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m4 obgyn > Preterm labour & PPROM > Flashcards

Preterm labour & PPROM Flashcards

1
Q

Definition: Preterm birth

A

Birth before 37 weeks of pregnancy
- spontaneous
- iatrogenic: IOL or CS for maternal/fetal indications

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2
Q

Definition: Established preterm labour

A

Progressive effacement and dilatation of the cervix in the presence of regular painful contractions

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3
Q

Definition: Suspected/threatened preterm labour

A

Symptoms of preterm labour, but clinical assessment (speculum/digital VE) rules out established labour ie. no cervical change

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4
Q

Definition: PPROM

A

Preterm Prelabour Rupture Of Membrane: rupture membrane before 37+0W and not in established labour

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5
Q

Risk factors for preterm birth

A
  1. Previous preterm birth (strongest predictor for recurrence)
    - Risk increases with increasing number of preterm births
  2. Cervical trauma / surgery -> cervical insufficiency
    - Cervical surgery e.g knife cone biopsy or LLETZ/LEEP for CIN (where volume of cervical tissue removed is directly associated with the risk of preterm birth)
    - Previous termination of pregnancy in mid-trimester
  3. Uterine abnormalities e.g. didelphys (double uterus)
  4. Social
    - Smoking, alcohol, drugs
    - Low socioeconomic background
    - Increasing age
    - Low pre pregnancy weight
    - Short pregnancy interval
    - Domestic violence
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6
Q

Causes of spontaneous preterm birth

A
  1. Too much pressure
    - Multiple fetal gestation
    - Polyhydramnions
  2. Too weak
    - Cervical trauma / surgery -> cervical insufficiency
    - Cervical surgery e.g knife cone biopsy or LLETZ/LEEP for CIN (where volume of cervical tissue removed is directly associated with the risk of preterm birth)
    - Previous termination of pregnancy in mid-trimester
  3. Outside is better than inside
    - Infection
    - Abruption
    - Pre-eclampsia
    - IUGR
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7
Q

Clinical features of Preterm labour

A

Similar to normal labour but occurring before 37 weeks

Symptoms
- Menstrual-like cramping
- Lower back ache
- Painful regular uterine contraction
- Vaginal discharge: Bloody show

Abdominal PE
- Palpable contractions
- Tenderness
- Fundal height, lie, presentation

Speculum and VE
- Effacement and dilatation of the cervix

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8
Q

If preterm labour suspected, run investigations

A
  1. Predict likelihood of preterm delivery
    - Actim partus
    - Fetal Fibronectin test
    - Transvaginal US of cervical length
  2. Look for infection
    - Vaginal swab (including GBS)
    - UFEME, urine culture TRO UTI
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9
Q

Actim partus (rapid test kit)

A
  • Simple cervical swab
  • Detects phosphorylated insulin-like growth factor binding protein-1 (pIGFBP-1)
  • Found in decidua
  • Leaks into cervix when decidua and chorion detaches
  • High negative predictive value (If negative, 98% chance that the patient will NOT deliver preterm)
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10
Q

Fetal Fibronectin test

A
  • Simple cervical swab
  • Glycoprotein found in amniotic fluid and placenta
  • Disruption of the chorionic-decidual interface leads to detection of FFN in the cervicovaginal secretions
  • High negative predictive value (If negative, 97% chance that the patient will NOT deliver preterm
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11
Q

Transvaginal US of cervical length

A
  • Determines likelihood of birth within 48h in those >30 weeks
  • Cervical length 15mm or less = initiate treatment
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12
Q

Management of preterm labour

A

General:
- Admit mother to labour ward
- Serial vaginal examination: assess cervical effacement + dilatation
- Rest mother in lateral decubitus position
- Monitor maternal vitals
- CTG monitoring of fetus
- Inform neonatal unit to standby for premature fetus
- Send routine bloods: FBC, GXM, PT/PTT, UECr

Specific
+/- Prophylactic abx
- Antenatal steroids
- MgSO4
- Tocolytics
- Decision on time and mode of delivery (vertex (NVD) vs breech (C-sect) presentation)

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13
Q

Prophylactic abx for preterm labour

A

Only if GBS +ve or unknown
- Give IV penicillin G during delivery (clindamycin if allergic)

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14
Q

Antenatal steroids in preterm labour

A
  • Promotes fetal lung maturity
  • Reduces risk of respiratory distress syndrome, intraventricular haemorrhage (major cause of cerebral palsy)
  • Recommended to be given between 24 weeks to 34+6 weeks in women with established PTL, PPROM, planned preterm birth)
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15
Q

