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ESSAY 292 - Pre-term labour

ESSAY 292 - Pre-term labour Posted by PAUL A.
A healthy 35 year old woman presents at 28 weeks gestation with a 12 hour history of uterine contractions. (a) Describe your initial assessment of this patient [9 marks]. Discuss the factors that determine the likelihood of pre-term delivery [4 marks]. (c) Discuss which drugs you would use and indicate when and how you would initiate drug therapy [7 marks].
Posted by Johnson  O.
Brief history to know often is the uterine contraction, any associated pv bleeding, premature rupture of membrane, urinary symptoms like dysuria, frequency, urgency. In multiparous woman, I would like to know if there is any previous history of preterm delivery. Previous history of cervical biopsy like LLETZ treatment. It is important to confirm gestational age from the early dating scan. Single or multiple pregnancy and if any factors in previous scan point towards possibility of preterm labour.
General examination to check Blood pressure, pulse and temperature. Abdominal palpation for fundal height, presentation, lie, any palpable uterine contraction and for how long.
Speculum examination to see for any draining of liqour, cervical os if dilated or close.
Fetal wellbeing by doing Electronic Fetal monitoring. Ultrasound scan for presentation if I am sure and to check for estimated fetal weight and liqour volume. I would take blood for full blood count, CRP, Group and Save, Urinalysis and MSSU for culture and sensitivity.
B/ Multiple pregnancy, Polyhydramnios or any condition that would cause overdistension of the uterus can stimulate it to preterm labour.
Preterm rupture of membrane with uterine contraction maylikely result in preterm delivery.
Cervical Incompetence causing weakness of the cervix.
Abnormal lie or presentation as in breech presentation, transverse or oblique lie.
Asymptomatic bacteruria,cystitis or pyelonephritis can lead to preterm delivery. Previous history of preterm delivery.

C/ Any drugs to be used should follow unit protocol for the management of preterm labour. Involovement of the woman in descision makin.
Corticosteriod in form of bethametazone 12mg 24hours apart in 2 doses to reduce the risk of respiratory distress syndrome.
Tocolytic would be given to enable time for administration of steroid and for in-uetro transfer to tertiary unit.
Erythromycin 250mg qid if membrane has ruptured, to reduce the risk of chorioamnioitis.
Thromboprophlaxis if high risk for DVT and on admission, Low molecular eight heparin.
Broad spectrum antibiotic in urinary tract infection. Anti d if rhesus negative nonsensitize with pv bleeding.
Posted by SANCHU R.
The patient should be initially admitted to the labour ward suite to assess and determine if she is in labour.The history should be obtained.The Gestational age should be determined accurately from her previous scan reports .If she is unbooked, a scan should be arranged to be done when she is stable.
The risk factors for preterm labour should be sought for. Previous H/O preterm deliveries, midtrimester losses, multiple pregnancy, H/o LLETZ, cone biopsy of cervix, bacterial vaginosis would predispose her to preterm labour.
The frequency of contractions, the intensity and duration of each contraction, the H/o any show or leaking of water PV should be asked for.
The general examination of the patient uncomfortable in pain would suggest an advanced preterm labour.
Abdominal examination is done to palpate the contractions and a CTG is done to assure the fetal well being and record the contractions.
A speculum examination is done to look for cervical dilatation . A High vaginal swab is taken. If cervix is closed but preterm labour is suspected, a fetal fibronectin test should be done to find out her risk of going into labour in the following 10 days .A negative test would be reassuring though not 100 percent sensitive and specific. I f the cervix cannot be visualised by speculum and labour is suspected, A VE should be done.
Progressive ,regular painful contractions with changes in the cervix and a positive fibronectin test all increase the probability of preterm delivery.
When a diagnosis of preterm labour is made, steroids should be given.,12 mg of Betamethasone 24 hours apart. Tocolytics should be initiated to postpone delivery at least to 24 hours for the steroids to act.
The recommended tocolytic is Atosiban infusion which is given as a loading dose followed by a maintenance infusion. given initially for 18 hours, reassessed and continued for 48 hours maximum.
The other alternative would be oral NIfedipine.
The paediatricians and the Neonatal Unit should be contacted to check for the availability of beds. If beds are not available and she is not in advanced labour, an in utero transfer would have to be arranged to the nearest hospital.
The paediatricians should explain the prognosis if the baby is delivered and the mother should be mentally prepared for a preterm delivery.


Posted by Hassan R.
Initial assessment include history,examination & investigations to put amangement plan.
History to explore risk factors for preterm delivery. Parity & history of preterm delivery to be documented. History of one preterm delivery risk is 20 % & 2 preterm deliveries 35 - 40%.
Current pregnancy history include confirmation of gestational age,uterine overdestention(multiple pregnancy& polyhydramnios ).Enqure about intercurrent illnesses & recurrent vaginal bleeding.Document uterine cotractions frequency & intensity.Document Fetal movements & spontaneous rupture of membranes.Examination include Pulse,tep,BP. Abdominal examination to determine fundal height, lie & presentation.Look for fetal heart beats & uterine tenderness (sign of abruption or chorioamnitis).Sterile speculum by experienced person may reviel the presece of liqor,bleeding or heavy discharge(H.V.S may taken) .Cervical dilatation may be seen.Avoid digital examination becaue of risk of inducing production of prostaglandins as well as introducing infection.
Bedside Fibronectin Test if positive gives risk of delivery within 28 days of 70% regardless of cevical dilatation.
With regard to factors detemining likelyhood of preterm delivery include progressive cervical dilatation , Positive Fibronectin Test.
Spontaneous rupture of membranes & vaginal bleeding may be warning signs for preterm delivery.
Drugs used are Steroids,Tocolytics & antibiotics.
Betamethazone is found to be effective in preventing respiratory distress syndrome & Intraventricular haemorrhge.It\'s given when contractions are regular & positive Fibronectin Test. It\'s given in doses of 12 mg. 24 hours apart.(2doses).
Tocolytics are indicated to give time for steroids to have effect or decision taken for in-utero transfere.Beta agonists have many side effects(palpitations, blurt vision,headache & seriously pulmonary oedema)these limit its current use. Atosiban(oxytocin antagonist) has less side effects but expensive. It\'s given as an infusion loading dose followed by maintinence dose for 48hours.Nifedipine (calcium channel blcker) is an alternative .Orally given loading dose 10 mg. every 15 minutes till contractions subside, then maintenance dose 20-40 mg. 3 times daily for 48 hours.
Antibiotics are not indicated if no rupture of membranes. If comfirmed ,Erthromycin is the antibiotic of choice for prophylaxis against infection.(Auracle Study).
Posted by Leen K.
(A)I would obtain a thorough history from the patient, including information about her contractions, such as the frequency, strength, duration and as well as whether any of these parameters are increasing to assess whether she is in labour. Directed questions about whether there is spontaneous rupture of membranes or any other vaginal loss such as bleeding or discharge is useful in assessing her situation. Other questions should include any pain elsewhere or constant abdominal pain; associated urinary or bowel symptoms; feeling feverish as some symptoms may point to infection or abruption.
I would ask about her current pregnancy, whether it is a multiple pregnancy & to see if there has been any problems such as growth restriction of the fetus, polyhydramnios or abnormal placentation. I would also find out about any medical and surgical history she might have that may predispose her to pre-term labour (such as diabetes, hypertension, autoimmune diseases, cervical surgery etc); as well as past obstetric history (such as previous pre-term delivery, and at what gestation those deliveries were).

My examination would first be to assess her general wellbeing, whether she looks unwell or in obvious pain; as well as to take measurements for blood pressure, pulse, temperature and respiratory rate. I would palpate her abdomen and quickly assess the size of the fetus (and check for small or large for dates pregnancy); presentation of the fetus (which would be important if she is in labour) as well as engagement of presenting part; liqour volume; palpate for uterine activity (assessing the strength, duration, frequency) and whether there is any associated pain elsewhere. I would listen in to the fetal heart; and consider a cardiotocograph if she looks to be in labour or has any signs of bleeding, infection or other concerns. A urinalysis should be done to check for protein, sugar and nitrates; and a MSSU sent if infection is suspected.
I would perform a gentle speculum examination to check if there is any dilatation of her cervix, check for signs of rupture of membranes and take swabs to check for infection. If there is any bleeding, it also allows me to assess how heavy it is, and assess where it is coming from. I will only perform a VE if she seems to be in active labour (if placenta is not low)

(B) Risk factors for preterm delivery can be maternal, fetal or pregnancy related. Maternal factors include any medical or surgical problems such as diabetes, hypertension, cardiac or renal problems, autoimmune disorders that may cause spontaneous or iatrogenic pre-term delivery. Other predisposing factors include maternal infection/inflammation (such as pyelonephritis, urinary tract infection, appendicitis, septicaemia etc). Anatomical factors include cervical weakness or abnormally shaped uterus (such as bicounuate uterus). Pregnancy factors, include multiple pregnancies, chorioamnionitis or abruption. Fetal factors include growth restriction, polyhydramnios.

