PTL, PPROM, chorio, multiple gestation Flashcards
-gestation 20 to <37 weeks
-uterine cxs
-cervical changes
preterm labor
gestation 20 to <37 weeks
birth
preterm birth
3 categories of preterm
very preterm: <32.0
moderately preterm: 32.0-33.6
late preterm: 34.0-36.6
3 categories of term
early term: 37.0-38.6 weeks
full term: 39.0-40.6 weeks
late term: 41.0-41.6 weeks
what is considered low birth weight
<2500 grams at birth
*lowdermilk box 32-1 and 32-2
factors that may explain increase in preterm birth rates
-increase twins and multiples from IVF
-increased births to AMA moms
-increase medically induced prematurity
-early repeat C/S
-C/S w/o medical indications
-advances in MFM and NN care
-increase pregnancies in HR women
-increased fetal complications requiring early birth (ex : IUGR)
potential triggers of inflammation
-microbial invasion amniotic cavity
-maternal obesity
-uterine overdistention
-subclinical genital tract infections
stimuli from an inflammatory response causes a withdrawal of functional progesterone
inflammatory response
examples of pathways of interaction of factors
-inflammation
-maternal/fetal stress
-abnormal uterine distention
-bleeding/thrombophilia
-hormones/toxins
big 3 risk factors for PTB
-current multifetal pregnancy
-h/o PTB
-uterine/cervical abnormalities
medical condition risk factors for PTB
-DM
-HTN
-clotting disorders
-previous 2nd tri abortion
-inadequate nutritional status (underweight/obese, inadequate weight gain, anemia)
-infections
-abnormal lipid metabolism
demographic risk factors for PTB
-age (<17 or >35)
-AMA
-low socioeconomic status
-black race
-tobacco
-substance abuse
-maternal/fetal stress
behavioral/environmental risk factors for PTB
-substance abuse
-DES exposure
-maternal/fetal stress
-intimate partner violence
-lack of social support
-long working hours
-long periods standing
-exposure to environmental substances (pollution, radiation, lead, paint, smoke)
pregnancy associated risks for PTB
-late/no prenatal care
-vaginal bleeding (esp 2nd/3rd tris)
-PPROM
-short interpregnancy interval (<18 mos)
-changes maternal microbiome
-fetal anomalies
when would fetal fibronectin be found in vaginal fluid
disruption in chorion
good for predicting you won’t go into labor
fFN shouldn’t be in vaginal fluid normally between 24-34 EGA
what factors could affect the accuracy of the fFN test for PTL
-ROM
-sexual intercourse past 24 hrs
-cervical examination/vaginal ultrasound past 24 hrs
-vaginal bleeding
-infections (intraamniotic/vaginal)
-douche/vaginal lubricant use
two tests for PTL/PTB
fFN
PAMG-1
what is considered a short cervix
<25 mm @16-24 EGA
who might get a cervical cerclage
h/o PTB @17-33.6 EGA
cervical length <25 mm before 23 EGA
only best for singleton pregnancies
who might receive progesterone
h/o PTB
cervical length <20 mm @ <24 EGA
*started at 15-20 weeks until 36 weeks
meds that inhibit contractions
tocolytics
when can tocolytics be given
22-33.6 wks EGA
4 tocolytic meds
-mag sulfate: CNS depressant, smooth muscle relaxant
-terbutaline/brethine: beta mimetic
-indocin: NSAID
-nifedipine (adalat, procardia): CCB
general contraindications for tocolytic meds
-acute fetal compromise
-intraamniotic infection/chorio
-eclampsia/severe preeclampsia
-fetal demise
-fetal maturity
-placental abruption
-maternal bleeding with instability
-pulmonary HTN
-PPROM (except for steroid admin and transfer)
*basically anything that means birth is imminent
contraindications to terbutaline
-tachycardia sensitive maternal cardiac disease
-poorly controlled maternal DM
-maternal hyperthyroidism
-maternal seizure disorders
contraindications to mag sulfate
-maternal hypocalcemia
-maternal myasthenia gravis
-maternal renal failure
contraindications to indomethacin
-gestation >32 weeks
-maternal asthma
-maternal coronary artery disease
-maternal GI bleeding
-platelet dysfunction/bleeding disorder
