin that you should use?

A

50 mg PO loading dose, followed by 25 - 50 mg q 6 hrs for 48 hrs

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20
Q

What are the contraindications to using Indomethacin?

A

Oligohydramnios OR > 32 wga

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21
Q

What is the best tocolytic age to use after 32 wga - 34wga ?

A

Nifedipine

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22
Q

What is the dosing for Nifedipine that you use for tocolysis

A

10 - 20 mg PO q 3-6 hrs until rare UC, THEN 30 - 60 mg XR q 8 hrs for 48 hrs

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23
Q

What are contraindications to tocolysis?

A

Chorioamnionitis, fetal compromise, abruption, lethal anomaly, IUFD, severe PreE, Maternal shock

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24
Q

What are the fetal benefits of preterm steroid administration?

A

Reduced RDS, IVH, CP

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25
Q

Steroids accelerate maturation in all fetal tissues by _____.

A

1 week

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26
Q

What are the two dosing regimens for preterm steroids?

A

Betamethasone 12.5 mg q 24 hrs 2 doses, Dexamethasone 6 mg q 12 hrs 4 doses

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27
Q

When should you offer a repeat course of steroids?

A

If greater than 7 days since first administration and gestational age < 34 wga

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28
Q

What gestational age is it appropriate to offer preterm steroids?

A

24w0d –> 33w6d if delivery is likely in the next 7 days

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29
Q

At what gestational age are late preterm steroids offered?

A

34w0d - 36w6d

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30
Q

What fetal risks are decreased by late preterm steroids?

A

decreased need for respiratory support, TTM, decreased in prolonged NICU stay > 3 days

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31
Q

When should you NOT administer late preterm steroids?

A

Chorioamnionitis, If previously received antenatal steroids

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32
Q

What are the risks of late preterm steroids?

A

Increased risk of neonatal hypoglycemia

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33
Q

up to what gestational age should magnesium sulfate be administered?

A

up to 32 wga

34
Q

What specific outcome does administration of mag sulfate for PTL < 32wga improve and by how much?

A

Decreases risk of moderate to severe CP by half

35
Q

What is the dosing for Mag Sulfate for neuroprotection in preterm labor?

A

6g load followed by 2g/hr for 12 hrs

36
Q

What should you do with mag sulfate if a PTL patient is not delivered within 12 hrs?

A

Stop magnesium and restart for delivery or if labor progresses.

37
Q

When is it necessary to rebolus the magnesium following discontinuation for preterm labor

A

If greater than 6 hrs from discontinuation

38
Q

How long are GBS cultures valid for?

A

5 weeks

39
Q

Should you start GBS prophylaxis for preterm labor if status is unknown?

A

Yes

40
Q

When should you stop GBS prophylaxis for preterm labor?

A

If patient not in true labor or GBS swab returns negative

41
Q

What is the most sensitive test for PROM?

A

nitrizine

42
Q

What is the most specific test for PROM?

A

Ferning

43
Q

Amniotic fluid is more _____(acidic/basic) than vaginal fluid

A

Basic

44
Q

What is the definitive test for PROM/PPROM

A

Amniocentesis with injection of indigo carmine

45
Q

What is the rate of chorioamnionitis associated with PPROM?

A

13 - 60%

46
Q

What is the rate of endometritis associated with PPROM?

A

2 - 13%

47
Q

What is the rate of maternal sepsis associated with PPROM?

A

0.8%

48
Q

What is the rate of maternal dealth associated with PPROM?

A

0.14%

49
Q

What are the most common fetal tracing abnormalities seen with PPROM?

A

Variable deceleration

50
Q

What are fetal complication associated with PPROM?

A

cord prolapse, abruption, fetal death, pulmonary hypoplasia if < 23 wks, neonatal sepsis, CP

51
Q

PPROM at what gestational age is associated with the highest rate of neonatal death?

