(IV) Early and late preg pt 2

when do symptoms of preterm labor occur?

after 20 weeks but before 37 weeks (20-37 weeks)

preterm labor contractions are regular and at frequent intervals.

Not necessarily painful at first

how many contractions per hour is needed to cause cervical change?

> 4 contractions/hr

what MUST be demonstrated in order to diagnose preterm labor and not just Braxton Hix contractions?

Cervical effacement and dilation

at how many weeks is considered a preterm birth?

before 37 weeks = preterm

what is the MCC of neonatal morbidity and mortality?

preterm birth

why is the MCC of preterm birth mortality?

mostly spontaneous:

- preterm labor

- PPROM

- cervical insufficiency

- placental abruption

what is a less common cause of preterm birth mortality

medical conditions that jeopardize health

most preterm births occur between _____________ weeks

32-36 weeks

what are the 5 major r/f for a preterm birth?

- obstetric hx

- extremities of age (

- HTV/CKD/DM

- asxs bacteremia

- GU infection

what are the 3 obstetric r/fs for a preterm birth

- hx preterm birth

- assisted reproduction

- multifetal gestation

how are the sxs for a preterm labor different from a term labor in the 1st stage - active phase?

they have the same sxs

what are the prodromal sxs like for preterm and term labors? (6)

- menstrual-like cramping

- mild/irregular contractions

- low back ache

- pressure in vagina/pelvis

- passage of mucus plug

- spotting

if the sxs of preterm and term labor are the same, how do you distinguish them?

Rate of change of cervical ripening

- preterm = days/weeks

- true = minutes/hours

1st manifestation of preterm labor?

short/dilated cervix

what are the 2 goals of evaluating a woman in possible labor?

- identify true preterm labor

- improve neonatal outcome

what do you use to perform a speculum exam when evaluating for true pre term labor?

use a sterile wet NON-LUBRICATEDspeculum

what cervical dilation (in cm) means preterm labor?

>= 3 cm

during the speculum exam, the cervicovaginal swab is rotated for _______ in posterior fornix (for fFN)

10 seconds

when is the digital vaginal exam done if evaluating for preterm labor?

after ROM/placenta previa excluded

what addition test do you get to evaluate a preterm labor (other than speculum and digital)?

- US (TV, abdominal)

- GBS swap of rectovagina

- urine culture

- STI testing (if +r/f)

- fetal fibronectin ( fFN) (in select cases)

a cervix less than _________ on TVUS is considered short

< 30mm

Extravillous protein present at decidual-chorionic interface.

Acts as a "glue" between amniotic sac and uterine lining

fetal fibronectin ( fFN)

why do we test for fFN?

- is a marker for helping to predict preterm birth

- infection/inflammation/contractions can release fFN into cervicovaginal secretions

Who should get the fFN test?

(all must be +)

-

what is the dx criteria for preterm labor? (4)

- uterine contractions >= 6 in 1 hour PLUS

- cervical dilation >= 3 cm OR

- cervical length < 20 mm on TVUS OR

- cervical length 20 to < 30 mm on TVUS with positive fFN

preterm labor is how many weeks?****

< 34 weeks

if pt is >34 weeks, should you admit the pt or send home?

admit

once admitted, and if there is no progression after 4-6 hrs, send home or observe?

send home

* if fetal well-being confirmed and obstetric complications ruled out

once admitted, and there IS progression of labor, what do you do?

manage the labor and delivery

if a pt is < 34 weeks and is in labor, should you send home or admit for observation?

admit for observation?

if the pt is

preterm labor

if the pt is >= 34 weeks and her cervical dilation >= 3 cm, is this preterm labor or false labor?

needs to be determined by cervical length and fFN results

if no cervical progression after 4-6 hours, but the mother is preterm, do you send home or continue observing?

send home

if pt is

betamethasone or dexamethasone

if mother in preterm labor (

tocolytics (reduce strength of contractions)

how many hours are tocolytics administered?

up to 48 hrs

give what bacterial prophylaxis to the pt if she hasn't already gotten a negative culture?

GBS prophylaxis

what is given to preterm mothers that is neuroprotective and provides protection against cerebral palsy and other motor disorders?

Mg sulfate

what type of tocolytic is given to pt >= 34 weeks?

- nifedipine = first-line

- terbutaline = second-line

what type of tocolytic is given to pt < 34 weeks?

- indomethacin = first-line

- nifedipine = second-line

- terbutaline = third-line

- may combine tocolytics for refractory case

if tocolytics are successful, when do you discontinue?

after 48 hrs

what's the difference between PROM and PPROM?