(C) Tocolytics should be considered if there is no contraindications; and the patient is in threatened pre-term labour. It is of no benefit if she is in established labour. There should not be any bleeding, fetal distress or signs of infection. Tocolytics can prolong a pregnancy up to 7 days inorder to administer steroids for fetal lung maturity or intrauterine transfer. other than that, it has not much benefit in terms of improving fetal outcome. Betamimetics such as ritrodrine is associated with a lot of adverse effects (such as pulmonary oedeme), and has fallen out of favour. Nifedipine and atosiban has similar efficacy to ritrodrine, but is associated with less side effects. Nifedipine has to advantage of being cheap and given orally, 10mg every 15 mins (maximum 1 hour) if her contractions do not improve. Then she is given nifedipine every 4 hours (dosage depends on initial dose). Atosiban is more expensive and requires to be given intravenously. A bolus dose is given slowly and maintenance dose given for up to 48 hours.
Intramuscular steroid (dexamethasone or betamethasone 12mg, 12 or 24 hours apart, 2 doses in total) should be given if there are no contradications such as severe infection (maternal or chorioamnionitis). It is to help mature the fetal lungs to reduce the risk of respitatory distress syndrome in the neonate.
Antibiotic such as oral erythromycin (250mg qds) should be considered if there is ruptured membranes +/- threatened preterm labour to reduce the risk of infection inthe pregnancy/fetus. It should not be given is there is no ruptured membranes, as it is associated with an increased risk of cerebral palsy. Augmentin is associated with increased risk of necrotising enterocolitis.
Pain relief in the form of inhaled nitrous oxide or intramuscular opiates may help settle an irritable uterus.
Posted by nilasha A.
Confirm the gestational age from LMP and early scans.Would like to know about the intensity and frequency regarding the uterine contractions.History regarding, if any presence of per vaginal bleeding,gush of fluid or trickling ,any foul smelling discharge , urinary symptoms like urgency , frequency and dysuria.Past obstetric history including any previous preterm deliveries.past gynaecological history including any cervical procedures like biopsies or LLETZ . would enquire regardind fetal movements.History regarding any recent trauma to the abdomen.

General examination include pulse and temperature,blood pressure.Abdominal palpation for fundal height,fetal lie , position, tenderness,contractions and fetal heart rate.
pad inspection for any fluid,speculum inspection for pooling of the liquor,bleeding and cervical dilatation.ultrasound scan for an estimated fetal weight,liquor,presentation,any anomalies.
Electronic fetal monitoring for fetal well being.FBC,CRP,MSU culture and sensitivity,high vaginal swabs,endocervical swabs.Fetal fibronectin testing in the abscence of cervical dilatation and membrane rupture is performed.

Factors which determine the likelihood of premature labor are,uterine factors like polyhydramnios,multiple pregnancies,anomalies like septate or bicornuate uterus,fibroids,cervical biopsies.Fetal factors like abnormal lie,presentation,anomalies can contribute towards premature labour.Asymptomatic bacteruria,Group B streptococcal infection , preterm rupture of membranes , previous history of preterm deliveries lead to premature labor.Other factors like poor nutritional status,low socioeconomic status,alcohol, smoking,drugs also contribute.

Judicial usage of the drugs based on the department protocol would be preferred in the treatment of preterm labor.
Commence corticosteroids , intramuscular betamethasone 12mg 2 doses ,24 hours apart .It aids in fetal lung maturation and significantly decreases perinatal morbidity and mortality. Ideally to be adminstered 48hrs to 7 days before preterm labor.Tocolytics are all equal in their efficacy,its the side effects profile which varies.Oxytocin antagonist atosiban is given intravenously as loading and maintanence doses.Total duration of the treatment should not
exceed 48 hours.Oral erythromycin should be commencd in the presence of ruptured membranes , 250mg qid for a total of 10days.Thromboprophylaxis during postpartum period for the high risk groups should be provided,in the form LMWH.IV penicillin 3g, and 1.5 g 4hrly should be administered for GBS positive mothers during intrapartum.
Posted by DARE A.
A healthy 35 year old woman presents at 28 weeks gestation with a 12 hour history of uterine contractions. (a) Describe your initial assessment of this patient [9 marks]. Discuss the factors that determine the likelihood of pre-term delivery [4 marks]. (c) Discuss which drugs you would use and indicate when and how you would initiate drug therapy [7 marks].

a. A good history, focussed physical examination and investigations should be carried out.
A careful look at when uterine contractions began, how strong it is and how often they have been occuring is very important. Abdominal pain may feature in this presentation. Hence, patient should be asked about onset of pain, severity, site and radiation. A history of what makes the pain worse or better should taken. Every associated sypmtoms such as amount of bleeding per vaginam, any urinary symptoms and liquor leakage.
A careful look present pregnancy is important. Patient\'s last menstrual period should be correlated with an early dating scan to establish the appropriate gestational age. The number of fetuses is also important as twin gestation is one of the leading causes of preterm delivery. A careful look at patient\'s handheld notes will reveal if any anomaly had been identified in current pregnancy.
Patient\'s past obstetric history is important and should be explored. Number of pregnancies, when and how they ended are important. A history of previous preterm delivery is the most significant point in her past history.
Previous history of cervical surgery or laceration during childbirth is important. A history of diabetes mellitus, antiphospholipids syndrome, epilepsy to mention these few, shuold be asked. History of cigarette smoking, alcohol use and use of other illicit drugs is important. A family history of preterm delivery should also be noted.
Initial examination will involve looking at patient\'s general status and to resuscitate if shocked or unstable. A cursory look at patient\'s vital signs is important. Abdominal examination should involve estimating symphysio-fundal height, fetal presentation, lie, heart rate and a rough estimation of liquor volume. Uterine tenderness may point to placental abruption as the cause of preterm labour.
With patient\'s consent, a careful vaginal examination may provide a useful hint towards the diagnosis. Patient should be examined with a chaperone. An aseptic speculum will reveal presence of cord, liquor or blood. A high vaginal swab should be taken and sent for microscopy, culture and sensitivity. Digital examination should be performed if membranes are still intact and, may confirm cervical dilatation, thinning and an intact or ruptured membranes.
An intravenous venflon should be cited, and blood taken for full blood count and other blood tests as dictated by medical history. A midstream urine should be sent for microscopy, culture and sensitivity. A 30 minutes cardiotocography trace is mandatory to check fetal status. Special care baby unit and Paediatricians
should be informed and availability of cot should be ascertained.

B. Previous history of preterm delivery is the single most important risk factors for preterm delivery. Other important risk factors are presence of multiple pregnancies with its attendant omplications such as twin to twin transfusion syndrome, previous cervical surgery or injury such cervical excisional procedures and cervical laceration at childbirth. History of cigarette smoking, alcohol use and illicit drugs are important.
Multiple congenital anomalies and antepartum haemorrhage are other risk factors for preterm delivery.

C. I will consider the use of antenatal steriods, tocolytics in indicated and antibiotics.
Firstly, antenatal steroids have been shown to be beneficial to fetus if used 48 hours to one week before preterm delivery and should be initiated as soon as possible. I will consider using betamethasone 24mg intramuscularly within 48 hours. This has been shown to reduce respiratory distress syndrome, intracranial haemorrhage and bowel necrosis. However, it may be counterproductive in diabetics.
Once preterm labour is established and delivery is imminent, I will start intravenous antibiotics as benzyl penicillin 3g start and 1.5g 4 hourly until delivery. In patient with allergy to penicillin, I will start clindamycin intravenously.
Tocolytics such as atosiban, nifedipine and indomethacin to mention these few, have not been shown to be useful more than 48 hours. Hence, they may be started to allow antenatal steroids to work or when a patient is been considered for inutero transfer to tertiary hospital with neonatal intensive care facilities. I will consider starting these drugs immediately if there are no contraindications to it use. Contraindication include antepartum haemorrhage, intrauterine growth restriction, chorioamnionitis, multiple congenital anomalies, advanced labour or other maternal conditions that necessitated immediate delivery.
Posted by dr neelangini G.
As History suggest ,a case of pre term labour , I will like to know the nature of pain, like constant tonic pain or intermittent pain,& how long pain persist, & how frequently she gets it. As constant tonic pain may be abruption placenta. History of any pv bleeding or leaking through vagina at present or in recent past ,to rule out APH or PPROM respectively. Hx of fever, or dysurea may be cause of infection in the form of chorioamnionitis or UTI (may be asymptomatic bacteruria).Hx of previous preterm labour & recurrent pregnancy loss ,is a risk factor .Ethinicity ,non white race & poor socioeconomic factor also a risk factor for preterm labour.Any surgery in the form of amputation , or repeated dilation & curettage of os may cause preterm labour.Any Hx of trauma to abdomen may be a factor for preterm labour,so it should be explored .On examination,I would like to assess her general condition like Temperature, pulse, BP & BMI, as BMI less than 19 at booking visit has a significant risk for preterm labour. Per abdominal exam ,to ensure the gestational age by measuring uterine height in singleton pregnancy & presentation, lie of the fetus. Per speculum exam should be done to assess any leaking, dilation of cervix. During per speculum exam if required high vaginal swab can be taken for culture & rule out the infection. Other investigations like FBC,CRP,MSU for microscopy & culture,U & E to rule out infection.USG, may be an important investigation,to measure cx length,Placental location,presentation,lie of the fetus ,fetal wt,& anomaly.
Factors which determines the likelihood of labour,is the status of the cx like dilation,effacement,PPROM,previous surgery of cx,& congenital anomalies of fetus.As cervical dilation >3cm,& cx length <20 mm ,may increase the chance preterm delivery .,Chorioamnionitis may need immediate delivery,& PPROM is another risk factor for preterm labour.
The drugs in the form of tocholytics,like betamimetics(ritordine or terbutalin),Calcium channel blockers,(nifedipine),Oxytocin antagonist like atosiban,.may help for delaying the delivery for 48hrs to 7 days.MgSo4 as a tocholytics may not be helpful rather it has significant adverse effect on perinatal morbidity so it is not recommended .Indomethasin ,a COX inhibiter may be used as a tocholytics.Single course of Corticosteroids ,betamethasone 12 mg 24 hr apart, should be used for fetal lung maturity .Antibiotics in the form of Erythromycin ,in case of PPROM ,helps in preventing morbidity & prolongation of pregnancy .Tocholytics are helpful to delay the labour during which time corticosteroids can be given for lung maturity.It is also helpful for transfering the patient with fetus in utero to higher centre because of lack of SCBU.
Posted by Albert A.
A healthy 35 year old woman presents at 28 weeks gestation with a 12 hour history of uterine contractions. (a) Describe your initial assessment of this patient [9 marks]. Discuss the factors that determine the likelihood of pre-term delivery [4 marks]. (c) Discuss which drugs you would use and indicate when and how you would initiate drug therapy [7 marks].

