Preterm stuff Flashcards by Rebecca Waldron

in PPROM, between what gestations SHOULD you give steroids, and up to what gestation can they be considered?

Women who have PPROM between 24+0 and 33+6 weeks’ gestation should be offered corticosteroids;
steroids can be considered up to 35+6 weeks’ gestation

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If PPROM was suspected but, on speculum examination, no amniotic fluid is observed, clinicians should consider performing which tests of vaginal fluids to guide further management

insulin-like growth factor-binding protein 1 (IGFBP-1) or placental alpha microglobulin-1 (PAMG-1) test

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In women who have PPROM and are in established labour or having a planned preterm birth within 24 hours,
intravenous magnesium sulfate should be offered between what gestation

24+0 and 29+6 weeks (<30)

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what is the brand name for PAMG-1 test for PPROM

PartoSure

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what percentage of patients admitted for threatened preterm labor IN THE USA do NOT deliver within 7 days (hence wasted admission and overtreatment)

85% of patients admitted for threatened preterm labor do not deliver within 7 days

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theory behind partosure. Who to use PartoSure on.

PAMG-1 is a placental protein found in high concentrations in the amniotic cavity, and low concentrations in normal vaginal discharge
Strong correlation between a positive PAMG-1 test and imminent delivery in patients presenting with threatened PTL and INTACT membranes (I suppose there’s no point doing it if they have obviously PPROM’d(?))
But can also test vaginal fluid to see if it’s actually amniotic if a non-obvious PPROM on inspection but a good history.

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in PPROM, what’s the insulin-like growth factor-binding protein 1 (IGFBP-1) test brand name?

Actim PROM test
can be used as complimentary test to confirm the clinical diagnosis of Premature rupture of fetal membranes.

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to whom would you DEFINITELY offer prophylactic vaginal progesterone OR prophylactic cerclage
(rather than ‘consider’)

need BOTH:
- history of >16+0 miscarriage or <34+0 preterm birth
PLUS
- TVUS cervical length <= 25mm (done between 16 - 24+0)
(you would ‘consider’ progesterone (but not cerclage) if someone had only one of the factors above)

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vaginal progesterone regime for prophylaxis for preterm birth

start between 16 and 24+0 weeks
continue until AT LEAST 34/40
vaginal 200mg capsules

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What additional factors should be present to offer or consider offering a prophylactic cerclage (on top of a TVUS cervical length of <=25mm between 16-24/40)

If they also have a history of preterm birth then you should offer a cerclage (or vaginal progesterone)
HOWEVER
If only a <=25mm cervical length, to consider giving a cerclage they must ALSO have EITHER;
- previous PPROM (previous pregnancy)
OR
- a history of cervical trauma

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define cervical trauma

Physical injury to the cervix including surgery; for example, previous cone biopsy (cold
knife or laser), large loop excision of the transformation zone (LLETZ; any number) or
radical diathermy.

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what would make you ‘consider’ offering vaginal progesterone prophylaxis

history of >16+0 miscarriage or <34+0 preterm birth
OR
TVUS cervical length <= 25mm (done between 16 - 24+0)

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P-PROM oral ABx regime

erythromycin 250 mg 4 times a day for a maximum of 10 days or until the woman
is in established labour (whichever is sooner)

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For women with P-PROM who cannot tolerate erythromycin or in whom
erythromycin is contraindicated, consider….

an oral penicillin for a maximum of
10 days or until the woman is in established labour

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which ABx should you NOT offer women with P-PROM as prophylaxis for intrauterine infection.

co-amoxiclav

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If you are known to have GBS colonisation AND you PPROM >34/40, what should you do?

offer immediate birth (IOL/CS)

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Women whose pregnancy is complicated
by PPROM after 24+0 weeks’ gestation
and who have no contraindications to
continuing the pregnancy should be
offered expectant management until
how many weeks?

37+0 weeks

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If you have PPROM, should you be routinely tested for GBS?

