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23- Obstetric Complications > Preterm Labour PTL > Flashcards

Preterm Labour PTL Flashcards

1
Q

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

A

Prophylactic vaginal progesterone

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2
Q

history of spontaneous preterm birth or mid trimester loss( 16- 34 w)
+ cervical length < 25 mm between 16 -24 w?

A

EITHER:
- prophylactic vaginal progesterone
- or cervical cerclage

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3
Q

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

A

Prophylactic cervical cerclage

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4
Q

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

A

Prophylactic cervical cerclage

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5
Q

If the woman reported symptoms suggestive of preterm PROM How to make the diagnosis?

A

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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6
Q

What is the role of NITRAZINE to diagnose P PROM ?

A

Don’t use nitrazine to diagnose P PROM

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7
Q

Is there a role for diagnostic tests of P PROM if the labour becomes established?

A

If the labour becomes established don’t perform diagnostic tests for P PROM

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8
Q

Regarding antenatal prophylactic antibiotics for women with P PROM , what is the drug of choice?

A

*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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9
Q

How to identify infection in women with P PROM ?

A

COMBINATION of clinical assessment & tests ( CRP, WBCs count, FHR on cardiotocography
⚠️ don’t use one of them in isolation

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10
Q

When to consider rescue cervical cerclage?

A

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

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11
Q

What are the contraindications for rescue cervical cerclage?

A

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

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12
Q

How to make a diagnosis of preterm labour for women with intact membranes?

A

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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13
Q

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

A

TVS
Followed by fetal fibronectin

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14
Q

If tocolytic drugs are indicated, what are the options?

A
  • 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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15
Q

Regarding maternal steroids in cases of suspected or diagnosed PTL ,what is the protocol of management?

A

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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16
Q

When to offer or / consider MGSO4 women with PTL?

A

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

17
Q

For women on MGSO4 for PTL & develop oliguria or other signs of renal failure, what is next?

A
  • monitor more frequently for MGSO4 toxicity
  • think about reducing the dose
18
Q

How to monitor the fetus in women with diagnosed or established PTL with no other risk factors?

A

Offer a choice of FHR monitoring using either :
- cardiotocography using external Ultrasound
- intermittent auscultation
⚠️ absence of evidence that cardiotocography improves the outcomes

19
Q

What is the role of fetal scalp electrodes in monitoring the fetus during PTL?

A

Possible use between 34 - 37 w if isn’t possible to monitor using other ways
⚠️ Don’t use fetal scalp electrodes before 34 w

20
Q

What is the role of fetal blood sampling in monitoring the fetus during PTL ?

A

Discuss the use between 34 - 37 w
If benefits outweigh the risks
⚠️DON’T carry out fetal blood sampling before 34 w

21
Q

Breech presentation between 26 - 37 w + diagnosis of PTL ?

A

Consider CS

22
Q

What is the recommendations about timing of cord clamping for preterm babies?

A

🚩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

23
Q

What is the definition of established preterm labour? Treatment??

A

She has progressive cervical dilation from 4 cm with regular contractions
❤ MGSO4 + GBS prophylaxis

24
Q

What is the neonatal survival rate between 23 w & 28 w ?

A

23w 👉 8%
28w 👉 74 %
Equating to an improvement of
3% per day
The effect is lost after 32w of gestation

25
Q

What is the percentage of spontaneous preterm labours the infection is responsible for ?

A

20 - 40 % of them

26
Q

What is the recurrence rate of PTL if one , two , three prior consecutive Preterm deliveries?

A

After 1 preterm delivery 16- 19%
2 preterm deliveries 32 - 41 %
3 preterm deliveries 67%

27
Q

Which is the most important factor that will predict preterm labour in the upcoming pregnancy ?

A

Previous preterm labour

28
Q

What are the risk factors for spontaneous preterm labor?

A

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

29
Q

At what gestational age fetal fibronectin can predict preterm birth?

A

22 - 34 w

30
Q

What are the contraindications to do fetal fibronectin test?

A

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

31
Q

When should nifedipine as a tocolytic drug be avoided?

A

1- cardiac disease
& care should be taken in
Diabetes + multiple pregnancy
( reports of pulmonary edema)

32
Q

When should a history- indicated cervical cerclage be offered?

A

1- 3 or more previous preterm birth
OR
2- 2nd trimester losses

33
Q

If miscarriage (or fetal death ) occurs in women of abdominal cerclage , what is the management?

A

🚩Up to 18 w 👉 evacuation through the stitch by suction or D&C
🚩 posterior colpotomy
🚩or hysterotomy
🚩or CS

34
Q

What is the period of time “rescue cervical cerclage” may delay birth by ,compared with expectant management?

A

4 - 5 weeks

35
Q

Rescue cervical cerclage may be associated with a reduction in PT birth, how much is the reduction?

A

2 folds reduction in the chance of birth before 34w

36
Q

In women with cervical cerclage + P PROM between 24 -34 w , what is the management?

A

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

37
Q

How should preterm labour be managed in women without known GBS colonization?

A

IAP is recommended for women in confirmed preterm labour
⚠️ not recommended for women not in labour & having planned CS with intact membranes

38
Q

History of spontaneous preterm birth or mid trimester losses without shortness of cervical length?

A

Prophylactic vaginal progesterone

23- Obstetric Complications (6 decks)

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