Types and dose of antenatal steroids that can be administered

A

Only 2 can pass through placenta and reach fetus:
a. 24mg IM Betamethasone in 2 divided doses: 12mg 24H apart

b. 24mg IM Dexamethasone in 2 divided doses: 12mg 24H apart OR 4 divided doses: 6mg 12H apart

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16
Q

Maximum effectiveness of antenatal steroids is achieved

A

Benefit begins 24h after initiation for 1st dose to 7th day of administration of the second dose
- if mother does not delivery within 7 days, cannot give to her again

17
Q

Use of MgSO4 in preterm labour

A

Reduces cerebral palsy (neuroprotection)

18
Q

Indications of tocolysis

A
  1. Delay of birth by 48h is necessary to administer ANS
    - Prolongs pregnancy by inhibiting uterine contractions
  2. In utero transfer

*NOT used in PPROM - a/w increased risk of chorioamnionitis

19
Q

Types of tocolytics used

A
  1. PO Nifedipine (most commonly used) (CCB)
  2. PO indomethacin (NSAIDs)
  3. SC/IV terbutaline (b2 agonist)
  4. IV salbutamol (b2 agonist)
  5. IV MgSO4
  6. IV Atosiban (oxytocin antagonist)
20
Q

Symptoms of PPROM

A
  • Typically gush of clear fluid/ Steady leak of fluid
  • Sudden, unprovoked
  • Foul-smelling discharge indicates chorioamnionitis
  • Painless uterine contraction
  • Bleeding
  • Fetal movements +
21
Q

Physical Examination for PPROM

A

Sterile Speculum examination to prevent risk of infection
- Amniotic fluid pooling in posterior fornix
- Coughing reveals leaking fluid from cervix

**Vaginal examination is C/I so as to prevent infection and stimulation of preterm labour, only done in certain circumstances
- Regular painful contraction (Possible preterm labour)
- Non-reassuring CTG status (Check for cord prolapse)

22
Q

Diagnosis of PPROM

A

Maternal history followed by sterile speculum examination demonstrating liquor – ‘gold
standard’

23
Q

If PPROM suspected, run investigations

A
  1. Confirm presence of amniotic fluid
    - Amnicator
    - Actim PROM
  2. Look for infection
    - Vaginal swabs, including GBS
    - UFEME, urine culture TRO UTI
  3. If PPROM confirmed, inflammatory markers used to monitor for chorioamnionitis
    - FBC
    - CRP
    *don’t use ESR as ESR levels are always raised in pregnancy
24
Q

Amnicator for PPROM

A

Nitrazine-based test for detection of amniotic fluid
- Normal vaginal pH: 4.5-6
- Amniotic fluid pH: 7-7.5
- Colour change from yellow to blue indicates possible presence of amniotic fluid
- False positives: blood or semen

25
Q

Actim PROM for PPROM

A

Similar to actim partus

26
Q

PPROM management

A

Similar to PTL
Except
+Abx: Erythromycin for 10D after PPROM reduces the risk of chorioamnionitis
- tocolysis (no need)

Monitor for chorioamnionitis
- Clinical assessment of vital signs
- Maternal blood tests (WBC, CRP)
- Fetal heart rate

27
Q

When to deliver in PPROM?

A

Expectant management until 37W, in discussion with mommy and ongoing clinical assessment

28
Q

Exclusion criteria from expectant management in PPROM

A
  • Active labour
  • Chorioamnionitis
  • Concerns about fetal wellbeing
  • Monochorionic multiple pregnancy
  • Hypertensive disorder
  • Other contraindications to continuing pregnancy
29
Q

Complications of PPROM

A
  1. Significant neonatal morbidity and mortality, due to:
    - prematurity
    - sepsis
    - cord prolapse
    - pulmonary hypoplasia
    - limb contractures
  2. Chorioamnionitis
    - ascending infection -> chorioamnionitis ->
    fetal/neonatal infection
    - strict indication for delivery regardless of gestation
  3. Placental abruption
30
Q

Prevention of preterm birth / PPROM in future pregnancies

A
  1. Next pregnancy manage in preterm birth clinic
  2. Target modifiable risk factors e.g. smoking
  3. Screen and treat for infection: UTI, STI, BV
  4. Cervical length screening with serial TVUS
    - Monitor from 16-24weeks for women with previous preterm birth, PPROM or previous 2nd trimester miscarriage
    - Short cervix = cervical length < 25mm before GA 24 weeks
  5. Vaginal progesterone suppository
  6. Cervical cerclage
31
Q

Cervical cerclage

A

Insertion of suture in the cervix to prevent preterm labour
- Vaginal / trans-abdominal approach
- Elective or emergency
(rescue cerclage)
- Vaginal cerclage usually removed around 36W because mommy can go into labour after that and if cerclage is still present, it can lead to cervical tear and heavy bleeding

m4 obgyn (37 decks)

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