MRCOG - Part 2 > Preterm labor > Flashcards

Preterm labor Flashcards

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1
Q

What is suspected PTL

A

Suspected - symptoms of PTL with clinical assessment suggestive of PTL

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2
Q

Diagnosed PTL

A

Diagnosed - suspected PTL with positive diagnostic test for PTL

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3
Q

Established PTL

A

Established - regular uterine contractions with progressive cervical dilatation from 4 cm

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4
Q

How many preterm births are planned births?

A

25%

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5
Q

Who are at risk of PTL ?

A

Previous preterm births <34 wks
Previous pregnancy loss from 16 wks onwards
Previous PPROM
History of cervical trauma
Current pregnancy CL <=25 mm

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6
Q

For whom to Offer prophylactic vaginal progesterone or prophylactic cervical cerclage?

A
  • a history of spontaneous preterm birth (up to 34+0) or loss (from 16+0 onwards) AND
  • TVS carried out between 16+0 and 24+0 that show a cervical length of 25 mm or less

Consider prophylactic vaginal progesterone for women who have either of the above two

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7
Q

When to perform history indicated cerclage

A

At 11-14 w

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8
Q

most common cardiac SE of atosipan

A

tachycardia
others:
1. chest pain
2. palpitation

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9
Q

the recommended tocolytic in PTL is

A

Nifedipine

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10
Q

most common long term consequence of prematurity

A

Neurodevelopmental disability

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11
Q

Categories of PTL

A
  1. Symptoms of PTL: <37w , no examination done
  2. Suspected: symptoms+ clinical assessment
  3. Diagnosed PTL: suspected+ +ve diagnostic test( tvs for CL + f. Fibrobectin)
  4. Established: progressive cx dilatation >4cm + contractions
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12
Q

What is PPROM

A

Rom <37w not in established labor

Affects 3% of pregnancy

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13
Q

Prerequisites to do rescue cerclage

A

Only if no contraction or infection

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14
Q

Giving corticosteroids 7 days prior to PTL benefits

A

Reduces
1. Perinantal and neonatal mortality & RDS
2. Intraventricular hmge
3. Developmental delay

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15
Q

When to give corticosteroids in PTL

A

Most benefit: 22-34+6

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16
Q

Risks of corticosteroids in 22-34+6

A
  • affect GTT up to 5 days after admin.
  • dec birth weight of birth >7d of admin
  • no benefit if birth >7 d
  • inc psychiatric and behavioral diagnosis if birth at term
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17
Q

Risks of corticosteroids if taken 35-36+6

A
  • inc neonatal hypoglycemia 24%
  • inc psychiatric and behavioral diagnosis if born at term
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18
Q

Risks of giving corticosteroids in planned CS 37-39w

A

May reduce educational attainment at school age

Benefits: dec NNU admission by respiratory morbidity from 0.5 to 0.2%

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19
Q

What if i give corticosteroids in ptl >7d ago and i need to repeat and what is the risk of giving multiple courses

A

Give rescue course

Reduce:
birth weight 80gm
Head circumference
Neonatal blood pressuref

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20
Q

Corticosteroid administration in DM patients

A

Corticosteroid + additional insulin + close monitoring

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21
Q

Administration of corticosteroids in diabetic patients at term may cause

A

Inc rates of neonatal hypoglycemia

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22
Q

PPROM IS ASSOCIATED WITH WWHAT PERCENT OF PTL

A

30-40%
So offer corticosteroids to women with PPROM

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23
Q

Do corticosteroids benefit women giving virth after 37 weeks

A

No evidence

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24
Q

Dose of corticosteroids ptl

A

24 mg dexamethasone IM
ON 2 divided doses every 12/24hrs
Or 4 divided doses 6mg every 12 hours (most used in trials)

