PTL

Question 1

Cervical changes and regular contractions between 20-37 weeks’ gestation

Answer 1

Preterm labor

Question 2

Potential long term health issues associated with PTL

Answer 2

cerebral palsy, intellectual disabilities, chronic lung disease, blindness, hearing loss

Question 3

Any birth that occurs before the completion of 37 weeks of pregnancy, regardless of birth weight.

Answer 3

Preterm birth

Question 4

Extremely preterm

Answer 4

less than 28 weeks

Question 5

Very preterm

Answer 5

28-32 weeks

Question 6

Moderate to late preterm

Answer 6

32-37 weeks

Question 7

PTL Risk Factors

Answer 7

-Previous PTB (Women with a previous PTB are 2-3x more likely to have another)
-Short cervix
-Multiple gestation
-PPROM (preterm premature rupture of membranes)
-Hormonal changes (from fetal or maternal stress)
-Infections
-African-American Race

Question 8

PTL Modifiable risk factors

Answer 8

Smoking
Short inter-pregnancy intervals
Low pre-pregnancy weight and poor nutrition
Substance use

Preconception is the best time to address these risks

Question 9

Signs and symptoms of PTL

Answer 9

Uterine activity
-Uterine contractions that may be painful or painless

Discomfort
-Menstrual-like cramps; low, dull back ache; intestinal cramping; diarrhea; pelvic pressure or heaviness; urinary frequency

Vaginal discharge
-Change in character or amount of usual discharge; SROM; bleeding, spotting

Question 10

Rupture of the amniotic sac beginning at least 1 hour before the onset of labor before 37 weeks’ gestation

Etiology unknown, often preceded by infection

S/Sx: gush/trickle of fluid from vagina

Answer 10

Preterm Premature Rupture of Membranes (PPROM)

Question 11

PPROM treatment includes

Answer 11

-Strict sterile technique (Fern/Nitrazine/Amnisure Test)
-No vaginal exams, unless delivery is imminent
-Expectant management (AKA watch and wait) is recommended as long as there are no contraindications

Question 12

PPROM interventions

Answer 12

-Hospitalization, bed rest PRN
-Fetal surveillance
-Antibiotics
-Tocolytics
-Corticosteroids

Question 13

Rupture of amniotic sac before labor begins at any gestational age

Answer 13

Premature rupture of membranes (PROM)

Question 14

PTL test

fFN is a protein that is released into cervical and vaginal secretions when there is disruption of maternal-fetal interface of membranes and decidua (keeps amniotic sac attached to uterine lining)

Tested between 24-34 weeks’ gestation

Specimen must be collected by sterile speculum exam PRIOR to digital examination

Answer 14

Fetal Fibronectin (fFN)

Question 15

fFN Interpretation

Answer 15

Result is either negative or positive within 24-48 hours

Negative result: likelihood of giving birth within the following week is <1%, predict pregnancy will continue for another 14 days

Positive result: increased chance of preterm birth (labor may start within 7-14 days), specific time frame undetermined by test, continue preventative treatment

Question 16

fFN contraindications

Answer 16

fFN is NOT tested/valid in the case of:
-Vaginal bleeding
-Intercourse, vaginal exam, or vaginal US within 24 hours prior to collection
-Cervical dilation > 3 cm
-PPROM or bulging membranes
-Open cervical/vaginal sores

Question 17

Which of the following patients would be eligible for a fFN test?

A. A patient presenting with vaginal bleeding
B. A patient at 31 weeks’ gestation with cramping
C. A patient who had a vaginal ultrasound this morning
D. A patient at 22 weeks’ gestation

Answer 17

B. A patient at 31 weeks’ gestation with cramping

Question 18

PTL Prevention w/ lifestyle modifications

Answer 18

“Bed rest and pelvic rest”

Individualized/bed rest as needed
Strict bed rest is not evidence based!
Increased clotting tendency

Avoid:
Sexual activity
Riding long distances
Carrying heavy loads
Standing for long periods
Hard, physical labor

Question 19

Medication to decrease risk of going into PTL

Keeps uterus quite, keep the uterus from contractions

“Maintains pregnancy”

Used in women with previous hx of PTB and/or shortened cervix

Answer 19

Progesterone therapy

Question 20

Routes progesterone can be given

Answer 20

vaginal gel, suppositories, and IM injection

Question 21

The use of medications (tocolytics) to inhibit uterine activity

Given between 24-34 weeks

Goal is to suppress uterine activity and buy time to administer antenatal glucocorticoids to accelerate fetal lung maturity (stop/delay labor!)

Answer 21

Tocolysis

Question 22

Tocolytic contraindications

Answer 22

-If baby’s heart rate drops or spikes, tocolysis will be discontinued
-Not indicated for use before neonatal viability or after 34 weeks
-Fetal demise or lethal fetal anomaly
-Severe pre-eclampsia, eclampsia
-PPROM
-Maternal bleeding with instability
-Chorioamnionitis

Question 23

Which patient would be eligible for tocolytic therapy?

A. A patient with absent fetal heart tones
B. A patient at 21 weeks’ gestation
C. A patient at 32 weeks’ with gestational diabetes
D. A patient with a 101° F fever

Answer 23

C. A patient at 32 weeks’ with gestational diabetes

Question 24

Beta-adrenergic receptor agonist: relaxes smooth muscle, decreasing uterine contractility

Given subq injections (common), IV, and orally

Adverse reactions:
Tachycardia, SOB, tachypnea, pulmonary edema, palpitations

Monitor maternal vital signs and FHR

Answer 24

Terbutaline (Brethine)

Question 25

Calcium channel blocker: reduces contractions by inhibiting calcium from entering smooth muscle cells

Given PO

Adverse reactions:
Hypotension
Monitor maternal vital signs and FHR

Answer 25

Procardia (Nifedipine)

Question 26

Mineral, anticonvulsant, CNS depressant: interferes with calcium uptake in myometrium cells, reducing muscular ability to contract resulting in smooth muscle relaxation (similar to calcium channel blockers)

Given IV

Adverse reactions:
Hot flushes, sweating, n/v, drowsiness, dizziness, transient hypotension, hypocalcemia, respiratory depression
Monitor maternal vital signs and FHR

Answer 26

Magnesium Sulfate

Question 27

When preterm birth appears inevitable, magnesium sulfate may be administered to reduce or prevent

Answer 27

neonatal neurologic morbidity (ex: cerebral palsy)

Question 28

Antidote for magnesium sulfate toxicity

Answer 28

calcium gluconate

Question 29

Magnesium sulfate is contraindicated in patients w/

Answer 29

myasthenia gravis

Use cautiously in clients with myocardial infection and those with renal disease

Question 30

Accelerates fetal lung maturity

Promotes release of enzymes to induce production of surfactant in fetal lungs

The most beneficial intervention for the improvement of neonatal outcomes among women who give birth preterm

Answer 30

Antenatal Glucocorticoids

Question 31

Why should blood glucose levels be monitored when patient is given antenatal glucocorticoids?

Answer 31

Steroids can cause hyperglycemia