Delivery Before Term

Question 1

What is the definition of delivery before term?

Answer 1

Delivery at 24-37 weeks gestation, either spontaneous or iatrogenic.

Question 2

What time scales are considered very premature and miscarriage?

Answer 2

1. <34 weeks - very premature

2. <24 weeks - miscarriage

Question 3

What are the causes of delivery before term?

Answer 3

1. 40% unknown cause
2. Multiple pregnancy, polyhydramnios, pre-eclampsia, IUGR, infection, placental abruption.
3. Uterine abnormalities, cervical incompetence.
4. Infection (BV, GBS, trichomonas, chlamydia)
5. UTI, poor dental hygiene

Question 4

What are the risk factors for delivery before term?

Answer 4

History or preterm delivery, extremes of maternal age, short interpregnancy interval, CKD, DM, thyroid disease, PET, IUGR, high Hb, male, STI, UTI, cervical surgery, multiple pregnancy, uterine abnormalities, polyhydramnios, congenital foetal abnormalities, antepartum haemorrhage.

Question 5

How is delivery before term prevented?

Answer 5

1. Cervical cerclage (keep closed)
2. Progesterone supplementation
3. Treat infection
4. Foetal reduction
5. Polyhydramnios treatment

Question 6

What is this a presentation of?

Painful contraction, stops spontaneously in 50%, fluid loss could be present, dilated cervix, 35/40.

Answer 6

Potential for delivery before term.

Question 7

How would you assess the likelihood of delivery in potential preterm delivery?

Answer 7

1. If cervix unaffected - foetal fibronectin assay (should not be in vaginal secretion until 36/49.
2. If negative, preterm delivery unlikely
3. TV USS to assess cervical length, >15mm = unlikely to deliver.

Question 8

How would you assess foetal state in potential preterm delivery?

Answer 8

CTG and USS

Question 9

How would you assess infection in potential preterm delivery?

Answer 9

1. Vaginal swabs
2. Urinalysis and dip
3. CRP and WCC

Question 10

What are the five aspects of management in preterm delivery?

Answer 10

1. Steroids
2. Tocolysis
3. Infection treatment
4. Magnesium sulphate
5. Delivery

Question 11

What is the steroid regime for preterm delivery?

Answer 11

1. Give between 23-34 weeks, IM betamethasone

2. Takes 24 hours to work so delivery is delayed using tocolysis

Question 12

What is the tocolysis regime for preterm delivery?

Answer 12

1. Nifedipine or oxytocin receptor antagonist
2. Allows steroids time to act
3. Delay labour, do not stop it
4. Maximum use of 24 hours, do not use in infection

Question 13

What is magnesium sulphate used for in preterm delivery and what is the regime?

Answer 13

1. Neuroprotective for neonate
2. Give <12 hours prior to planned delivery
3. 4g IV between 23-34 weeks

Question 14

What is the benefit of a vaginal preterm delivery?

Answer 14

Reduces neonatal respiratory distress syndrome

Question 15

What should you do with babies born <28/40?

Answer 15

Wrap in plastic bag and kept under heat, 3 min delay in cutting cord (unless resus needed).

Question 16

What is the definition of preterm rupture of membranes?

Answer 16

Membranes rupture before labour at <37/40.

Question 17

What are the complications of preterm rupture of the membranes?

Answer 17

1. Preterm labour
2. Chorioamnionitis
3. Cord prolapse

Question 18

What are the clinical features of preterm rupture of membranes and chorioamnionitis?

Answer 18

1. Gush of clear fluid, followed by further leaking.

2. Abdominal pain, fever, tachycardia, coloured/offensive liquid.

Question 19

What are the steps of investigation after a suspected preterm rupture of membranes?

Answer 19

1. Confirm with Actim Partus test
2. High vaginal swab, FBC, CRP, temperature, MSU
3. CTG - persistent tachycardia suggests infection

Question 20

What is the management of preterm rupture of membranes?

Answer 20

1. Admit for 48 hours
2. Give steroids and erythromycin 500mg QDS for 2 weeks.
3. If infection - IV Abx and deliver regardless of gestation
4. If labour does not occur spontaneously after 48 hours - discharge, weekly follow up, aim to deliver by 34/40.