a.
Initial assessment will involve a review of her past obstetric history, noting her parity, modes of delivery and any history of preterm deliveries. A review of the index pregnancy should also be done, confirming her dates, number of fetuses and noting her anomaly ultrasound findings, including the placental location.
Further detail of her presenting complaint will be obtained, including the severity and frequency of the contractions over the past 12 hours, any associated vaginal bleeding, and loss of liquor. Fetal movements will be enquired about. Any history of a febrile illness, urinary and bowel symptoms is also noted.
Her medical and surgical history will be obtained, especially any history of any cervical surgery.
Clinical examination will include temperature, pulse and blood pressure; abdominal examination for symphysio-fundal height to assess growth, and the presentation. The strength of uterine contractions can also be determined from abdominal examination.
A speculum examination will be undertaken, with verbal consent and a chaperone; to assess the cervix for shortening and dilatation, and note any bleeding or liquor. A high vaginal swab and a fetal fibronectin, or similar test, can be done at the same time, to screen for vaginal infections and predict the likelihood of preterm delivery respectively.
A cardiotocograph will be done to assess the fatal heart rate and the frequency of contractions.
Blood will be sent for a full blood count for haemoglobin and white cell count and CRP as a marker for inflammation. Urinalysis should be done, with urine sent for culture and sensitivity if suggestive of infection with leucocytes and nitrites.
A clinical diagnosis can be arrived from the above assessment.

b.
Factors that determine the likelihood of preterm delivery include-:
1. Previous history is associated with a high risk of recurrence.
2. Preterm Prelabour Rupture of Membranes- this is associated with the release of prostaglandins as well as subclinical or overt intrauterine infection, all leading to preterm delivery.
3. Uterine irritability form antepartum haemorrhage and febrile illnesses, also urinary tract infections/
4. Uterine distension- multiple pregnancy and polyhydramnious.
5. Cervical incompetence secondary to shortening from previous surgery or from connective tissue disorders.
6. Uterine anomalies and submucous fibroids are also associated with preterm labour.
7. Certain medical conditions- inflammatory bowel disease, chronic renal failure, autoimmune diseases- maybe associated with preterm labour and delivery, sometime iatrogenic.

c.
Drugs considered in the setting of preterm labour include tocolytics, to abort/ameliorate contractions long enough to enable administered corticosteroids have an effect in improving fetal lung maturity.
There are different groups of tocolytic agents, similar in efficacy, but with a varied side effect profile.
Atosiban is an oxytocin antagonist which is given intravenously as a bolus and then maintenance infusion. Side effects include nausea, vomiting.
B-sympathomimetc agents- terbutaline and salbutamol, given i.v or inhaled. Side effects and mostly cardiovascular- with palpitations, tachycardia, flushing.
Calcium channel blocker Nifedipine is used, with side effects being hypotension, headache.
Indomethacin, a NSAID, is an effective tocolytic with the side effect of early closure of the ductus arteriosus and also possible oligohydramnious. It is usually given orally.
Isorsobide mono/dinitrate is also used with hypotension being the main side effect

Betamethasome (or Dexamethasone) 12mg intramuscular, 2 doses 24 hours apart, is recommended to improve fetal lung maturity if less than 34 weeks gestation.

Appropriate analgesia and antiemetics is recommended.

With ruptured membranes, erythromycin 250mg qds x 10 days,is recommended as prophylaxis against chorioamnionitis.


Posted by SN  K.
a/ A history should be taken on contractions (start, duration, response to analgesics, any precipitating factors such as spontaneous rupture of membranes proceeding contractions). History of preterm labour in past obstetric history if a multiparous should be taken as previous preterm delivery is associated with recurrent preterm deliveries. Systemic review should be done to exclude infections as infections are associated with preterm labour (urinary tract infections, respiratory tract infections). Medical history and Surgical history is important on management (may need anaesthetist’s review pre-operatively if high risk and surgical history may be significant if there’s a history such as previous myomectomy opening into uterine cavity which would indicate the indication for a caesarean section if in preterm labour).
Antenatal notes should be reviewed to look for risks (E.g. HIV positivity, Hypertension) in index pregnancy.
Examination includes general examination (E.g.: pallor for anaemia), systems examination including Cardiovascular system (pulse, BP. Heart if any particular complaints such as chest pains, shortness of breath), Respiratory system. Abdominal examination includes fundal height (to check whether equal to dates), any tenderness in uterus ( if abruption or chorioamnionitis may have uterine tenderness), renal angle tenderness (if pyelonephritis which could precipitate pre term labour) and palpation for uterine contractions. If contracting, the duration and frequency of contractions should be checked. A speculum and a vaginal examination is important if there are palpable uterine contractions or history of rupture of membranes or bleeding per vagina. A low vaginal swab should be taken to exclude infections such as bacterial vaginosis (which can give rise to pre term labour) and to exclude group B streptococcus, which indicates antibiotic prophylaxis in established labour. (Any examination and investigations should be done following patient’s consent).
Fetal heart should be checked with a Cardiotocograph if contracting (to determine whether normal, suspicious or a pathological CTG). Fetal lie should be palpated (if transverse lie and in established labour, will need an emergency caesarean section).
A mid stream urine sample should be dip stixed to look for urine tract infections (UTI) ( for nitrites) and to send for culture and sensitivity if suggestive of a UTI.
Bloods include full blood count, group and save. May need all acute abdomen bloods including renal function tests, liver function tests if suggestive of an acute abdomen ( also if preeclampsia which may precipitate preterm labour).


b/ In index pregnancy any precipitation factors such as a UTI, Spontaneous rupture of membranes (SRM) are associated with preterm labour. Any features suggestive of Chorioamnionitis will give rise to preterm labour. If SRM, around 90% may go into established labour within 72 hours since SRM. Previous history of preterm labour is associated with preterm labour in index pregnancy. Also, multiple pregnancy is associated with preterm labour. Placental abruption may precipitate preterm labour. Intra-uterine death may give rise to pre-term labour.