But if you had it in a previous pregnancy or known to have it in this one already, it does affect recommendations for timing of IOL (34/40 rather than 37/40)

If you have known GBS and PPROM, what gestation is thought to be the cutoff, before which continuing with the pregnancy rather than expediting the delivery is lower risk

34+0

for whom would you consider an emergency cerclage?

between 16 and 27+6
with dilated cervix
and exposed, unruptured fetal membranes

(but not bleeding, in labour or with signs of infection)

discuss with a consultant obstetrician AND consultant paediatrician

contra-indications to an emergency cerclage

active bleeding
contractions
signs of infection

gestations at which you would consider an emergency cerclage

between 16 and 27+6

at what gestation with TPTL do you offer TVUS to measure cervical length to determine likelihood of birth within 48h

30+0

If a 30+/40 with TPTL declines TVUS to measure cervical length to determine likelihood of birth within 48h, what can you offer instead

fetal fibronectin

what is the length of cervix on TVUS at >30+0 with TPTL that would reassure you that TPTL and birth within 48h is unlikely?

15mm, FIFTEEN (not 25, which is the cutoff for PTB prophylaxis from 16-24/40)

>30+0 with TPTL, and a TVUS c. length of <=15mm, what can you 'diagnose'

preterm labour offer treatment

what is a negative fetal fibronectin level What does it mean

<=50ng is negative unlikely to give birth in the next 48h

If I've done a TVUS for c. length and it's >15mm at >30/40, should I then do a fetal fibronectin to diagnose PTL?

No. Don't use both TVUS and fetal fibronectin.

where do you collect a partoSure swab from?

The vagina (with or without a speculum) - does not need to be from the cervical os like Actim Partus (IGFBP-1)

what do two lines and one line mean in PartoSure?

Two lines indicate a positive result and a high risk of delivery within 7 days; 1 line indicates a negative result and a low risk of delivery within 7 to 14 days;

what are the allowances and contra-indications to PartoSure?

The test CAN be used if vaginal infections, urine, semen and trace amounts of blood are present, and also CAN be used shortly after a VE, but should NOT be used if there is significant discharge of blood

what gestation range can you use partosure for PTL according to NICE (REMEMBER TVUS and then FFN are preferred though, and used >30/40)

Partosure can be used with intact amniotic membranes and minimal cervical dilatation (3 cm or less), between 20+0 days and 36+6

how do you collect a fetal fibronectin test?

fFN sample is collected from the posterior fornix of the vagina during a speculum examination.

how to interpret fFN in presence of semen, blood, cervical disruption etc.

a negative test result (less than 10 ng/ml) in the presence of blood or semen is valid

gestation for nifedipine tocolysis with intact membranes and preterm labour (suspected or diagnosed)

<34 weeks i.e. really it's 26+0 - 33+6 (from 24-25+6 it's 'consider' offering tocolysis)

gestation for offering steroids in PTL or PPROM vs 'consider'

24+0 - 33+6 = offer steroids 34+0 - 35+6 THIRTYFIVE+6 = consider steroids

what are the max number of steroid courses for PTB?

2 courses

for whom might you consider a single repeat course of steroids?

<34/40 who have had a course of steroids >7 days ago AND are at VERY high risk of giving birth in the next 48h (but N.B., be even more hesitant if <30/40 or if there is suspected growth restriction).

at what gestations do you offer intravenous magnesium sulfate for neuroprotection in PTL

Offer at <30/40 (between 24+0 and 29+6) 'consider' <34/40 (from 30+0 - 33+6)

For women on magnesium sulfate, monitor for clinical signs of magnesium toxicity at least every 4 hours by recording...what?

pulse blood pressure respiratory rate deep tendon (for example, patellar) reflexes.

how should you monitor the baby during preterm labour?

you might not at the threshold of viability (d/w senior <26/40) there is an absence of evidence that using CTG improves the outcomes of preterm labour for the parent or the baby compared with intermittent auscultation Don't use an FSE <34/40 unless ABSOLUTELY necessary

below what gestation is FBS contra-indicated

<34/40

<30/40 with TPTL, what test(s) can you do to diagnose TPTL?

None recommended. Diagnose clinically.