Preterm Labour and PPROM Flashcards
1
Q
definition of preterm labour
A
labour at 20-37 wks
2
Q
mechanisms/causes of preterm labour
A
hemorrhage overdistention of uterus uterine distortion cervical incompetence cervical inflammation/infection environmental exposure/drugs uteroplacental insufficiency fetal role: hostile environment
3
Q
RF for preterm birth
A
- hx!!!
- stress
- young or old
- low SES
- low weight
- cervical trauma (multiple 1st trim abortion or 1 second, surgeries)
- hx of G, C, trich (reinfection, not clear risk), BV = RISK, tx doesn’t cure so only if symptomatic
- hx midtrimester loss - workup .w hx, APA, thrombophilia, sonohyst, vag swab, path reports
4
Q
assessment of risk of PTL during preg
A
- review hx
- assess cervical integrity /w spec + VE
- investigate bacteriuria, STI, BV
- +/- assess placentation
- +/- formal cervical length assessment
5
Q
cervical length assessment + management
A
- most sensitive predictor of PTL
- short = <25mm (before 28wk)
- if patient has risk factors, unclear if prophylactic cerclage vs rescue (after see shortening)
- prophylactic placed at 12-14wk
no cerclage:
- multiples
- no hx of past or current shortening
- if no past insuff but short now, consider progesterone only instead
6
Q
progesterone for prevention of preterm labour
A
- intravag micronized progesterone 100-200mg/day, during 16-37 weeks
- for hx preterm birth or very short cervix /w singleton
7
Q
Diagnosis of PTL
A
- contractions + cervical change
- if unsure and <34wks, vag swab for FFN BEFORE VE
- also swab for GBS before VE
- FFN high neg predictive value
- if ctxn and no cervical change, observe +/- analgesia, if FFN and abate can send home
8
Q
role of tocolytics + weeks applicable
A
- tocolytics only if 24-33 weeks
- if contractions >6/hr –> cervical change
- goal: delay delivery for 48 to give steroids
- alt: bedrest + hydration
9
Q
managemetn of PTL
A
assess
- dates
- r/o infection or abruption
- assess fetal wellbeing
- confirm preterm labour
- vag swabs: GBS, BV
- urine C + S
- assess med CI for tocolysis
treatment
- betamethasone if 24-34wks, 12 mg 24 hrs apart
- GBS: preterm = high risk, tx if culture unknown, administer now + continue until delivery or 48hrs, return if labour recurs
- MgSO4 for neuroprotection if <32 wks and delivery inevitable, 4gIV dose over 30min, 1g/hr IV until birth
tocolytics
- indomethacin: if <30wks or polyhydraminos, decreases prostaglandins, monitor urine output, temp, AFI, 100mg PR then 50mg PO q6hr for 48hrs (not more than 48!)
- nifedipine - more effective/new, CI: hypotension, liver issues, beta-mimetics, other antihypertensives, MgSO4 relative CI
- Nitro patch
follow-up: if labour arrests, limited activity (no bedrest), ?discharge
10
Q
PPROM outcomes
A
- 50% deliver each week
- very few remain for more than 3-4 weeks
- rare spont resealing occurs (usually if ROM after amnio)
11
Q
Initial evaluation of PPROM
A
- maternal vitals + FHR monitoring
- sterile spec: cervix, nitrazine, ferning
- AFI on US
- fetal biometry + position
- cervical cultures for C and G if not obtained
- GBS swab
- avoid digital exam
12
Q
further management of PPROM
A
indications for immediate delivery:
- chorioamnionitis
- advanced labour
- fetal distress
- abruption + non-reassureing FHR
- documented fetal lung maturity (amnio or vag fluid collection)
- non-cephalic + advanced dilatation (cord prolapse risk)
- after 34-37 weeks can consider but unclear if benefit to expectant
expectant:
- cont monitor NST (24-48hr), then admit
- monitor for chorio (fever, tachycardia, leukocytosis, uterine tenderness, fetal tachy, foul discharge)
- monitor fetus (NST/BPP)
- monitor for abruption
- steroids if <34
- broad spectrum antibiotics x7 days
tocolytics:
- only if specific clear indication, like transfer to better NICU
if <23 wks very poor prognosis
- can choose expectant if well informed, or induction
- <20wks induce if mom’s at risk