c/ If in preterm labour (PTL, where there are regular uterine contractions and cervical changes) I would suggest steroid therapy with 12mg of Betamethasone 24 hours apart Intramascular 2 doses as Steroids in preterm labour reduces morbidity and mortality due to respiratory diseases such as transient tachypnoea of new born, respiratory distress syndrome. Also steroids are associated with reduction in intraventricular haemorrhages and necrotising enterocolitis. I will also start her on Normal saline infusion as this is known to inhibit Pituitary secretion of Oxytocin , there by preventing preterm labour.
If the patient is in PTL, I will start her on tocolytic drugs according to availability in my unit. The tocolytic drugs used in UK are Nifedipine (though not licensed to use) or Atosiban. Other drugs such as Ritodrine are not in use due to side effects compared to Nifedipine or Atosiban.
I would start the patient on Nifedipine Oral 10mg every 15 minutes until the contractions cease. Then 20mg tds can be given for 48 hours. If there’s ruptured membranes, Erythromycin 250mg tds will be given for 10 days to prevent infection. If there is symptoms and signs suggestive of chorioamnionitis, broad spectrum antibiotics such as Cephalexin and Metronidazole should be given (IV if fever or can not take orally due to vomiting). If there’s UTI, I will give an antibiotic such as Cephalexin or Amixycillin to treat the UTI.
Posted by V R.
Pre-term delivery is the single most important determinent of adverse pregnancy outcome. I will ask her the duration of the pain, any associated h/o gush of fluid from vagina to rule out preterm-prelabour rupture of membrane[pprom],color and odor.I will ask any reduced fetal movements to clinically assess fetal wellbeing.
Clinical examination include pulse rate, blood pressure and temperature measurements.Abdominal examination to know fetal lie, any uterine contrations and tenderness.
A sterile speculum examination is done to look for any pool of fliud in the vagina, any odour, and color of the discharge. I will look for any cevical diatation .Avoid digital examination as it may precipitate the labour and also cause risk of chorioamnionitis. Digital examination is done onlyif there is signs of immediate labour.
The initial investigation include full blood count to know infection , any leucocytosis. A high vaginal swab is taken to rule infection. None invasive procedure ultrasound abdomen is done to look for fetal lie, liqour volume -any oligohydramnoius.
Biophysical profile or doppler is not reqired in the first line surveillnace.Cardiotocography is done.
B]
Polyhydramious of any cause may lead to preterm labour. Multiple pregnacies are associated with preterm labour then singleton pregnancies.
The other factors are teenage pregancy, previos h/o preterm as if one preterm is associated with 20-40% risk of recurrence.
Preeclampia, urinary tract infection are associated with preterm.
C]
Tablet Erythromycin 250 mg qid is recommended to reduce the risk of preterm, infection and better neonatal outcome. If Group B Streptococcous is diagnosed and women is in labour , intrapartum dose of penicllin G is started to avoid neonatal neurological complications.
Tocolytics by itself is of no use in improving the outcome. But it is given to buy time to inject steroids and for in -utero -tranfer.
Atosiban is the recommend drug . Its side effect is nause , hypotension.
Nifedipine is not prescribed in UK.
Corticosteroids should be given to reduce the risk of respiratatory distresss in newborn. Betamethasone can be given as 12 mg , 2 doses , 24 hours apart. It action is best if treatment - deivery interval is 24hrs to 7 days of the first dose.Dexamethasone is the alternative steroid which can be used .
Posted by A A.
Preterm birth is associated with significant perinatal morbidity and mortality so management aims at improving the outcome.History and examination is essential to find out cause.I will ask about rupture of membranes ,vaginal bleeding[abruption],infections especially symptoms ofurinary tract infection like frequency,dysuria and any bowel comlaint like diarrhoea.Any histort of vaginal discharge. whether singleton or multiple pregnancy and any fetal anomaly or polyhydramnias.I will take previous obstetric history of preterm labour as it is most important predictor of recurrence-.History of previous antenatal complications like mid trimester miscarriages, preeclampsia ,IUGR [APS/thrombophilia]and pregnancy outcome.I will ask about any uterine malformation ,cervical surgery[cone biopsy]or surgical cervical dilatation as it can cause cervical incompetence.As she is healthy so medical history may be unremarkable.I will ask about smoking,illicit drug use,alcohol,hygiene and socioeconomic status as these are minor risk factors associated with PTL.In examination I will check her pulse,BP and temp.In abdominal examination I will check for fundal height, fetal lie,presentation,presence of contractions,tone,and uterine tenderness in case of abruption or chorioamnionitis.Iwill do speculum examination to identify pooling of liquor,vaginal bleeding or discharge and visual assessment for cervical dilatation/effacement .I will take low vaginal swabs,uretharal and rectal swabs for group B streptococcus .Per vaginal examination should be avoided as it can accelerate labour process and cause ascending infection.If done it should be limited.
B] These include obstetric factors like previous preterm delivery as it is most important predictor of recurrence[15-20% if one and 35%-40% if previous two preterm deliveries].Multiple pregnancy and polyhydramnias cause uterine overdistention.Malformations of uterus like bicornuate ut,uterine fibroids[submucosal] and cervical incompetence.Infections like chorioamnionitis,asymptomatic bacteriuria,pyelonephritis and bacterial vaginosis either directaly cause or by releasing chemical mediators initiate preterm labour.placental abruption and previa also important factors.preeclampsia,fetal anomalies and trauma[surgical and others]can also cause it.smoking ,alcohol,recreational drugs,low BMI,low socioeconomic status can also contribute.
C] If it is a genuine preterm labour and there is no contraindications to tocolysis like chorioamnionitis,abruption,fetal anomaly etc,Iwill start tocolysis.Although tocolysis itself does not improve outcome but it allows time for corticosteroids action on lungs or if in utero transfer to other hospital if required for SCBU.Ritrodine is no longer a best choicebecause of adverse maternal effects.Atosiban[oxytocin antagonist] and nifedipine[ca channel blocker]are better choices with less side effects and comparable results in delaying delivery for few days.Nifidipene is cheaper than Atosiban and can be used orally but is not licensced in uk for tocolysis so risk and benefits should be explained and informed consent should be taken before its use.Atosiban is expensive and requires intravenous administration but is licensed in uk so i will use it according to my local unit protocol.Maintaience tocolytic treatement is not recommended.I will give two IM dosesof Betamethasone 24 hrs apart because there is evidence that corticosteroids significantly reduces risk of RDS,intraventricular hemorrhage and perinatal mortality.No sideeffects with single administration.Iwill not give antibiotics if membranes are intact however if ruptured than oral tab erythromycin 250mg 8hrly is to be given.If urinary tract infection or other systemic infection is suspected I will give appropriate antibiotic orally/iv depending on severity.If abruption than anti D in non sensitized women.

Posted by A R.
I would start by taking a good history and a thorough examination supported by some investigations.

a). History to exclude presenting complaint of vaginal bleeding, liquor drainage, vaginal discharge, foetal movements, abdominal pain, fever, dehydration, urinary symptoms

Know more about the contractions- for how often, duration, regular/irregular, becoming more severe?

Previous history of similar episodes, cervical injury including cone biopsy, trauma should be looked for.

Medical history- hypertension, Diabetes, past history of premature rupture of membranes,

History of smoking/ alcohol/ illegal drugs need to be excluded since these can cause preterm labour.

Any evidence of Sexually transmitted diseases since infections are a risk factor too.

On Examination- Fever, abdominal examination- size of the uterus, presentation, lie, liquor, tenderness,

Sterile speculem examination for liquor and its colour and smell. If blood is present then the amount and perform Kleihaur test. If Rh negative administer Rhogam.

Check for foetal fibonectin in the vaginal secretions. Its a sensitive test but not a very specific test.

CTG- look for the contractions and how strong they are and the base line variability and the beat to beat variability.

USS- liquor, Biophysical profile, Estimated Foetal weight

Blood for Full blood count, CRP, Random blood sugar levels, MSSU and urine for culture and sensitivity will be also sent. I will make sure she has her blood group and Rh type known already if not I would order them too.


b).
Previous preterm deliveries in multiparous women since they will be more likely to have another one.
cervical trauma or surgery like cone biopsy or LLEEPZ procedure may cause incompetence of the cervix.
Multiple pregnancies or increased volume of liquor as in polyhydramnios can lead to preterm labour due to overdistension of the uterus.
obesity is a known risk factor for preterm birth.
Premature rupture of membranes eventually leads to preterm delivery in most women.
Chorio amnionitis also is a cause for preterm delivery



c). Tocolytics- can be used for in utero transferto a tertiary unit and or for completion of steroid therapy


Atosiban- Oxytocin antagonist
Salbutamol- side effects- tachy cardia,Hypertension, Diabetogenic effect
Ritodrine- Less side effects,can be used orally
Nifedipine- Oral



Steroids- to promote lung maturity, not if impending delivery, needs 24 hours to act
Betamethasone- 12mg daily X 2 doses,
Dexamethasone- 6mg 12 hourly X 4 doses
IV Hydrocortison- Not found to be very effective

Erythromycin- to prevent ascending infection if thre is rupture of membranes.

Thromboprophylaxis- Low molecular weight heparin is found to be safe in pregnancy
Posted by Y.H. S.
Preterm labour is initiation of uterine contractions before 37 completed weeks. It can lead to premature delivery with its associated increased risk of perinatal mortality and morbidity.
Initial assessment includes history, examination, & investigation. In the history, confirm the gestational age by reviewing the dating scan. History of the pain, any associated dysurea to rule out UTI ; any associated vaginal discharge to rule out infection; Because UTI and vaginal infection can precipitate PTL. ASk about leaking to rule out PPROM. Also enquire about any trauma history to rule out possibility of abruptin.
Review current pregnancy for ANC, no of fetuses,any recurrent urinary tract & vaginal infections, macrosomia, history of bleeding or threatened miscarriage, because all these factors can precipitate PTL.
Review past obstetric history, for parity, history of preterm labour and delivery.
Any past history of cervical surgeries and cone biopsy.
Examine the general look of the patient, is she in pain, conscious.
Check B.P., pulse rate, temperature, & respiratory rate. Abdominal examination, check for tenderness to rule out abruption; SFH to confirm gestation; lie & presentation to determine mode of delivery if delivery is needed; and check the FHR to confirm viability and rule out distress.
Vaginal speculum examination for cervical dilatation, and to rule out bleeding & leaking. Take a high vaginal swab.
Invstigations, do FBC for HB level to rule out anaemia, look for leukocytosis to rule out infection, and platelets to rule out coagulopathy. Send urine for R/M & C/S to rule out UTI.
Ultrasound is requested for gestational age & estimated fetal weight to inform paediatrician in case delivery is needed. Check the lie and presentation ( mode of delivery ). AFI to rule out leaking . Do placental localization, and look for abruption if possible.
CTG to confirm normality of FHR, and for contractions frequency and intensity.
Factors that determine delivery are maternal or fetal. Maternal factors includes active labour with dilated cervix, indicating that delivery can\'t be prevented. Severe bleeding with maternal & /or fetal distress necessitating urgent delivery to save mother &/or fetal life. Associated severe abruption with maternal deterioration and fetal distress. Presence of associated medical problem like HTN, pre-eclampsia, eclampsia, or HELLP, with which delivery is needed to resolve the problem and save the mother\'s life.
Fetal factors include severe fetal distress, severe IUGR , with which delivery is needed to prevent fetal death. IUFD where delivery is neded to reduce maternal psychological distress.

