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what is the definition of preterm delivery?
24 - 37 weeks
when is preterm delivery most important?
before 34 weeks as this is when neonatal risks are higher
before 24 weeks what is labour the same as?
what % of deliveries are preterm?
what are the risk factors for premature labour?
- PREVIOUS PRETERM LABOUR!!!
- 1. low social class
- 2. extremes of age
- 3. low BMI < 19
- 4. short inter-pregnancy interval
- 5. maternal medical disease
- 6. pregnancy complications eg PET
- 7. smoking
- 8. bacterial vaginosis
- 9. blacks
what are the causes of preterm labour? think Is
- 1. infection: chorioamnionitis, maternal pyelonephritis, maternal appendicitis. STI (chlam gon), GBS heavy growth, BV, enteric
- 2. ischaemia: uteroplacental eg abruption
- 3. increased distension: polyhydramnios, multiple pregnancy
- 4. incompetence of cervix
- 5. iatrogenic: interests of fetes eg IUGR, mother eg PET (delivery is only cure)
which Ix can predict preterm labour?
- transvaginal scan: measure cervical length
- need to have empty bladder
how is preterm labour prevented?
- 1. cervical cerclage: suture to strengthen it and keep it closed. elective at 12-14 weeks if previous hx of incompetence; if significant shortening on scan; rescue suture when incompetent cervix is dilated
- 2. infection: treat STIs and BV
- 3. fettle reduction: reduce higher order multiples at 10-14 weeks
- 4. treat polyhydramnios - needle aspiration (amnioreduction) or NSAIDs which reduce fettle urine output BUT may cause premature closure of fettle ductus arterioles
- 5. progesterone supplementation: suppositories from early pregnancy reduce risk of preterm in high risk women
what are the symptoms of preterm labour?
- 1. painful contractions (in over half - contractions will stop spontaneously and labour at term)
- 2. painless cervical dilatation in cervical incompetence
- 3. APH, fluid loss - ROM
what should be monitored in a patient with preterm labour?
- 1. temperature
- 2. abdominal tenderness
- 3. lie and presentation
- 4. fettle heart rate
- 5. maternal pulse
- 6. checking for vaginal loss - avoid VE
which investigations are done in preterm labour?
- 1. CTG - assess fettle state
- 2. to assess likelihood of DELIVERY: if cervix is UNEFFACED, fettle fibronectin. high NPV (-ve FFN means delivery is unlikely)
- 3. TVS of cervical length. if long > 15mm, delivery extremely unlikely
- 4. infection: high vaginal swabs using STERILE SPECULUM if ROM,
- 5. CRP rises with chorioamnionitis
- 6. WCC may be high due to steroids
name 3 aspects to the management of preterm labour?
- 1. steroids: dexamethasone 10mg x 2 12 hours apart to reduce RDS as increase fettle surfactant production
- 2. tocolysis eg oxytocin antagonist atosiban (or salbutamol, terbutaline, NSADs but used less as SE). tocolysis for 2 purposes: time for steroids to work, time for in uteri transfer to unit where neonatal care facilities
- 3. antibiotics esp if suspect chorioamnionitis or ROM give erythromycin
- INFORM PAEDS ALWAYS
which type of assisted delivery is contraindicated in preterm labour?
what is preterm prelabour ROM?
- when membranes rupture BEFORE LABOUR at < 37 weeks
- happens in 1/3 of preterm deliveries
what are the complications of PROM?
- 1. preterm delivery happened in 48h in >50% of cases
- 2. INFECTION: fetus, placenta (chorioamnionitis), cord (funisitis)
- 3. PROLAPSE of umbilical cord
- 4. pulmonary hypoplasia and postural deformities if absence of liquor
in PROM why would you want to do a VE?
to exclude cord prolapse if presentation is NOT CEPHALIC
what are the signs of chorioamnionitis?
- 1. contractions or abdominal pain
- 2. fever
- 3. tachycardia
- 4. uterine tenderness
- 5. coloured or offensive liquor
what are signs of PROM?
- gush of clear fluid and further leaking
- speculum: pool of fluid in posterior fornix
in PROM, what Ix should be done?
- 1. USS: hoe much fluid, but may be normal if fettle UO continues
- 2. infection: HVS, FBC, CRP, amniocentesis with gram stain and culture
- 3. CTG: persistent tachycardia suggests infection
what is management of PROM?
- need to balance risk of preterm delivery v risk of infection which will increase neonatal mortality and morbidity long term
- close observation: maternal - look for signs of infection; fettle: CTG
- if reaches 36 weeks do IOL
if signs of chorioamnionitis appear, what is management?
- iv antibiotics immediately
- fetes is delivered whatever the gestation as abx alone wont eliminate the chorioamnionitis
how is infection prevented in women with PROM?
prophylactic erythromycin in women even if no signs of infection
which antibiotic should not be used and why?
- co-amoxiclav is contraindicated
- neonate more prone to NEC: necrotising entero colitis
in preterm labour, why would LSCS be difficult?
- as the lower segment of the uterus is poorly formed at early gestations
- so classical incisions may have to be made by this means higher risk of uterine rupture in next pregnancy
why is epidural analgesia advocated in preterm labour?
- avoid expulsive efforts before full dilatation
- relax pelvic floor and perineum
which 2 types of communication is essential in preterm labour?
- 1. to parents: understand risks involved and clear management plan
- 2. to neonatologists ensure adequate resources