Preterm labor: Difference between revisions
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==Background== | ==Background== | ||
*Defined as labor before 37 weeks (uterine | *Defined as labor before 37 weeks (uterine contraction and cervical change) | ||
*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 | *Can be triggered by infections, stress, HTN, uncontrolled DM | ||
==Clinical Presentation== | ==Clinical Presentation== | ||
*Similar to term labor | *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== | ==Differential Diagnosis== | ||
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==Diagnosis== | ==Diagnosis== | ||
*Do NOT perform digital exam in patients who present with vaginal bleeding when >20 weeks pregnant | *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 | *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 | *Swabs for fetal fibernectin, Group B strep should also precede digital exam | ||
**Some lubricants can affect FFN and amniotic fluid pH strip | |||
*Proceed with digital exam if placental previa unlikely, and digital exam is urgently needed to assist patient care, such as in fetal HR decels | *Proceed with digital exam if placental previa unlikely, and digital exam is urgently needed to assist patient care, such as in fetal HR decels | ||
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*U/S to assess placental position / fetal position | *U/S to assess placental position / fetal position | ||
*Digital exam to assess cervical thickness, effacement, rupture of membranes | *Digital exam to assess cervical thickness, effacement, rupture of membranes | ||
*CBC, Chem, Coags, U/A w/ culture, Utox (cocaine increases risk of abruption) | *Type and Screen, CBC, Chem 10, Coags, U/A w/ culture, Utox (cocaine increases risk of abruption) | ||
===Cervical length=== | ===Cervical length=== | ||
* >30mm - Labor less likely | *>30mm - Labor less likely | ||
**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 | ||
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==Disposition== | ==Disposition== | ||
*Admission to OB floor for delivery, or transfer to facility to manage delivery | |||
* | |||
*If cervix >30mm, ctx have stopped, consider 6 hours of obs | *If cervix >30mm, ctx have stopped, consider 6 hours of obs | ||
Revision as of 09:40, 22 March 2015
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, 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
Vaginal Bleeding in Pregnancy (>20wks)
- Emergent delivery
- Placental abruption
- Placenta previa
- Vasa previa
- Uterine rupture
- Preterm labor
- Vaginal trauma
- Placenta accreta
- Intrauterine fetal demise
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
- Some lubricants can affect FFN and amniotic fluid pH strip
- 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
- Type and Screen, CBC, Chem 10, Coags, U/A w/ culture, Utox (cocaine increases risk of abruption)
Cervical length
- >30mm - Labor less likely
- Observation of 6 hours might be appropriate
- 20-30mm - Increased risk for preterm labor
- Fetal fibernetin result can assist, if over 50ng/ml manage labor actively
- <20mm - labor very likely
- Manage actively
Management by Weeks
- 24-32 weeks
- Mag sulfate (neuroprotection against cerebral palsy)
- <34 weeks
- Betamethasone, and hospitalization
- Tocolytics
- Antibiotics for GBS prophylaxis if status unknown
- Other abx only indicated in setting of active infx
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
- 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"