The drugs given include corticosteroids to enhance fetal lung maturity in case delivery is needed. It is given as dexamethasone intramuscular injection 12 mg 12 hourly for 1 day.
Tocolytics is given to delay delivery either to allow time for corticosteroids to work, or for in utero transfer for another center with NICU service.
Tocolytics include Atosiban, nifedipine, ritodrinr MgSo4 and others. Atosiban is given as a bolus dose followed by in fusion pumb. hospital protocol for administration should be followed. Ritodrine ( B- mimetic ) is no longer recommended because of its side effects. Nifedipine can be given orally,but not licensed for use as tocolytic. Indomethacin can be given as rectal suppository but it has maternal side effects, and risk of fetal premature closure of ductus arteriosus, therefore use is limited.

Antibiotics is given if there is evidence of UTI , vaginal infection, or chorioamnionitis. Antibiotics are given orally or intravenously if severe infection.

Anti D immunoglobulin to RH negative non sesitized mothers, if there\'s associated bleeding. It is given intramuscularly after calculating the needed dose.

Treatment is also given to any associated medical condition, e.g. antihypertensives for HTN or pre-eclampsia, & insulin pump for diabetics.
Blood transusion is given if severe bleeding and after haematologist consultation.
Posted by PAUL A.
Brief history why does your history have to be brief? When you see patients, your consultant will want you to be detailed rather than brief to know often is the uterine contraction, any associated pv bleeding, premature rupture of membrane, urinary symptoms like dysuria, frequency, urgency (1) these symptoms have different implications – you have not provided any detail . In multiparous woman, I would like to know if there is any previous history of preterm delivery why? . Previous history of cervical biopsy like LLETZ treatment why? . It is important to confirm gestational age from the early dating scan. Single or multiple pregnancy and if any factors in previous scan point towards possibility of preterm labour what is it in the scan that might point to preterm labour and how will the examiner know that you know it? .
General examination to check Blood pressure, pulse and temperature. Abdominal palpation for fundal height, presentation, lie, any palpable uterine contraction and for how long (1) .
Speculum examination to see for any draining of liqour, cervical os if dilated or close would you do VE? .
Fetal wellbeing by doing Electronic Fetal monitoring. Ultrasound scan for presentation if I am sure and to check for estimated fetal weight and liqour volume. I would take blood for full blood count, CRP, Group and Save, Urinalysis and MSSU for culture and sensitivity (1) ? Fetal fibronectin test .
B/ Multiple pregnancy, Polyhydramnios or any condition that would cause overdistension of the uterus can stimulate it to preterm labour.
Preterm rupture of membrane (1) with uterine contraction maylikely result in preterm delivery.
Cervical Incompetence how will you know if this is present? causing weakness of the cervix.
Abnormal lie or presentation as in breech presentation, transverse or oblique lie do these affect risk of prematurity or are they consequences?? .
Asymptomatic bacteruria,cystitis or pyelonephritis can lead to preterm delivery. Previous history of preterm delivery you were adked to DISCUSS – this is a factor but where is the discussion? This is the most important factor but you have not put it into any context .

C/ Any drugs to be used should follow unit protocol for the management of preterm labour. Involovement of the woman in descision makin.
Corticosteriod in form of bethametazone 12mg 24hours apart in 2 doses to reduce the risk of respiratory distress syndrome (1) how would you administer? .
Tocolytic would be given to enable time for administration of steroid and for in-uetro transfer to tertiary unit which drug and when / how? Atosiban administered by iv bolus followed by maintenance dose (HOW) if fetal fibronectin is positive (WHEN).. .
Erythromycin 250mg qid if membrane has ruptured, to reduce the risk of chorioamnioitis (1) .
Thromboprophlaxis if high risk for DVT and on admission, Low molecular eight heparin.
Broad spectrum antibiotic in urinary tract infection. Anti d if rhesus negative nonsensitize with pv bleeding.
Posted by ELIZA SHIREEN E.
Eliza
This woman may be go into preterm labour which is associated with significant perinatal mortality and morbidity.A detailed history ,clinical examination and some investigations are important in conferming diagnosis,detecting potential causes and fetal condition.
History includes nature of uterine contraction (regularity,intensity and duration), pervaginal passage of any water or any bleeding or any foul smelling discharge to look for preterm labour or preterm premature rupture of membrane or APH or chorioamnionitis.
Any urinary complain such as dysuria, frequency of micturation or symtoms of cystitis ,pyelonephritis should be asked.
History of fever, hypertention, heart disease, fetal movement should also be known.
General examination includes pulse, temperature,blood pressure is to be done.Abdominal examination is done for tenderness,fetal lie and position,frequency,intensity and duration of uterine contraction,fetal heart rate.
A sterile speculum examination is done to look for cervical dilatation and any fluid comes through the cervix. A High vaginal swab is taken.
Fetal wellbeing is cheked by CTG.A ultrasound scan should be done for fetal lie and presentation.Multiple pregnancy, congenital anomaele,intrauterine fetal death, polihydromnios, placenta preaviae can also be detected by USS.
BLOOd group and save, full blood count, CRP, HVS for GBS,MSU for culture should also be done.
b)
Obstetrical factors such as preterm rupture of membrane,abruptio placenta,multiple pregnancy, fetal congenitalies or death can stimulate preterm labour.
Multiple pregnancy, fetal congenitalies or death can also stimulate it.
Maternal infection like chorioamnionitis,, urinary tract infection,asymtomatic bacteruria, bacterial vaginosis can facilitates it.
Uterine abnormality ,cervical incompetency may cause preterm delivery.
Low socioeconomic status,low prepregnancy weight,heavy smoking sometimes lead to PTD.
c)
Any drugs to be used depends upon the unit protocol and the potential cause.Drugs are used to reduce perinatal mortality and morbidity.
If there is no contraindication (fetal death or gross congenital malformatio,abruptio placenta Corticosteriod should be started in form of bethametasone 12mg 24hours apart in 2 doses to reduce the risk of respiratory distress syndrome.
Tocolytics should be initiated to postpone delivery at least 48hours to 7days to allow time for fetal lung maturity and for in utero transfer to an appropriate SCBU unit available hospital.
The recommended tocolytic is Atosiban given in parenteral route as a loading dose followed by a maintenance for 18 hours, reassessed and continued for 48 hours maximum.It is coastly and not available evrywhere.The other alternative is Nifedipine orally as a loading dose 10 mg every 15 minutes till contractions subside, then maintenance dose 20-40 mg 3 times daily for 48 hours.
Erytromycine oraly (250mg qds for 10 days) should be considered if there is ruptured membranes.
Other antibiotics is given if there is evidence of UTI(cephalosporin) GBS(amoxicillin) in appropriate dose. Anti D immunoglobulin to RH negative non sesitized mothers is given after delivery.
Posted by PAUL A.
The patient should be initially admitted to the labour ward suite to assess and determine if she is in labour.The history should be obtained. The Gestational age should be determined accurately from her previous scan reports in the exam, you should accept the gestation age as given . If she is unbooked what is it in the question that makes this relevant? What if she had a placenta previa or a cervical suture??? , a scan should be arranged to be done when she is stable.
The risk factors for preterm labour should be sought for. Previous H/O preterm deliveries (1) , midtrimester losses, multiple pregnancy, H/o LLETZ, cone biopsy of cervix, bacterial vaginosis would predispose her to preterm labour.
The frequency of contractions, the intensity and duration of each contraction (1) , the H/o any show or leaking of water PV should be asked for.
The general examination of the patient uncomfortable in pain would suggest an advanced preterm labour ? value?? How many women do you see with pain who are not in labour? .
Abdominal examination is done to palpate the contractions and a CTG is done to assure the fetal well being and record the contractions.
A speculum examination is done to look for cervical dilatation how do you assess dilatation on speculum examination? . A High vaginal swab is taken. If cervix is closed but preterm labour is suspected, a fetal fibronectin test (1) should be done to find out her risk of going into labour in the following 10 days .A negative test would be reassuring though not 100 percent sensitive and specific. I f the cervix cannot be visualised by speculum and labour is suspected, A VE should be done (1) .
HOW DO WE KNOW WHERE PART B BEGINS? Progressive ,regular painful contractions with changes in the cervix and a positive fibronectin test you were asked to DISCUSS – where is the discussion? all increase the probability of preterm delivery.
When a diagnosis of preterm labour is made, steroids should be given.,12 mg of Betamethasone 24 hours apart how? Orally? . Tocolytics should be initiated to postpone delivery at least to 24 hours for the steroids to act.
The recommended tocolytic is Atosiban infusion which is given as a loading dose followed by a maintenance infusion (1) . given initially for 18 hours, reassessed and continued for 48 hours maximum.
The other alternative would be oral NIfedipine.
The paediatricians and the Neonatal Unit should be contacted is this drug treatment? to check for the availability of beds. If beds are not available and she is not in advanced labour, an in utero transfer would have to be arranged to the nearest hospital.
The paediatricians should explain the prognosis if the baby is delivered and the mother should be mentally prepared for a preterm delivery.
drugs – tocolytics, corticosteroids, antibiotics. When would you administer and how?
Posted by robina K.
My answer:


a) Assessment of this patient aims at diagnosis of preterm labor, identification of possible causes and their treatment to prevent preterm delivery, prematurity and its consequences of respiratory distress syndrome, intra ventricular hemorrhage and pulmonary hypoplasia. Information should be obtained about the frequency, intensity and regularity of uterine contractions with vaginal leakage and pressure in the pelvis which indicates imminent delivery. To confirm gestational age, menstrual cycle regularity, LMP, early dating scan reports need to be reviewed. History of previous preterm delivery increases the recurrent risk. Blood pressure, pulse and temperature should be recorded and abdominal examination including FHT, liquor volume, presentation should be carried out.