A

PPROM < 22 wga

52
Q

What is the neonatal survival rate for PPROM < 22wga

A

14%

53
Q

What is the neonatal survival rate for PPROM > 22wga

A

58%

54
Q

What is the total duration of antibiotic treatment for PPROM?

A

7 days, 2 days of IV antibotics, 5 days oral antibiotics

55
Q

What is the IV antibiotic regimen for PPROM?

A

Ampicillin 2 g q 4 + Erythromycin 250 mg q 6 for 48 hrs

56
Q

What is the PO antibiotic regimen for PPROM?

A

Amoxicillin 250 mg + erythromicin 333mg q 8 hrs for 5 days

57
Q

What outcomes do Antibiotic therapy improve in a patient with PPROM?

A

Increases latency period, decreases maternal and fetal infection rates

58
Q

PPROM patients are typically delivered at what gestational age?

A

34wga

59
Q

True or false: You can consider expectant management in a PPROM patient 34wga - 36.6wga

A

True

60
Q

What are the risks of expectant managment in a PPROM patient following 34wga?

A

2 x increased risk of maternal infection

61
Q

Vaginal progesterone decreases the rate of preterm birth by —-.

A

45%

62
Q

What does ACOG recommend in terms of administration of Betamethasone (Gestational age and dose) ?

A

16 wga - 36w6d wga, 250 mg IM q week

63
Q

Which patients are candidates for vaginal progesterone?

A

No history of PTD but CL < 2.0 cm

64
Q

What is the dosage used for vaginal progesterone?

A

Progesterone 200mg QHS

65
Q

What is the definition of a history indicated cerclage?

A

Cerclage placed between 12- 14 weeks gestation in a patient with a history of 3 or more PTD or a second trimester loss

66
Q

When should CL start for patients with previous PTD?

A

16 - 24 wga

67
Q

When should a cerclage be placed in a patient undergoing CL surveillance and history of PTD

A

When CL < 25 mm and EGA > 24 wks

68
Q

Would you also recommend treating patients with 17 OHP with a cerclage in place?

A

yes

69
Q

ACOG recommends that you screen all pregnant women for GBS at what gestational age?

A

36w0d - 37wga

70
Q

What is your treatment plan If a patient has GBS Bacteuria < 10^5 colonies on Urine culture?

A

No treatment of GBS cystitis, PCN in labor

71
Q

What is your treatment plan If a patient has GBS Bacteuria >10^5 colonies on Urine culture?

A

Treatment of GBS cystits and PCN in labor

72
Q

What are the indications for GBS treatement in labor of a patient with unknown status?

A

< 37wga. ROM > 18 hrs, Temp > 38

73
Q

If a patient was GBS positive in a prior pregnancy, what is the risk of recurrent colonization?

A

50%

74
Q

What is the optimal duration of GBS in labor?

A

4 hours, 2 dose

75
Q

At what time point of PCN administration is there a decrease in GBS colony count and adequate bactericidal levels in Amniotic fluid?

A

After 2 hrs of administration

76
Q

What is the regimen for PCN to treat GBS?

A

Penicillin G 5 million Units IV load then 3 million units q 4 hrs until delivery

77
Q

What is the regimen for Ampicillin to treat GBS?

A

Ampicillin 2 g IV load, 1 g Ampicillin q 4 hrs until delivery

78
Q

What regimen should be used to treat GBS in a patient with a low risk PCN allergy (nonurticarial maculopapular rash without systemic or respiratory symptoms?)

A

Cefazolin 2g IV load then 1 g q 8 hrs until delivery

79
Q

What regimen should be used in a patient with a high risk PCN allergy (systemic symptoms, anaphylaxis)?

A

Clindamycin 900 mg IV q 8 hrs or Vancomycin 20 mg/kg IV q 8 hrs

80
Q

What must be ordered on GBS testing for a patient with PCN allergy?

A

susceptibility testing

81
Q

If susceptibility testing was not done for a patient with GBS and an allergy to PCN, what is the drug of choice?

A

Vancomycin 20 mg/kg IV q 8

Obstetrics (28 decks)

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