Preterm labour and PROM Flashcards Preview

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Flashcards in Preterm labour and PROM Deck (20):
1

Incidence of PROM

1. 2-3% of all pregnancies
2. 30% of all preterm

2

History in PROM

1. Gush of fluid
2. Continued leaking
3. May have signs of chorioamnionitis
4. SROM prior to 37 weeks

3

Examination and assessment of fetal well-being in PPROM

1. AVOID digital examination
2. Maternal
Vital signs
Abdominal examination
Sterile speculum->liquor pooling->exclude prolapsed cord, cervical dilitation, take swabs and PROM test (for amniotic fluid)
3. Assess fetal well being
Fetal movements
CTG
USS with doppler
Biophysical->liquor volume, CTG, fetal breathing movement, limbs moving, tone

4

Investigations in PROM

1. FBC
2. UEC
3. Vaginal/rectal swabs
4. MSU
5. Formal USS

5

Management of PROM

1. Consider admission to hospital, look for clinical signs of chorioamnionitis
2. Antibiotic prophylaxis for GBS if in labour
3. Tocolysis? probably not
4. Steroids
5. Timing and mode of delivery
6. Surveillance for infection and fetal well-being
7. Notify if delivery (NICU)->aim for 34 weeks gestation
8. General
Analgesia
Antiemetics
Regular medications
DVT prophylaxis
Diet, activity
Allergies
Regular monitoring

6

Complications of PROM

1. Preterm labour >50%, most with deliver within 1 day-7 days
2. Ascending infections 15-25%
(chorioamnionitis, neonatal sepsis, endometritis)
3. Abruption
4. Umbilical cord prolapse
5. Preterm complications
6. Oligohydramnios (pulmonary hypoplasia, limb positioning defects)

7

What is preterm labour

1. 20 weeks->36+6 with regular painful contractions and effacement of the cervix

8

Common associations with preterm labour

1. Maternal
Low SES, poor nutrition, single, recreational drug use, caffeine
Low weight
Cervical trauma, induced abortion, short cervix
Bacterial vaginosis
Infection and PROM
Previous PTL
UTI, dental
2. Fetal
Abnormalities
3. Uterus
Polyhydramnios
Multiples
APH

9

Inidicators labour has started

1. frequent uterine contraction, a positive fetal fibronectin test, cervical dilation to >3 cm, and ruptured membranes all increase the likelihood that labour has started

10

History in preterm labour

1. Regular contractions >1/10
2. Gush of fluid, bleeding, leak, discharge
3. UTI, bacteruria, dysuria, flank pain
4. Trauma, abortion
5. Previous PTL
6. Twins
7. Fetal movements
8. Rapidly increasing girth
9. CIN/surgery
10. Complete family and social history

11

Initial assessment in PTL

1. Review History
• Medical, surgical, obstetric, social
2. Assess for signs and symptoms
• Pelvic pressure
• Lower abdominal cramping
• Lower back pain
• Vaginal loss – mucous, blood, fluid
• Regular uterine activity
3. Physical examination
• Vital signs
• Abdominal palpation
• Fetal surveillance – FHR, CTG
• Sterile speculum exam
o Identify if ROM. Avoid digital unless ++possibility of prolapsed cord
o Visualise cervix/membranes
o High vaginal swab
o Test for fFN
• Low vaginal/anorectal GBS swab
• Cervical dilatation
o Sterile digital vaginal exam
unless ROM, placenta praevia
• Ultrasound – if available
o Fetal growth and wellbeing, Cervical length
4. Laboratory
• High vaginal swabs for MC&S
• One swab (low vaginal + anal) for
GBS
• Midstream urine for MC&S1.

12

Overview of management of PTL

1. In utero transfer, admission?
2. Corticosteroids
3. Antibiotics
4. Tocolysis
5. Magnesium sulphate
6. Analgesia, clinical surveillance, Continuous CTG, consult
7. Prep for birth
8. Mx after birth

13

Steroid regime

Antenatal corticosteroids:
• Recommend course of Betamethasone (2 doses)
o 11.4 mg IM then 2nd dose in 24 hours
o Consider 2nd dose at 12 hours if PTB likely within
24 hours
• If risk of PTB remains ongoing in 7 days, repeat dose

14

Tocolysis options, indication, contraindications, purpose

1. Nifedipine
2. Signs of PTL 24-34 weeks
3. Do not give if a) any reason not to prolong= PET, fetal distress, lethal congenital anomalies, b) significant bleeding, c) evidence of infection
4. Purpose->to allow corticosteroid loading

15

Antibiotic regime, when to start, cease

1. Antibiotics if:
a. Established labour (or imminent risk of PTB) give
intrapartum GBS prophylaxis regardless of GBS
status or membrane status
b. Evidence of chorioamnionitis (membranes intact or
ruptured)
o Ampicillin (or Amoxycillin) 2 g IV initial dose, then
1 g IV every 4 hours
o Gentamicin 5 mg/kg IV daily
o Metronidazole 500 mg IV every 12 hours
2. If labour does not ensue (and no evidence of
chorioamnionitis) and if:
o Membranes intact then cease antibiotics
o PPROM, then convert to Erythromycin 250 mg oral
every 6 hours for 10 days
3. If Penicillin hypersensitivity give:
o Lincomycin 600 mg IV every 8 hours OR
o Clindamycin 600 mg IV every 8 hours

16

Magnesium sulphate regime

1. Gestational age 24-30 weeks
2. Labour established or imminent birth->load and maintenance
3. Neuroprotective

17

Most common cause of PTL

1. PROM
2. Chorioamionitis
3. UTI/pyelonephritis

18

Minor side effects of tocolysis

1. Facial flushing
2. HA
3. Nausea
4. TachyC
5. Dizziness

19

Indications for admission

Consider admission if:
• fFN > 50 ng/mL or
• Cervical dilation or
• Cervical change over 2–4 hours or
• ROM or
• Contractions regular & painful or
• Further observation or investigation
indicated or
• Other maternal or fetal concerns

20

Management post threatened PTL

1. Maternal and fetal assessments
2. T/F to referring hospital hen appropriate
3. D/C if usual criteria met
4. Inform woman, GP and usual care provider about recommendations for future care