-oligohydramnios
-renal failure
-suspected fetal cardiac/renal anomaly
-maternal liver disease
-IUGR
contraindications to nifedipine
-maternal CV disease
-maternal aortic insufficiency
-maternal hemodynamic instability
-maternal hypoTN
-no combo with beta mimetic drugs
purpose of giving mag sulfate for PTL/PTB
decreased incidence cerebral palsy
NN neuroprotection
purpose of giving betamethasone/dexamethasone for PTL/PTB
DECREASED INCIDENCE OF:
-RDS
-intraventricular hemorrhage
-NEC
-NN death
S+S PTL pt teaching
-malaise/discomfort/fatigue
-uterine activity (Cxs q10mins, cramping like period)
-low dull backache
-suprapubic pain/pressure
-feeling baby is pushing down/balling up
-vaginal discharge (increased amount or change)
-urinary frequency
pt teaching what to do if S+S PTL
-empty bladder
-lateral rest 1 hr
-palpate for ctx
-if continues/worsens call hcp or go to clinic
when should woman go to clinic/birth facility immediately (S+S)
-ctx q10mins for 1 hr +
-vaginal bleeding
-fluid leaking from vagina
-odorous vaginal discharge
spontaneous rupture of amniotic sac and leakage of fluid prior to onset of labor at any EGA
premature rupture of membranes PROM
membranes rupture before 37.0 weeks EGA
preterm premature rupture membranes PPROM
PPROM risk factors
-low socioeconomic status
-poor nutritional status
-tobacco/substance abuse
-infection (including h/o STDs)
-incompetent cervix
-trauma
Tx PPROM for >34 weeks EGA
delivery
Tx PPROM for32-34 weeks EGA
assess fetal lung maturity
mature: deliver
Tx PPROM for <32 weeks EGA
expectant management:
-fetal assessment
-monitor for complications
-abx 7 days
-glucocorticoids
risk factors chorioamnionitis
-ROM
-maternal malnutrition, poverty, substance abuse
-repeated vaginal exams
-internal monitoring in labor
-vaginitis, cervicitis, previous cerclage
Dx chorio
-maternal fever (>39 C once, >38 C twice, >38 + additional criteria)
-fetal tachy (>160)
-leukocytosis (>15k)
-purulent cervical drainage
-pos gram stain for bacteria
S+S chorio
-maternal fever
-fetal tachy
-leukocytosis
-uterine pain and tenderness
-foul smelling vaginal discharge
-malaise
-maternal tachy
-uterine cxs
management chorio
-IV hydration
-IV abx and oxytocin
-decrease maternal temp
-delivery
possible NN complications from chorio
-sepsis/bacteremia
-pneumonia
-meningitis
-RDS
-cerebral palsy
-neurologic deficits
maternal body adaptations to multi fetal pregnancy
-hyperemesis
-increased plasma volume (50-100% increase)
-dependent edema, increased risk pulmonary edema
-increased O2 consumption, increased pH
-increased SOB
S+S of recipient twin in TTTS
-hypervolemia
-polycythemia
-polyhydramnios
-CHF
-death
S+S of donor twin in TTTS
-hypovolemia
-anemia
-growth restricted
-oligohydramnios
Dx of TTTS
-monochorionicity
-amniotic fluid discrepancy (poly and oligo)
timing for delivery for dichorionic twins:
-uncomplicated
-isolated fetal growth restriction
-fetal growth restriction and coexisting condition (maternal or fetal)
uncomplicated: 38.0-38.6
isolated growth restriction: 36.0-37.6
growth restriction and coexisting condition: 32.0-34.6
timing for delivery for monochorionic twins:
-MC/DA uncomplicated
-MC/DA w isolated fetal growth restriction
-MC/MA uncomplicated
-MC/DA uncomplicated: 34.0-37.6
-MC/DA w isolated fetal growth restriction: 32.0-34.6
-MC/MA uncomplicated: 32.0-34.0
purpose of tocolytics and how long should they be administered
can delay preterm birth up to 48 hrs (but not prevent it)
dont admin for >48 hrs
side effects mag
drowsiness
decreased RR
arrhythmias
bradycardia
hypoTN
diarrhea
muscle weakness
flushing
sweating
hypothermia
side effects nifedipine
headache
arrhythmias
HF
peripheral edema
flushing
stevens-johnson syndrome
main difference between testing fFN and PAMG-1 for PTB/PTL
-PAMG-1 testing is less affected by other factors (recent vaginal exam)
-PAMG-1 higher negative predictive value
