Preterm labor: Difference between revisions
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*Increased risks to child depending on age of fetus | *Increased risks to child depending on age of fetus | ||
**Cerebral palsy, poor lung development, cognitive delay, etc | **Cerebral palsy, poor lung development, cognitive delay, etc | ||
*Can be triggered by infections, stress, | *Can be triggered by infections, stress, hypertension, uncontrolled DM | ||
==Clinical | ==Clinical Features== | ||
*Similar to term labor | *Similar to term labor | ||
*Uterine contractions q 10 min (may be irregular) | *Uterine contractions q 10 min (may be irregular) | ||
*New onset of vaginal mucus, blood, pink discharge, amniotic fluid | *New onset of vaginal mucus, [[vaginal bleeding|blood]], pink discharge, amniotic fluid | ||
*Low back ache, vaginal pressure | *Low [[back pain|back ache]], vaginal pressure | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{VB DDX greater than 20}} | {{VB DDX greater than 20}} | ||
== | ==Evaluation== | ||
*Do NOT perform digital exam in patients who present with vaginal bleeding when >20 weeks pregnant | *Type and Screen, CBC, Chem 10, Coags, U/A with culture, Utox (cocaine increases risk of abruption) | ||
*Start with ultrasound to assess position of cervix and | *Do NOT perform digital exam in patients who present with vaginal bleeding when >20 weeks pregnant due to potential for placenta previa | ||
*Start with ultrasound to assess position of cervix and rule out placenta previa | |||
*Swabs for nitrazine, fetal fibronectin (FFN), GBS culture should also precede digital exam | *Swabs for nitrazine, fetal fibronectin (FFN), GBS culture should also precede digital exam | ||
**Some lubricants can affect FFN and amniotic fluid pH strip | **Some lubricants can affect FFN and amniotic fluid pH strip | ||
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==Management== | ==Management== | ||
*IV access, ABCs | *IV access x2, ABCs | ||
*Fetal | *Fetal heart monitor | ||
* | *Immediate obstetrical consult | ||
===Cervical length=== | ===Cervical length=== | ||
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**Observation of 6 hours might be appropriate | **Observation of 6 hours might be appropriate | ||
*20-30mm - Increased risk for preterm labor | *20-30mm - Increased risk for preterm labor | ||
**Fetal | **Fetal fibronectin result can assist, if over 50ng/ml manage labor actively | ||
*<20mm - labor very likely | *<20mm - labor very likely | ||
**Manage actively | **Manage actively | ||
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===Management by Weeks=== | ===Management by Weeks=== | ||
*24-32 weeks | *24-32 weeks | ||
** | **[[Magnesium sulfate]] (neuroprotection against cerebral palsy) | ||
*<34 weeks | *<34 weeks | ||
**Betamethasone | **Hospitalization | ||
**Tocolytics | **[[Betamethasone]] 12mg IM q24hrs x2 doses | ||
**Antibiotics for GBS prophylaxis if status unknown | **Tocolytics (see below for options/dosages) | ||
**Other | **[[Antibiotics]] for GBS prophylaxis if status unknown | ||
**Other antibiotics only indicated in setting of active infection | |||
===Tocolysis=== | ===Tocolysis=== | ||
====Indications==== | |||
*Only if fetus would benefit from delay in delivery of 48 hrs | |||
*Gestational age 22wks - 34 wks | |||
*Transport to facility for definitive delivery | |||
*Delay in delivery for treatment of reversible condition possibly triggering labor (UTI/pyelo) | |||
**Betamethasone requires approximately 48 hrs for maximal benefit for lung maturity, reducing intraventricular hemorrhage, NEC, and death | |||
**Tocolysis rarely effective for longer than 48 hrs | |||
**Does not remove underlying cause for tocolysis | |||
====Contraindications==== | |||
* | *Intrauterine fetal demise / lethal anomaly | ||
*Maternal [[vaginal bleeding in pregnancy (greater than 20wks)|hemorrhage]] or instability | |||
* | *[[chorioamnionitis|Intraamniotic infection]] | ||
*Severe [[preeclampsia]] or [[eclampsia]] | |||
*Nonreassuring fetal status | |||
*Contraindications to the drugs | |||
====Medications==== | |||
*[[Indomethacin]] 50-100mg loading dose, 25mg q4-6 hrs for 48 hrs. (avoid in gestation >32 weeks for concern of premature narrowing or closure of the ductus arteriosus) | |||
*[[Nifedipine]] 20mg x1, additional 20mg dose in 90min if ctx persist, followed by 20mg q3-8 hrs PRN ctx | |||
*[[Terbutaline]] 0.25mg sq q20-30 min up to 4 doses PRN ctx | |||