A sterile speculum examination should be carried out for any vaginal discharge, drainage of liquor and cervical dilatation. High vaginal swabs should be taken for culture and senstivity as infection is a possible cause. If cervix looks dilated then digital assessment for dilatation and effacement should be carried out otherwise it should be avoided due to increase risk of assending infection, release of prosta glandines and initiating or accelerating further contractions.

CTG should be performed for fetal well being and ultrasound performed for fetal viability, presentation and liquor volume.

Blood should be sent for group and save antobodies, full blood count, CRP, and urine for culture and sensitivity.



B) Previous history of preterm delivery increases the risk of recurrent preterm delivery by 20% with one previous PTD and 35%-40% with previous two preterm deliveries. Frequency and intensity of uterine contractions if regular and painful for more than three times in ten minutes increases the likelihood of PTD. Also rupture of membranes, cervical dilatation and effacement at presentation are the determinants. Non availability of treatment like tocolytics, steroids and antibiotics also increases the likelihood of imminent delivery.


C) Drugs used in preterm labour includes tocolytics to decrease frequency and intensity of uterine contractions, steroids that is beta methasone for fetal lung maturity and antibiotics if membranes are ruptured. Tocolytics drugs are given to delay delivery upto few days for the effect of steroids or in utero transfer. Commonly used drugs are Atosiban which is oxitocin receptor inhibitor and Nifedepine which is calcium channel blocker. Both are effective with minimal side effects as compared to Beta agonists like Ritordine. Atosiban is expensive and Nifedipine is not licensed in the UK. After discussing with the patient and giving her full information about the drug efficacy, side effects, these may be initiated. Atosiban given intravenusly in three steps:
A bolus dose of 6.75 miligrams over two minutes.
Then eighteen miligram per hour for three hours.
Followed by six miligrams per hour for a total of fortyfive hours.

Nifedipine is given as ten miligram sublingually. Every 15 minuted for one hour. Then 60-160 mili grams per day. Other tocolytics like indomethacin which causes premature closure of ductus arteriosus, magnesium sulphate and nitric oxide donors has been used successfully but not recomended due to adverse side effects.

Erythromycin 250 miligrams six hourly for 10 days, if membranes are ruptured and expectant management is decided.

Thanks

Posted by robina K.
A small addition:


C) continued..

Dexamethason 12 miligram given intramuscularly and repeated after 24 hours
Posted by PAUL A.
Initial assessment include history,examination & investigations to put amangement plan. not necessary – waste of time & space
History to explore risk factors for preterm delivery. Parity is parity a risk factor? & history of preterm delivery to be documented. History of one preterm delivery risk is 20 % & 2 preterm deliveries 35 - 40% (1) .
Current pregnancy history include confirmation of gestational age you have been given gestation age ,uterine overdestention(multiple pregnancy& polyhydramnios ).Enqure about intercurrent illnesses & recurrent vaginal bleeding.Document uterine cotractions frequency & intensity.Document Fetal movements & spontaneous rupture of membranes (1) .Examination include Pulse,tep,BP. Abdominal examination to determine fundal height, lie & presentation.Look for fetal heart beats & uterine tenderness (sign of abruption or chorioamnitis).Sterile speculum by experienced person may reviel the presece of liqor,bleeding or heavy discharge(H.V.S may taken) .Cervical dilatation may be seen how do you assess dilatation on speculum? .Avoid digital examination becaue of risk of inducing production of prostaglandins as well as introducing infection.
Bedside Fibronectin Test (1) if positive gives risk of delivery within 28 days of 70% regardless of cevical dilatation why 28 days? One can understand quoting risk over 7-10 days because of need for cirticosteroids .
With regard to factors detemining likelyhood of preterm delivery include progressive cervical dilatation , Positive Fibronectin Test you were asked to DISCUSS, not list. Where is the discussion? What about previous preterm delivery? .
Spontaneous rupture of membranes & vaginal bleeding may be warning signs for preterm delivery.
Drugs used are Steroids,Tocolytics & antibiotics waste of time / space – you do not get marks for writing a list .
Betamethazone is found to be effective in preventing respiratory distress syndrome & Intraventricular haemorrhge.It\'s given when contractions are regular & positive Fibronectin Test. It\'s given in doses of 12 mg. 24 hours apart.(2doses) (1) good – you have presented drug, when and how .
Tocolytics are indicated to give time for steroids to have effect or decision taken for in-utero transfere (1) .Beta agonists have many side effects(palpitations, blurt vision,headache & seriously pulmonary oedema)these limit its current use. Atosiban(oxytocin antagonist) has less side effects but expensive. It\'s given as an infusion loading dose followed by maintinence dose for 48hours (1) .Nifedipine (calcium channel blcker) is an alternative .Orally given loading dose 10 mg. every 15 minutes till contractions subside, then maintenance dose 20-40 mg. 3 times daily for 48 hours (1) .
Antibiotics are not indicated if no rupture of membranes. If comfirmed ,Erthromycin is the antibiotic of choice for prophylaxis against infection.(Auracle Study) ORACLE – how would you give it? iv? .
Posted by PAUL A.
(A)I would obtain a thorough history from the patient, including information about her contractions, such as the frequency, strength, duration (1) and as well as whether any of these parameters are increasing to assess whether she is in labour. Directed questions about whether there is spontaneous rupture of membranes or any other vaginal loss such as bleeding or discharge (1) is useful in assessing her situation. Other questions should include any pain elsewhere or constant abdominal pain; associated urinary or bowel symptoms; feeling feverish as some symptoms may point to infection or abruption.
I would ask about her current pregnancy, whether it is a multiple pregnancy & to see if there has been any problems such as growth restriction of the fetus, polyhydramnios or abnormal placentation. I would also find out about any medical and surgical history HEALTHY 35 year old tells you this is unnecessary she might have that may predispose her to pre-term labour (such as diabetes, hypertension, autoimmune diseases, cervical surgery etc); as well as past obstetric history ( such as previous pre-term delivery, and at what gestation those deliveries were surely this is the most important question in the entire history ).

My examination would first be to assess her general wellbeing, whether she looks unwell or in obvious pain; as well as to take measurements for blood pressure, pulse, temperature and respiratory rate. I would palpate her abdomen and quickly why quickly as opposed to taking as long as necessary? assess the size of the fetus (and check for small or large for dates pregnancy); presentation of the fetus (which would be important if she is in labour) as well as engagement of presenting part; liqour volume; palpate for uterine activity (assessing the strength, duration, frequency (1) ) and whether there is any associated pain elsewhere. I would listen in to the fetal heart; and consider a cardiotocograph if she looks to be in labour or has any signs of bleeding, infection or other concerns. A urinalysis should be done to check for protein, sugar and nitrates; and a MSSU sent if infection is suspected.
I would perform a gentle speculum examination to check if there is any dilatation of her cervix, check for signs of rupture of membranes and take swabs to check for infection. If there is any bleeding, it also allows me to assess how heavy it is, and assess where it is coming from. I will only perform a VE if she seems to be in active labour what else would make you think so apart from the fact that she is contracting? What is active labour, as opposed to active first stage which is progressive dilatation beyond 4cm? Is that what you mean? (if placenta is not low)

(B) Risk factors for preterm delivery can be maternal, fetal or pregnancy related. Maternal factors include any medical or surgical problems such as diabetes, hypertension, cardiac or renal problems, autoimmune disorders that may cause spontaneous or iatrogenic pre-term delivery is this question asking about iatrogenic pre-term delivery? . Other predisposing factors include maternal infection/inflammation (such as pyelonephritis, urinary tract infection, appendicitis, septicaemia etc no marks for this ). Anatomical factors include cervical weakness or abnormally shaped uterus (such as bicounuate uterus). Pregnancy factors, include multiple pregnancies, chorioamnionitis or abruption. Fetal factors include growth restriction, polyhydramnios. you were not asked for a list of risk factors. You were asked to DISCUSS: Demonstrate that having assessed the woman, you can come to some assessment of the likelihood of pre-term delivery. A previous Hx of pre-term delivery would be the most important factor

(C) Tocolytics should be considered if there is no contraindications not necessary ; and the patient is in threatened pre-term labour which she is by virtue of contractions . It is of no benefit if she is in established labour. There should not be any bleeding, fetal distress or signs of infection you were not asked about the drugs you would consider. You were asked about the drugs you would use . Tocolytics can prolong a pregnancy up to 7 days inorder to administer steroids for fetal lung maturity or intrauterine transfer. other than that, it has not much benefit in terms of improving fetal outcome. Betamimetics such as ritrodrine is associated with a lot of adverse effects (such as pulmonary oedeme), and has fallen out of favour you have already spent a lot of time / space and not yet mentioned a single drug that you would use . Nifedipine and atosiban has similar efficacy to ritrodrine, but is associated with less side effects. Nifedipine has to advantage of being cheap and given orally, 10mg every 15 mins (maximum 1 hour) if her contractions do not improve. Then she is given nifedipine every 4 hours (1) (dosage depends on initial dose). Atosiban is more expensive and requires to be given intravenously. A bolus dose is given slowly and maintenance dose given for up to 48 hours (1) .
Intramuscular steroid (dexamethasone or betamethasone 12mg which would you use? Are the effects / consequences identical? , 12 or 24 hours apart, 2 doses in total) should be given if there are no contradications such as severe infection (maternal or chorioamnionitis). It is to help mature the fetal lungs to reduce the risk of respitatory distress syndrome in the neonate (1) .
Antibiotic such as oral erythromycin (250mg qds) should be considered ?? if there is ruptured membranes +/- threatened preterm labour to reduce the risk of infection inthe pregnancy/fetus having considered them in this situation, would you give them??? . It should not be given is there is no ruptured membranes, as it is associated with an increased risk of cerebral palsy. Augmentin is associated with increased risk of necrotising enterocolitis so would you give it? You were asked about the drugs you would use .
Pain relief in the form of inhaled nitrous oxide or intramuscular opiates may help settle an irritable uterus do they provide pain relief of alter uterine activity?

