Preterm Labour and PPROM Flashcards
What are women at risk of preterm labour/late loss offered?
Prophylactic vaginal progesterone or cervical cerclage
Who are at risk of preterm/late loss choice of Mx
Hx spontaneous preterm birth/midT3 loss (16-34wk)
AND
TVUSS (wk16-24) cervical length <25mm
Prophylactic vaginal progesterone for risk of preterm labour/late loss
NO Hx spontaneous preterm birth
TVUSS wk16-24 cervical length <25
Prophylactic cervical cerclage for risk of preterm labour/late loss
TVUSS wk16-24 Cervical length <25mm
AND have either:
Hx PPROM
Hx cervical trauma
Diagnosing PPROM
Women with suggestive sx Offer sterile speculum examination looking for pooling amniotic fluid
If pooling amniotic fluid
NO diagonstic tests
Treat
If no pooling amniotic fluid
Order insulin like growth factor binding protein 1 or alpha microglobulin-1 test of vaginal fluid
- Positive: likely PPROM if Sx
- Neg: unlikely, no ABx
If labour becomes established in ?PPROM
Don’t do tests
Manage labour
Antibiotc proph. in PPROM
Erythromycin PO 250mg QDS
Max 10d or until established labour
2nd line: oral penicilin
Identifying infection in PPROM
Clinical assessment
CRP
WCC
CTG
Rescue cervical cerclage CI
Signs of infection
acute PV bleed
Uterine contractions
When to consider rescue cervical cerclage
16-27wk
dilated cervix
exposed unruptured membrane
Greatest benefits of rescue cerclage?
Earlier gestation
Risks of rescue cervical cerclage
ROM
Infection
Bleeding
Premature contractions
Aims of rescue cerclage
aims to delay birth and redeuce neonatal morbidity
Diagnosing preterm labour with intact membranes
Asessment: Hx, obs, speculum, cervical dilatation
<29+6 and clinical assessment suggests preterm labour
treatment necessary
If >30wk and assessment suggests preterm labour scan option
Consider TVUSS measurement of cervical length (likelihood of delivery in 48hrs)
if >15mm unlikely preterm
<15mm likely preterm and treat
If TVUSS unavailable/unacceptable use foetal fibronectin
- <50ng/ml unlikely preterm
->50 ng/ml likely preterm, treat
Tocolysis factors to consider
- suspected/diagnosed preterm labour?
- Other clinical features that suggest stopping labour is CI (bleeding)
- Gestational age
- Likely benefit of maternal CS
- Availability of neonatal care
- Maternal preference
Tocolysis - when to offer nifedipine
Consider: 24-25+6wk and intact membranes and sus/diagnosed PTL
Offer: 26-33+6: intact and in sus/diagnosed PTL
2nd line to nifedipine in tocolysis
oxytocin R antagonists
Atosiban
NOT beta-mimetics
Maternal cortical steroids in PTL - discuss with
23-23+6wks
PTL (suspected/established)
Having planned preterm birth
PPROM
Benefits of maternal CS
reduce morbidity and mortality
reduce late miscarriage and baby death
MgSO4 in PTL?
neuroprotection given IV
4g bolus/15min
IV infusion of 1g/hour until birth or 24hrs
When to offer MgSO4 in PTL
24-34wk:
established PTL
OR
having planned PT birth within 24hrs
Monitoring with MgSO4
Signs of Mg tox. (pulse, BP, RR, deep tendon reflexes)
every 4hr
Foetal monitoring in PTL
CTG useful
?foteal scalp electrode
?foetal blood sampling
Mode of birth on PTL
Offer 24 expectant Mx to commence labour (consider IOL after this)
Discuss C-section vs vaginal
Aim for delivery by 34wk
Consider C-sec if breech and pretern
Difficulties of PTL c-section
More difficult to perform
higher chance vertical incision
No known benefits/harms of c-section/vaginal but limited evidence
Summary of PTL/PPROM
Admit for obs (chorioamonitis)
PO erythromycin 10d
Antenatal CS
34wk delivery im
PACES counselling of PPROM
RF: smoking, STI, Hx, mulitple preg ADMIT Risks: infection Risk of prematurity (want to keep inside as long as poss) Importance of obs (maternal and CTG) Antenatal CS Discuss delivery