PROM = rupture of amniotic sac before onset of labor

PPROM = PROM that occurs before 37 weeks gestation

what is 24 hrs between PROM and the onset of labor called?

prolonged PROM

what is associated with preterm birth and risk of infection, PROM or PPROM?

PPROM

which has a risk of developing chorioamnionitis, PROM or PPROM

PROM

Surrounds the fetus in utero

protects fetus from trauma and cushions umbilical cord

Has antibacterial properties

Major sources of production: Fetal urine, fetal lung secretions

amniotic fluid

r/f for PROM (4)

- amniocentesis

- PUBS

- cervical cerclage

- chorioamnionitis

what is chorioamnionitis?

Infection and inflammation of intrauterine structures (placenta)

Migration of cervicovaginal microorganisms to decidual-chorionic interface

what increases the risk of chorioamnionitis?

longer duration of ruptured membranes

presentation of chorioamnionitis

- fever

- maternal/fetal tachycardia

- leukocytosis > 15,000 cells/mcL

- uterine tenderness

- purulent amniotic fluid

Protraction/arrest disorders of labor

Sepsis

Perinatal death

postpartum infection.......

are all complications of what?

chorioamnionitis

FEVER plus what makes a presumptive diagnosis of chorioamnionitis?

(one needs to be +)

- baseline FHR > 160 bpm for >= 10 minutes

- maternal WBC > 15,000 cells/mcL

- purulent fluid coming from cervical os

a confirmed diagnosis of chorioamnionitis is a presumptive diagnosis PLUS

(one needs to be +)

- (+) Gram stain of amniotic fluid

- amniotic fluid glucose level

How do you manage chorioamnionitis?

- initiate delivery (do not delay)

- intrapartum ABX (asap after presumptive dx)

what intrapartum ABX do you give for chorioamnionitis?

- Ampicillin q 6 hours PLUS

- Gentamicin once daily

typical hx of PPROM?

leaking or gushing of clear/pale yellow fluid from the vagina

"my water broke"

what do NOT do on physical exam for PPROM?

what is the gold standard diagnostic sign for PPROM on PE?

- DO NOT do digital vaginal exam

- DO use a sterile speculum

- Fluid pooling in vaginal canal (GOLD STANDARD)

- cough if unclear to pool fluids

What is the nitrazine test for dxing PPROM?

- test of vaginal pH

- pH of 7.0 - 7.3 = abnormal

- normal is pH 3.8 - 4.2

what is the fern test for dxing PPROM?

- fluid from posterior fornix swabbed and viewed under microscope

- dried amniotic fluid shows arborization (ferning) pattern

how to treat full term PROM if >= 37 weeks?

(delivery)

- oxytocin for labor induction

- (+/-) misoprostol for cervical ripening if needed

- cesarean delivery if vaginal delivery is contraindicated

how to treat PPROM >= 34 but < 37 weeks (34-37 weeks)?

(delivery)

- oxytocin for labor induction

- (+/-) misoprostol for cervical ripening if needed

- cesarean delivery if vaginal delivery is contraindicated

- (+/-) corticosteroid

- GBS prophylaxis if status is unknown

how to treat PPROM < 34 weeks?

- expectant management as inpatient

- corticosteroids

- antibiotic prophylaxis

- daily NST

- (+/-) tocolytics

how to treat PPROM if < 32 weeks?

same as < 34 weeks PLUS

- Magnesium sulfate

posterm pregnancy goes beyond how many weeks?

42 and beyond

eti of post term preg

- no known etiology

- inaccurate estimation of gestational age

r/f for post term preg

- previous post-term pregnancy (#1 r/f)

- nulliparity

- obesity

- male fetus

- older maternal age

what are 4 fetal complications to post term preg?

- macrosomia

- shoulder dystocia

- dysmaturity : impaired nutrition, reduced subcutaneous tissue, WL

- oligohydramnios

- abnormal FHR patterns

- meconium passage/aspiration

- perinatal mortality

sterile, thick, black-green, odorless material within fetal intestine ("baby's first poop")

meconium

it is unlikely that meconium would be passed in the 3rd trimester but may occur with what?

fetal stress

respiratory distress in an infant born through meconium-stained amniotic fluid.

is more common with what term births, preterm or post term ?

MAS (meconium aspiration syndrome)

post term

how to manage a pregnancy at >= 41 weeks gestation

induce labor

OR expectant management

how do you monitor a 41 and up pregnancy with expectant management

- NST with amniotic fluid volume assessment

- or BPP x 2 week

how to manage a pregnancy at >= 42 week (+6day) gestation?

induce labor, no expectant management

inherited antigen found on surface of RBCs

Rh factor

Antigen present = _______

Antigen absent = ______

Used for blood type classification (A+, B+, O-, etc.)