You have substantial factual knowledge. You need to develop a practical decisive method of converting that knowledge into a focused answer. Your answer is almost too long
.
Posted by PAUL A.
Confirm the gestational age from LMP and early scans.Would like to know about the intensity and frequency regarding the uterine contractions (1) .History regarding, if any presence of per vaginal bleeding,gush of fluid or trickling ,any foul smelling discharge , urinary symptoms like urgency (1) , frequency and dysuria.Past obstetric history including any previous preterm deliveries (1) .past gynaecological history including any cervical procedures like biopsies or LLETZ . would enquire regardind fetal movements.History regarding any recent trauma to the abdomen need more detail to explain why these are important .

General examination include pulse and temperature why? ,blood pressure.Abdominal palpation for fundal height,fetal lie , position, tenderness,contractions and fetal heart rate.
pad inspection for any fluid,speculum inspection for pooling of the liquor (1) ,bleeding and cervical dilatation.ultrasound scan for an estimated fetal weight,liquor,presentation,any anomalies.
Electronic fetal monitoring for fetal well being.FBC,CRP,MSU culture and sensitivity why? You have simply written a list ,high vaginal swabs,endocervical swabs.Fetal fibronectin testing (1) what is the value of this test? in the abscence of cervical dilatation and membrane rupture is performed. you have presented an undergraduate answer – these are the tests we do. A post-graduate answer should include why the tests are relevant and if appropriate, their limitations

Factors which determine the likelihood of premature labor are,uterine factors like polyhydramnios,multiple pregnancies,anomalies like septate or bicornuate uterus,fibroids,cervical biopsies this is what you will expect from a final year med student. You were not asked to list. You were asked to discuss .Fetal factors like abnormal lie,presentation do abnormal lie / presentation contribute to premature labour? So if the fetus is in a transverse lie at 10am at 24 weeks gestation, the woman is at increased risk of preterm labour?? ,anomalies can contribute towards premature labour.Asymptomatic bacteruria,Group B streptococcal infection , preterm rupture of membranes , previous history of preterm deliveries lead to premature labor.Other factors like poor nutritional status,low socioeconomic status,alcohol, smoking,drugs also contribute. you have not discussed anything. It is not clear, for instance, that you recognise that a history of previous preterm delivery is the most important factor

Judicial usage of the drugs based on the department protocol would be preferred in the treatment of preterm labor.
Commence corticosteroids , intramuscular betamethasone 12mg 2 doses ,24 hours apart .It aids in fetal lung maturation and significantly decreases perinatal morbidity and mortality (1) . Ideally to be adminstered 48hrs to 7 days before preterm labor.Tocolytics are all equal in their efficacy,its the side effects profile which varies.Oxytocin antagonist atosiban is given intravenously as loading and maintanence doses.Total duration of the treatment should not
exceed 48 hours (1) .Oral erythromycin should be commencd in the presence of ruptured membranes , 250mg qid for a total of 10days (1) .Thromboprophylaxis during postpartum period for the high risk groups should be provided,in the form LMWH.IV penicillin 3g, and 1.5 g 4hrly should be administered for GBS positive mothers during intrapartum.
Posted by PAUL A.
a. A good history, focussed physical examination and investigations should be carried out waste of time & space .
A careful look at how do you look at this? when uterine contractions began, how strong it is and how often they have been occuring is very important. Abdominal pain may feature in this presentation she presented with contractions . Hence, patient should be asked about onset of pain, severity, site and radiation. A history of what makes the pain worse or better should taken. Every associated sypmtoms such as amount of bleeding per vaginam, any urinary symptoms do you mean any urinary symptom? Are there specific symptoms you are looking for or is any symptom just as important? and liquor leakage.
A careful look how do you look? Is this history or examination? present pregnancy is important. Patient\'s last menstrual period should be correlated with an early dating scan to establish the appropriate gestational age you have been given gestation age . The number of fetuses is also important as twin gestation is one of the leading causes of preterm delivery. A careful look at patient\'s handheld notes will reveal if any anomaly had been identified in current pregnancy.
Patient\'s past obstetric history is important and should be explored. Number of pregnancies, when and how they ended are important. A history of previous preterm delivery is the most significant point in her past history (1) .
Previous history of cervical surgery or laceration during childbirth is important. A history of diabetes mellitus, antiphospholipids syndrome, epilepsy to mention these few HEALTHY woman – what is it that makes these few relevant? , shuold be asked. History of cigarette smoking, alcohol use and use of other illicit drugs is important. A family history of preterm delivery should also be noted ? relevance?? .
Initial examination will involve looking at patient\'s general status and to resuscitate if shocked or unstable. A cursory look at patient\'s vital signs is important if it is important, why does it have to be cursory?? . Abdominal examination should involve estimating symphysio-fundal height, fetal presentation, lie, heart rate and a rough estimation of liquor volume. Uterine tenderness may point to placental abruption as the cause of preterm labour would you palpate contractions? .
With patient\'s consent, a careful vaginal examination may provide a useful hint towards the diagnosis. Patient should be examined with a chaperone. An aseptic speculum will reveal presence of cord, liquor or blood (1) . A high vaginal swab should be taken and sent for microscopy, culture and sensitivity. Digital examination should be performed if membranes are still intact and, may confirm cervical dilatation, thinning and an intact or ruptured membranes.
An intravenous venflon should be cited, and blood taken for full blood count and other blood tests as dictated by medical history. A midstream urine should be sent for microscopy, culture and sensitivity (1) . A 30 minutes cardiotocography trace is mandatory to check fetal status. Special care baby unit and Paediatricians
should be informed and availability of cot should be ascertained.

B. Previous history of preterm delivery is the single most important risk factors for preterm delivery (1) . Other important risk factors are presence of multiple pregnancies with its attendant omplications such as twin to twin transfusion syndrome, previous cervical surgery or injury such cervical excisional procedures and cervical laceration at childbirth. History of cigarette smoking, alcohol use and illicit drugs are important.
Multiple congenital anomalies and antepartum haemorrhage are other risk factors for preterm delivery. do these tell you how likely she is to deliver preterm?

