Preterm labor: Difference between revisions
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Revision as of 14:23, 21 March 2015
Background
- Defined as labor before 37 weeks (uterine ctx and cervical change)
- Increased risks to child depending on age of fetus
- Cerebral palsy, poor lung development, cognitive delay, etc
- Can be triggered by maternal infx, stress, HTN, uncontrolled DM
Clinical Presentation
- 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
Diagnosis
- Do NOT perform digital exam in patients who present with vaginal bleeding when >20 weeks pregnant
- Start with ultrasound to assess position of cervix and r/o placenta previa
- Swabs for fetal fibernectin, Group B strep should also precede digital exam
- 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, ABCs
- Fetal Heart Monitor
- U/S to assess placental position / fetal position
- Digital exam to assess cervical thickness, effacement, rupture of membranes
- CBC, Chem, Coags, U/A w/ culture, Utox (cocaine increases risk of abruption)
- Cervical length >30mm - Labor less likely
- Observation of 6 hours might be appropriate
- Cervical length 20-30mm - Increased risk for preterm labor
- Fetal fibernetin result can assist, if over 50ng/ml manage labor actively
- Cervical length <20mm - labor very likely
- Manage actively
- <34 weeks
- Betamethasone, and hospitalization
- Tocolytics
- Antibiotics for GBS prophylaxis if status unknown
- Other abx only indicated in setting of active infx
- 24-32 weeks
- Mag sulfate (neuroprotection against cerebral palsy)
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 tx of reversible condition possibly triggering labor (UTI/pyelo)
- Betamethasone requires approx 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
- Intratuterine fetal demise / lethal anomaly
- Maternal hemorrhage or instability
- Intraamniotic infx
- Severe preeclampsia or eclampsia
- Nonreassuring fetal status
- Contraindications to the drugs
- Medications
- Indomethacin 50-100mg loading dose, 25mg q4-6 hrs for 48 hrs
- 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
- Patient will need admission to OB floor for delivery, or transfer to facility to manage delivery
- If cervix >30mm, ctx have stopped, consider 6 hours of obs
See Also
External Links
References
UpToDate "Overview of preterm labor and birth"
UpToDate "Inhibition of acute preterm labor"