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25
How long after afmin of antenatal corticosteroids is effective
If birth bet 24 h and 7 d of admin of 2nd dose of Antenatal corticosteroids If delivered after a week she will take SE only
26
CI OF ANTENATAL CORTICOSTEROIDS
1. Serious maternal or fetal concerns tagt will increase by expedited birth 2. Systemic infection
27
Max number pf corticosteroid doses
3
28
When to perform TVS for CL assesement
14-24 w with empty bladder
29
What is history indicated cerclage
- prophylactic cerclage as a result of factors in a obstetric or gynaecological history, increase the risk of spontaneous second trimester loss or preterm birth in asymptomatic women at 11-14 weeks. History of 3 or more PTL ending bef 37w
30
Ultrasound indicated cerclage
therapeutic cerclage in cases of CL shortening on TVS. In asymptomatic women who do not have exposed fetal membranes. TVS assessment of the cervix is usually performed 14 - 24 weeks with an empty bladder.
31
What is emergency cerclage
premature cervical dilatation with exposed fetal membranes in the vagina. discovered by TVS or speculum/physical examination. It can be considered up to 27+6 weeks gestation.
32
Types of cerclage
1. Mcdonald (transvaginal) 2. Shirodkar (high transvaginal rquiring bladder mobilization) 3. Trans abdominal cerclage 4. Occlusion cerclage: obsolete
33
Mcdonald cerclage
transvaginal purse-string suture placed at the cervical isthmus junction, without bladder mobilization.
34
Shirodkar cerclage
A transvaginal purse-string suture placed following bladder mobilization, to allow insertion above the level of the cardinal ligaments.
35
Transabdominal cerclage
laparotomy ordaparoscopy. placing the suture at the cervicoisthmic junction.
36
What if CL<25 mm with no other obstetrics risk factors
No need for cerclage Only vaginal progeaterone
37
Woman w hx of 1 or 2 spontaneous 2nd trimester loss orPTL CL<25 mm
Should have cercalge before 24w
38
Do we do cerclage in case of funneling w/o CL<25 mm
No us indicated cercalge
39
Do funneling inc risk of PTL ASSOCIATION W CL
no
40
What is funneling
Dilatation of the internal os on us
41
How to measure cx length in case of funneling
Measure the functional length not the funneling length
42
Who needs serial CL assessment by TVS
- hx of spontaneous 2nd trimester loss Or PTL :who didn’t have hx indicated cerclage, so she can benefit from US indicated cerclage if <25 mm
43
Woman at intermediate risk of of PTL
- hx of pvs full dilatation CS - significant cervical excisional surgery: LLETZ depth>1 cm - > 1 procedure - cone biopsy Single TVS CL 18-22w
44
Woman at high risk of of PTL
- previous preterm birth or second trimester loss (16-34 weeks' gestation) - previous (PPROM) less than 34 weeks - previous use of cerclage - known uterine variant - intrauterine adhesions - history of trachelectomy. Serial TVS CL every 2-4 w between 16-24
45
Is cerclage effective in women with high BMI e
Yes
46
Indication of transabdominal cercalge
Women with pvs unsuccessful TV cercalge Performed preconception or in early pregnancy
47
Anterior and posterior knots of abdomianl cerclage
Ant: less adhesions but risk of erosion into bladder Post: more adhesions but easily removed by colpotomy to allow vaginal delivery
48
What to use un cerclage mersilene or prolene
Mersilene is better: doesn’t cut in uterine tissue of there is contractions but may cause fibrosis and hard to remove Prolene: easier to insert and remove but it cut through uterine tissue
49
What is interval cerclage
Operation done between pregnancies
50
When to do ceclage
9-12 w (early operation is better esp if there is multiple preg) Interval operation: easier- less fetal loss
51
How to remove cercalge anterior knots
By hysterotomy
52
How to evacuate miscarriage on a cerclage
<18w: Through the stitch by suction curettage or D&C >18w: Posterior knots: Cut suture via posterior colpotomy Anterior knot: hysterotomy or CS
53
Prerequisites of Rescue cerclage
1. <28 w 2. Living baby 3. No CI to extend pregnancy 4. No infection or contraction
54
# **RECALL** How long does rescue cerclage delay birth
5 weeks (34 days)
55
Investigations to be done before cerclage
1. 1st trimester US 2. Screening for aneuploidy 3. TLC and CRP: if signs of chorioamnionitis (Crp<4 and tlc<14000: better outcome)
56
Do we need sexual intercourse abstinence after cerclage
Should not be routinely recommended
57
Should women receive supplement progesterone ecologists following cerclage?
No
58
When to remove cercalge
Planned delivery VD: 36+1-37w CS: remove at CS Established PTL: remove stitch If transabdomina cerclage: birth by CS and may leave suture in place
59
WHEN TO REMOVE CERCLAGE WITH PPROM
If 24-34w : delay removal 48 hr useful Bef 24- after 34: delay not useful
60
Each 1 ml LLETZ inc prematurity risk by
6%
61
Indications of abdominal cerclage
1. a grossly disrupted cervix 2. an absent vaginal cervix, 3. previous failed elective vaginal cerclage.
62
Successful preganncy rate after abdominal cerclage
85%
63
Diagnosis of suspected PTL
<30w: tocolysis + corticosteroids >30w: Tvs CL: >15: not PTL - <15: ttt as PTL fetal fibronectin: <50: NOT PTL - >50: PTL
64
When to offer nifedipine in PTL
24-25+6: consider in PTL + intact membrane 26-33+6: offer in PTL + intact membrane
65
Risk of nifidipine before 34 w
Inc risk of chorioamnionitis
66
Do we gove tocolysis in PPRom
Insufficient evidence, inc tisk of chorioamnionitis
67
Suspecting PPROM WHAT TO DO
Symptoms suggests PPROM -> casco exam -> pooling is absent -> amnisure or actinRom test -> if ve :: PPROM If there is pooling : PPROM
68
Most women enter labor after how long of ROM
A week or less
69
Do women of PPROM need hospitalization
No benefit Home risk of cord prolapse if malpresentation is present
70
The only reliable indicator for diagnosis of chorioamnionitis
Fever > 38 w + ROM Leckocytosis alone not reliable
71
What to do if chorioamnionitis is diagnosed
Delivery preffered vaginally
72
What antibiotoic prophylaxis that we give with PPROM
Erythromycin 250 mg 4 times a day Or Oral penicillin (2nd line) for max 10 days or until woman in established labour (whatever sooner)
73
Do TLC increases after corticosteroids
Yes in 24 hours and return to baseline after 3 days
74
Benefit of using tocolysis in PTL
Prolongation of pregnancy 7days
75
When to give MGSO4 in PTL
Women in established labour or have planned PTL WITHIN 4-24 hours 24-29+6: offer 30-33+6 consider
76
MgSO4 dose in PTL
4g IV bolus over 15 mins then 1 gm/hr for 24 hours or until birth Monitor signs of toxicity every 4 hrs (pulse, BP, RR, tendon reflexes)
77
Benefits of mgso4 in ptl
- reduces CP - reduces motor dysfunction More benefits <30 w
78
At what GA we use fetal scalp elctrode or FBS
Not before 34 w
79
When to clamp cord in preterm babies
Wait one minute
80
Fetal monitoring after PPROM
- fetal growth: fortnghtly - AFV & UAD: weekly
81
Whata ge to perofrm rescue cerclage
16-27+6
82
when to remove cerclege in case of PPROM + suspected infection
Remove immediately
MRCOG - Part 2
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