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what is the definition of preterm delivery?
24 - 37 weeks
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when is preterm delivery most important?
before 34 weeks as this is when neonatal risks are higher
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before 24 weeks what is labour the same as?
miscarriage
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what % of deliveries are preterm?
5-8%
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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
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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)
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which Ix can predict preterm labour?
- transvaginal scan: measure cervical length
- need to have empty bladder
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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
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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
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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
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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
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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
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which type of assisted delivery is contraindicated in preterm labour?
ventouse
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what is preterm prelabour ROM?
- when membranes rupture BEFORE LABOUR at < 37 weeks
- happens in 1/3 of preterm deliveries
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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
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in PROM why would you want to do a VE?
to exclude cord prolapse if presentation is NOT CEPHALIC
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what are the signs of chorioamnionitis?
- 1. contractions or abdominal pain
- 2. fever
- 3. tachycardia
- 4. uterine tenderness
- 5. coloured or offensive liquor
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what are signs of PROM?
- gush of clear fluid and further leaking
- speculum: pool of fluid in posterior fornix
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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
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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
- admit
- steroids
- close observation: maternal - look for signs of infection; fettle: CTG
- if reaches 36 weeks do IOL
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if signs of chorioamnionitis appear, what is management?
- iv antibiotics immediately
- fetes is delivered whatever the gestation as abx alone wont eliminate the chorioamnionitis
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how is infection prevented in women with PROM?
prophylactic erythromycin in women even if no signs of infection
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which antibiotic should not be used and why?
- co-amoxiclav is contraindicated
- neonate more prone to NEC: necrotising entero colitis
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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
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why is epidural analgesia advocated in preterm labour?
- avoid expulsive efforts before full dilatation
- relax pelvic floor and perineum
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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
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