Preterm Labour PTL Flashcards by Siba Kherbek

No history of spontaneous preterm birth or mid trimester loss
+ cervical length < 25 mm between 16 -24 w?

Prophylactic vaginal progesterone

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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

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History of preterm PROM + cervical length < 25 mm between 16 - 24 w?

Prophylactic cervical cerclage

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History of cervical trauma + cervical length < 25 mm between 16 - 24 w?

Prophylactic cervical cerclage

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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

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What is the role of NITRAZINE to diagnose P PROM ?

Don’t use nitrazine to diagnose P PROM

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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

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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

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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

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When to consider rescue cervical cerclage?

Between 16 - 27⁶ of pregnancy with dilated cervix and exposed unrupture fetal membranes

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What are the contraindications for rescue cervical cerclage?

Infection / active bleeding / contractions / PROM
* if dilatation > 4 cm 👉 high risk of failure.

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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

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What is the best diagnostic test to determine likelihood of birth within 48h in women with suspected PTL > 30w ?

TVS
Followed by fetal fibronectin

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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

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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

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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