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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)
given < 32 weeks

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. Chorioamnionitis
    - ascending infection -> chorioamnionitis ->
    fetal/neonatal infection
    - strict indication for delivery regardless of gestation
  2. Placental abruption
  3. Cord prolapse
  4. Preterm baby
  5. Fetal demise
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

32
Q

Worrying sign seen in transvagical cervical length U/S

A

Funneling
- means labour is impending
- cervix length is shortening

m4 obgyn (41 decks)

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