==Disposition== | ==Disposition== | ||
*Admission to OB floor for delivery, or transfer to facility to manage delivery | *Admission to OB floor for delivery, or transfer to facility to manage delivery | ||
*If cervix >30mm, | *If cervix >30mm, contractions have stopped, consider 6 hours of obs | ||
==See Also== | ==See Also== | ||
*[[Vaginal Bleeding (Main)]] | *[[Vaginal Bleeding (Main)]] | ||
*[[Pregnancy (main)]] | |||
==External Links== | |||
==References== | ==References== | ||
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*UpToDate "Overview of preterm labor and birth" | *UpToDate "Overview of preterm labor and birth" | ||
*UpToDate "Inhibition of acute preterm labor" | *UpToDate "Inhibition of acute preterm labor" | ||
[[Category:OBGYN]] |
Revision as of 19:04, 15 April 2020
Background
- Defined as labor before 37 weeks (uterine contraction and cervical change)
- Increased risks to child depending on age of fetus
- Cerebral palsy, poor lung development, cognitive delay, etc
- Can be triggered by infections, stress, hypertension, uncontrolled DM
Clinical Features
- Similar to term labor
- Uterine contractions q 10 min (may be irregular)
- New onset of vaginal mucus, blood, pink discharge, amniotic fluid
- Low back ache, vaginal pressure
Differential Diagnosis
Vaginal Bleeding in Pregnancy (>20wks)
- Emergent delivery
- Placental abruption
- Placenta previa
- Vasa previa
- Uterine rupture
- Preterm labor
- Vaginal trauma
- Placenta accreta
- Intrauterine fetal demise
Evaluation
- Type and Screen, CBC, Chem 10, Coags, U/A with culture, Utox (cocaine increases risk of abruption)
- Do NOT perform digital exam in patients who present with vaginal bleeding when >20 weeks pregnant due to potential for placenta previa
- Start with ultrasound to assess position of cervix and rule out placenta previa
- Swabs for nitrazine, fetal fibronectin (FFN), GBS culture should also precede digital exam
- Some lubricants can affect FFN and amniotic fluid pH strip
- Nitrazine test (5% FP rate, 1% FN rate) - pH swab turns blue, indicating alkalotic amniotic fluid (pH 6.5 - 7.5 positive test); do not touch to mucous plug in cervix[1]
- Proceed with digital exam if placental previa unlikely, and digital exam is urgently needed to assist patient care, such as in fetal HR decels
Management
- IV access x2, ABCs
- Fetal heart monitor
- Immediate obstetrical consult
Cervical length
- >30mm - Labor less likely
- Observation of 6 hours might be appropriate
- 20-30mm - Increased risk for preterm labor
- Fetal fibronectin result can assist, if over 50ng/ml manage labor actively
- <20mm - labor very likely
- Manage actively
Management by Weeks
- 24-32 weeks
- Magnesium sulfate (neuroprotection against cerebral palsy)
- <34 weeks
- Hospitalization
- Betamethasone 12mg IM q24hrs x2 doses
- Tocolytics (see below for options/dosages)
- Antibiotics for GBS prophylaxis if status unknown
- Other antibiotics only indicated in setting of active infection
Tocolysis
Indications
- Only if fetus would benefit from delay in delivery of 48 hrs
- Gestational age 22wks - 34 wks
- Transport to facility for definitive delivery
- Delay in delivery for treatment of reversible condition possibly triggering labor (UTI/pyelo)
- Betamethasone requires approximately 48 hrs for maximal benefit for lung maturity, reducing intraventricular hemorrhage, NEC, and death
- Tocolysis rarely effective for longer than 48 hrs
- Does not remove underlying cause for tocolysis
Contraindications
- Intrauterine fetal demise / lethal anomaly
- Maternal hemorrhage or instability
- Intraamniotic infection
- Severe preeclampsia or eclampsia
- Nonreassuring fetal status
- Contraindications to the drugs
Medications
- Indomethacin 50-100mg loading dose, 25mg q4-6 hrs for 48 hrs. (avoid in gestation >32 weeks for concern of premature narrowing or closure of the ductus arteriosus)
- Nifedipine 20mg x1, additional 20mg dose in 90min if ctx persist, followed by 20mg q3-8 hrs PRN ctx
- Terbutaline 0.25mg sq q20-30 min up to 4 doses PRN ctx
Disposition
- Admission to OB floor for delivery, or transfer to facility to manage delivery
- If cervix >30mm, contractions have stopped, consider 6 hours of obs
See Also
External Links
References
- ↑ Nitrazine Test. https://www.pathology.med.umich.edu/poc/onsite/pH-amniotic.html
- UpToDate "Overview of preterm labor and birth"
- UpToDate "Inhibition of acute preterm labor"