Preterm Labour PTL Flashcards
No history of spontaneous preterm birth or mid trimester loss
+ cervical length < 25 mm between 16 -24 w?
Prophylactic vaginal progesterone
history of spontaneous preterm birth or mid trimester loss( 16- 34 w)
+ cervical length < 25 mm between 16 -24 w?
EITHER:
- prophylactic vaginal progesterone
- or cervical cerclage
History of preterm PROM + cervical length < 25 mm between 16 - 24 w?
Prophylactic cervical cerclage
History of cervical trauma + cervical length < 25 mm between 16 - 24 w?
Prophylactic cervical cerclage
If the woman reported symptoms suggestive of preterm PROM How to make the diagnosis?
1- offer speculum examination
2- if pooling of AF isn’t observed
👉 insulin like growth factor binding protein-1 OR
placental alpha microglobulin-1
3- if tests are
negative: it’s unlikely PROM
What is the role of NITRAZINE to diagnose P PROM ?
Don’t use nitrazine to diagnose P PROM
Is there a role for diagnostic tests of P PROM if the labour becomes established?
If the labour becomes established don’t perform diagnostic tests for P PROM
Regarding antenatal prophylactic antibiotics for women with P PROM , what is the drug of choice?
*Erythromycin 250 / 4 times a day
For 10 days or until labour is established
Or if the erythromycin is contraindicated or intolerant
* penicillin for 10 days
⛔ Don’t offer co-amoxicalv as prophylaxis for intrauterine infection
How to identify infection in women with P PROM ?
COMBINATION of clinical assessment & tests ( CRP, WBCs count, FHR on cardiotocography
⚠️ don’t use one of them in isolation
When to consider rescue cervical cerclage?
Between 16 - 27⁶ of pregnancy with dilated cervix and exposed unrupture fetal membranes
What are the contraindications for rescue cervical cerclage?
Infection / active bleeding / contractions / PROM
* if dilatation > 4 cm 👉 high risk of failure.
How to make a diagnosis of preterm labour for women with intact membranes?
1- take clinical history
2- speculum examination
3- TVS
⚠️Clinical suspicion of PTL
🚩< 29⁶ w👉 treatment
🚩> 30 w
👉 1-TVS ➡️ cervical length
> 1.5 mm 👉 unlikely
< 1.5 mm 👉 treatment
2- fetal fibronectin if TVS not
available <50 👉 unlikely
> 50 👉 treatment
What is the best diagnostic test to determine likelihood of birth within 48h in women with suspected PTL > 30w ?
TVS
Followed by fetal fibronectin
If tocolytic drugs are indicated, what are the options?
- 24 - 26 w👉 consider nifedipine for suspected PTL
- 26 - 34 w 👉 offer nifedipine for suspected or diagnosed PTL
( not licensed)
⚠️ if nifedipine is contraindicated: offer oxytocin receptor antagonist [ atosiban IV only - licensed]
⚠️ don’t offer betamimetics
Regarding maternal steroids in cases of suspected or diagnosed PTL ,what is the protocol of management?
OFFER ; between 26 - 34 w
CONSIDER: between 24 - 26 w
between 34 - 36 w
DISCUSS : between 23 - 24 w
⚠️ don’t routinely repeat courses
When to offer or / consider MGSO4 women with PTL?
1- established preterm labour
2- planned preterm birth within 24h
OFFER : 24 - 30 w
CONSIDER : 30 - 34 w
⚠️ 4 g IV bolus of MGSO4 over 15 minutes followed by IV infusion 1g/hour until birth or 24 hours whichever is sooner
For women on MGSO4 for PTL & develop oliguria or other signs of renal failure, what is next?
- monitor more frequently for MGSO4 toxicity
- think about reducing the dose
How to monitor the fetus in women with diagnosed or established PTL with no other risk factors?
Offer a choice of FHR monitoring using either :
- cardiotocography using external Ultrasound
- intermittent auscultation
⚠️ absence of evidence that cardiotocography improves the outcomes
What is the role of fetal scalp electrodes in monitoring the fetus during PTL?
Possible use between 34 - 37 w if isn’t possible to monitor using other ways
⚠️ Don’t use fetal scalp electrodes before 34 w
What is the role of fetal blood sampling in monitoring the fetus during PTL ?
Discuss the use between 34 - 37 w
If benefits outweigh the risks
⚠️DON’T carry out fetal blood sampling before 34 w
Breech presentation between 26 - 37 w + diagnosis of PTL ?
Consider CS
What is the recommendations about timing of cord clamping for preterm babies?
🚩The baby is stable 👉 wait 30 seconds but no longer than 3 minutes before clamping the cord
🚩The baby needs resuscitation 👉 milk the cord & clamp as soon as possible
What is the definition of established preterm labour? Treatment??
She has progressive cervical dilation from 4 cm with regular contractions
❤ MGSO4 + GBS prophylaxis
What is the neonatal survival rate between 23 w & 28 w ?
23w 👉 8%
28w 👉 74 %
Equating to an improvement of
3% per day
The effect is lost after 32w of gestation
What is the percentage of spontaneous preterm labours the infection is responsible for ?
20 - 40 % of them
What is the recurrence rate of PTL if one , two , three prior consecutive Preterm deliveries?
After 1 preterm delivery 16- 19%
2 preterm deliveries 32 - 41 %
3 preterm deliveries 67%
Which is the most important factor that will predict preterm labour in the upcoming pregnancy ?
Previous preterm labour
What are the risk factors for spontaneous preterm labor?
Low BMI / smoking/ poor nutrition
Age less than 18 & over 40 y
Multiple pregnancy
Infection / Bleeding < 24 w
Shortened cervix /Cervical surgery
Previous preterm labour
Previous 2nd trimester miscarriage
Previous repeated TOP
At what gestational age fetal fibronectin can predict preterm birth?
22 - 34 w
What are the contraindications to do fetal fibronectin test?
1- preterm PROM
2- multiple pregnancy
3- cervical dilation > 3 cm
4- active vaginal bleeding
5- vaginal exam or intercourse in previous 24h
6- use of lubricant gel
7- gestational age < 24w or > 34w
When should nifedipine as a tocolytic drug be avoided?
1- cardiac disease
& care should be taken in
Diabetes + multiple pregnancy
( reports of pulmonary edema)
When should a history- indicated cervical cerclage be offered?
1- 3 or more previous preterm birth
OR
2- 2nd trimester losses
If miscarriage (or fetal death ) occurs in women of abdominal cerclage , what is the management?
🚩Up to 18 w 👉 evacuation through the stitch by suction or D&C
🚩 posterior colpotomy
🚩or hysterotomy
🚩or CS
What is the period of time “rescue cervical cerclage” may delay birth by ,compared with expectant management?
4 - 5 weeks
Rescue cervical cerclage may be associated with a reduction in PT birth, how much is the reduction?
2 folds reduction in the chance of birth before 34w
In women with cervical cerclage + P PROM between 24 -34 w , what is the management?
If no signs of or preterm labour:
Delay suture removal 48h to facilitate in utero transverse
⚠️ delayed suture removal until labour is associated with increased risk of maternal & fetal sepsis & is not recommended
How should preterm labour be managed in women without known GBS colonization?
IAP is recommended for women in confirmed preterm labour
⚠️ not recommended for women not in labour & having planned CS with intact membranes
History of spontaneous preterm birth or mid trimester losses without shortness of cervical length?
Prophylactic vaginal progesterone