Rh system has many antigens

______ most commonly produces antibodies

Becomes a problem in pregnancy if maternal blood is RhD ________ and fetal blood is RhD _________

Rh +

Rh -

RhD

negative, positive

how does transplacental fetomaternal bleeding happen?

- tiny amounts of fetal RBCs gain access to maternal circulation

- more often during birth (or procedures/preg loss)

maternal RhD negative blood makes __________ if the fetus has RhD positive blood

antibodies

*immune system views blood as foreign substance

antibodies can cross back through placenta and destroy fetal RBCs

and can lead to __________ of the fetus and newborn (HDFN)

hemolytic disease

hemolysis produces heme -> converted to bilirubin (jaundice)

when are the risk of HDFN the greatest vs smallest?

- first pregnancies typically have fewer issues due to time it takes for antibodies to develop

- effects of isoimmunization worsens with subsequent pregnancies

effects on the baby with HDFN

- anemia

- elevated bilirubin (jaundice)

- kernicterus = bilirubin-induced neurological damage

- thrombocytopenia

- neutropenia

- hydrops fetalis: when fetal hgb < 5 g/dL

(edema, ascites, pericardial or pleural effusion)

when is ABO and RhD checked?

initial prenatal visit

who do you refer to if prenatal antibodies are present in mother?

maternal - feral med

what is preanal HDFN treatment based on ?

titer levels from an indirect Coombs test

what is used to monitor fetal hemoglobin?

PUBS (cordocentesis)

neonatal HDFN many need what emergently?

emergent transfusion

how to treat neonate HDFN?

- drainage of ascites/effusions in hydrops fetalis

- stabilization of respiratory distress

- phototherapy (transforms bilirubin to a water-soluble isomer that can be excreted through the kidneys and stool)

how are most Rh isoimmunizations prevented?

- initial prenatal visit check blood/RhD type

- antibody screen

how to treat if mother is RhD + ?

no treatment needed

how to treat if mother is RhD negative and antibody posative/negative?

- repeat antibody testing at 28 weeks

- if antibodies are positive = refer to specialist

- if antibodies are negative = administer anti-D immune globulin (Rhogam)

ANY maternal-fetal hemorrhage event needs what med?

rhogam

If infant is RhD positive, mother is negative = administer Rhogam within _____ hours of delivery

Infant blood type can be assessed through sampling of what?

72

cord blood

A 39-year-old female presents for her initial prenatal visit at 8 weeks gestation. You order a blood type and RhD type/antibody screen as part of her standard labs. Results are consistent with O- blood and negative for antibodies.

Is she at risk for Rh isoimmunization?

yes bc she is (-)

A 39-year-old female presents for her initial prenatal visit at 8 weeks gestation. You order a blood type and RhD type/antibody screen as part of her standard labs. Results are consistent with O- blood and negative for antibodies.

What is your next step in management?

28 week recheck

A 39-year-old female presents for her initial prenatal visit at 8 weeks gestation. You order a blood type and RhD type/antibody screen as part of her standard labs. Results are consistent with O- blood and negative for antibodies.

You repeat an antibody screen at 28 weeks and it's negative. What next?

administer Rhogam

A 39-year-old female presents for her initial prenatal visit at 8 weeks gestation. You order a blood type and RhD type/antibody screen as part of her standard labs. Results are consistent with O- blood and negative for antibodies. The patient is now 39 weeks pregnant and is in labor. After delivery of the baby, cord blood is assessed and results are consistent with A+ blood type.

What is the next step in management?

give her more Rhogam to prevent antibodies

A 39-year-old female presents for her initial prenatal visit at 8 weeks gestation. You order a blood type and RhD type/antibody screen as part of her standard labs. Results are consistent with O- blood and negative for antibodies. Say the father had documented O- blood type.

Is this patient still at risk for Rh isoimmunization?

NO, not if both parents are RhD -. then baby will also be -

A 39-year-old female presents for her initial prenatal visit at 8 weeks gestation. You order a blood type and RhD type/antibody screen as part of her standard labs. Now let's say she has O+ blood type and negative antibodies.

Is she at risk for isoimmunization?

no

What is a fetal fibronectin test used for?

preterm birth

A 31-year-old female is 31 weeks pregnant and found to be in preterm labor.

After she is admitted, what is the appropriate management?

1) steroids

2) tocolytic (indomethacin bc< 32 weeks)

3) Pen G (GBS prophylaxis)

4) Mg sulfate

What is the nitrazine test used for?

test ph of premature rupture for PPROM