C. I will consider you were not asked about what you will consider using the use of antenatal steriods, tocolytics in indicated and antibiotics.
Firstly, antenatal steroids have been shown to be beneficial to fetus if used 48 hours to one week before preterm delivery and should be initiated as soon as possible. I will consider using betamethasone 24mg intramuscularly within 48 hours having considered it, will you use it or will you not? . This has been shown to reduce respiratory distress syndrome, intracranial haemorrhage and bowel necrosis. However, it may be counterproductive in diabetics. when will you give it and how???
Once preterm labour is established and delivery is imminent, I will start intravenous antibiotics as benzyl penicillin 3g start and 1.5g 4 hourly until delivery why? What is the evidence?? . In patient with allergy to penicillin, I will start clindamycin intravenously.
Tocolytics such as atosiban, nifedipine and indomethacin to mention these few why just these few? Will you use all of these? Which one will you use, when and how? , have not been shown to be useful more than 48 hours. Hence, they may be started to allow antenatal steroids to work or when a patient is been considered for inutero transfer to tertiary hospital (1) with neonatal intensive care facilities. I will consider starting these drugs immediately if there are no contraindications to it use. Contraindication include antepartum haemorrhage, intrauterine growth restriction, chorioamnionitis, multiple congenital anomalies, advanced labour or other maternal conditions that necessitated immediate delivery.
Posted by PAUL A.
As History suggest ,a case of pre term labour , I will like to know the nature of pain she presented with contractions, NOT pain , like constant tonic pain or intermittent pain,& how long pain persist, & how frequently she gets it. As constant tonic pain may be abruption placenta. History of any pv bleeding or leaking through vagina at present or in recent past ,to rule out APH or PPROM (1) respectively. Hx of fever, or dysurea may be cause of infection in the form of chorioamnionitis or UTI ( may be asymptomatic bacteruria how will it be asymptomatic if she has dysuria? ).Hx of previous preterm labour (1) & recurrent pregnancy loss ,is a risk factor . Ethinicity ,non white race ? relevance – will you pay less attention to Caucasian women? & poor socioeconomic factor also a risk factor for preterm labour.Any surgery in the form of amputation , or repeated dilation & curettage of os may cause preterm labour.Any Hx of trauma to abdomen may be a factor for preterm labour,so it should be explored .On examination,I would like to assess her general condition like Temperature, pulse, BP & BMI, as BMI less than 19 at booking visit has a significant risk for preterm labour. Per abdominal exam ,to ensure the gestational age by measuring uterine height in singleton pregnancy & presentation, lie of the fetus would you palpate the contractions? . Per speculum exam should be done to assess any leaking, dilation of cervix how do you assess dilatation on speculum examination?? . During per speculum exam if required what will make this necessary? high vaginal swab can be taken for culture & rule out the infection. Other investigations like FBC,CRP,MSU for microscopy & culture,U & E to rule out infection (1) will you do U&E to exclude infection? .USG, may be an important investigation,to measure cx length what use is this at 28 weeks? ,Placental location,presentation,lie of the fetus ,fetal wt,& anomaly.
Factors which determines the likelihood of labour,is the status of the cx like dilation,effacement,PPROM,previous surgery of cx,& congenital anomalies of fetus this is a list – you were asked to discuss .As cervical dilation >3cm,& cx length <20 mm , may does it or does it not? increase the chance preterm delivery .,Chorioamnionitis may need immediate delivery,& PPROM is another risk factor for preterm labour (1) .
The drugs in the form of tocholytics,like betamimetics(ritordine or terbutalin),Calcium channel blockers,(nifedipine),Oxytocin antagonist like atosiban,.may help for delaying the delivery for 48hrs to 7 days.MgSo4 as a tocholytics may not be helpful rather it has significant adverse effect on perinatal morbidity so it is not recommended .Indomethasin ,a COX inhibiter may be used as a tocholytics which drug would you use, WHEN & HOW? .Single course of Corticosteroids ,betamethasone 12 mg 24 hr apart, should be used for fetal lung maturity (1) WHEN & HOW? .Antibiotics in the form of Erythromycin ,in case of PPROM HOW? Would you give it iv? ,helps in preventing morbidity & prolongation of pregnancy .Tocholytics are helpful to delay the labour during which time corticosteroids can be given for lung maturity.It is also helpful for transfering the patient with fetus in utero to higher centre because of lack of SCBU (1) .
Posted by PAUL A.
a.
Initial assessment will involve a review of her past obstetric history, noting her parity, modes of delivery and any history of preterm deliveries (1) . A review of the index pregnancy should also be done, confirming her dates, number of fetuses and noting her anomaly ultrasound findings, including the placental location.
Further detail of her presenting complaint will be obtained, including the severity and frequency of the contractions (1) over the past 12 hours, any associated vaginal bleeding, and loss of liquor (1) . Fetal movements will be enquired about. Any history of a febrile illness, urinary you specifically need symptoms of UTI and bowel symptoms is also noted.
Her medical and surgical history HEALTHY woman will be obtained, especially any history of any cervical surgery.
Clinical examination will include temperature, pulse and blood pressure; abdominal examination for symphysio-fundal height to assess growth, and the presentation. The strength of uterine contractions can also be determined from abdominal examination (1) .
A speculum examination will be undertaken, with verbal consent and a chaperone; to assess the cervix for shortening and dilatation how do you assess dilatation on speculum examination? , and note any bleeding or liquor. A high vaginal swab and a fetal fibronectin (1) , or similar test, can be done at the same time, to screen for vaginal infections and predict the likelihood of preterm delivery respectively.
A cardiotocograph will be done to assess the fatal heart rate and the frequency of contractions.
Blood will be sent for a full blood count for haemoglobin and white cell count and CRP as a marker for inflammation. Urinalysis should be done, with urine sent for culture and sensitivity if suggestive of infection with leucocytes and nitrites (1) .
A clinical diagnosis can be arrived from the above assessment.

b.
Factors that determine the likelihood of preterm delivery include-:
1. Previous history is associated with a high risk of recurrence.
2. Preterm Prelabour Rupture of Membranes- this is associated with the release of prostaglandins as well as subclinical or overt intrauterine infection, all leading to preterm delivery.
3. Uterine irritability form antepartum haemorrhage and febrile illnesses, also urinary tract infections/
4. Uterine distension- multiple pregnancy and polyhydramnious.
5. Cervical incompetence secondary to shortening from previous surgery or from connective tissue disorders.
6. Uterine anomalies and submucous fibroids are also associated with preterm labour.
7. Certain medical conditions- inflammatory bowel disease, chronic renal failure, autoimmune diseases- maybe associated with preterm labour and delivery, sometime iatrogenic.
if numbering your answer is appropriate, why did you not number the factors you will assess in the history, examination and investigations?
c.
Drugs considered in the setting of preterm labour include tocolytics, to abort/ameliorate contractions long enough to enable administered corticosteroids have an effect in improving fetal lung maturity.
There are different groups of tocolytic agents, similar in efficacy, but with a varied side effect profile.
Atosiban is an oxytocin antagonist which is given intravenously as a bolus and then maintenance infusion (1) when would you give it?. Side effects include nausea, vomiting.
B-sympathomimetc agents- terbutaline and salbutamol, given i.v or inhaled. Side effects and mostly cardiovascular- with palpitations, tachycardia, flushing.
Calcium channel blocker Nifedipine is used, with side effects being hypotension, headache WHEN & HOW? That was specifically asked for in the question .
Indomethacin, a NSAID, is an effective tocolytic with the side effect of early closure of the ductus arteriosus and also possible oligohydramnious. It is usually given orally.
Isorsobide mono/dinitrate is also used with hypotension being the main side effect

Betamethasome (or Dexamethasone) are the consequences identical? 12mg intramuscular, 2 doses 24 hours apart, is recommended to improve fetal lung maturity if less than 34 weeks gestation (1) .

Appropriate analgesia and antiemetics is recommended.

With ruptured membranes, erythromycin 250mg qds x 10 days,is recommended as prophylaxis against chorioamnionitis how would you give it – iv?? .
Posted by PAUL A.
a/ A history should be taken on contractions (start, duration, response to analgesics, any precipitating factors such as spontaneous rupture of membranes proceeding contractions). History of preterm labour in past obstetric history if a multiparous should be taken as previous preterm delivery is associated with recurrent preterm deliveries (1) . Systemic review should be done to exclude infections as infections are associated with preterm labour (urinary tract infections (1) , respiratory tract infections). Medical history and Surgical history read the question - HEALTHY is important on management (may need anaesthetist’s review pre-operatively if high risk and surgical history may be significant if there’s a history such as previous myomectomy opening into uterine cavity which would indicate the indication for a caesarean section if in preterm labour).
Antenatal notes should be reviewed to look for risks (E.g. HIV positivity, Hypertension) in index pregnancy ? relevance to the question .
Examination includes general examination (E.g.: pallor for anaemia), systems examination including Cardiovascular system (pulse, BP. Heart if any particular complaints such as chest pains, shortness of breath a healthy woman complains of contractions – why consider every other possible disease? The question is set to focus your answer ), Respiratory system. Abdominal examination includes fundal height (to check whether equal to dates), any tenderness in uterus ( if abruption or chorioamnionitis may have uterine tenderness), renal angle tenderness (if pyelonephritis which could precipitate pre term labour) and palpation for uterine contractions (1) . If contracting, the duration and frequency of contractions should be checked. A speculum and a vaginal examination is important if there are palpable uterine contractions or history of rupture of membranes or bleeding per vagina (1) . A low vaginal swab should be taken to exclude infections such as bacterial vaginosis (which can give rise to pre term labour) and to exclude group B streptococcus, which indicates antibiotic prophylaxis in established labour. (Any examination and investigations should be done following patient’s consent).
Fetal heart should be checked with a Cardiotocograph if contracting (to determine whether normal, suspicious or a pathological CTG). Fetal lie should be palpated (if transverse lie and in established labour, will need an emergency caesarean section).
A mid stream urine sample should be dip stixed to look for urine tract infections (UTI) ( for nitrites) and to send for culture and sensitivity if suggestive of a UTI (1) .
Bloods include full blood count, group and save. May need all acute abdomen bloods including renal function tests, liver function tests if suggestive of an acute abdomen why should a healthy woman complaining of contractions have an acute abdomen? ( also if preeclampsia which may precipitate preterm labour what if she had diabetes mellitus or polyhydramnios or cervical incompetence? If there were marks for ‘if she has xxx’ there will be no marks left for the main question asked ).


b/ In index pregnancy any precipitation factors such as a UTI, Spontaneous rupture of membranes (SRM) are associated with preterm labour. Any features suggestive of Chorioamnionitis will give rise to preterm labour is this correct? Maternal tachycardia may suggest chorioamnionitis so does maternal tachycardia give rise to preterm labour? . If SRM, around 90% may go into established labour within 72 hours since SRM this is not correct . Previous history of preterm labour is associated with preterm labour in index pregnancy. Also, multiple pregnancy is associated with preterm labour. Placental abruption may precipitate preterm labour. Intra-uterine death may give rise to pre-term labour.
you have simply given a list of risk factors for preterm labour with no discussion. If you saw this woman, what would make you think she is highly likely (or unlikely) to deliver pre-term?


c/ If in preterm labour (PTL, where there are regular uterine contractions and cervical changes) I would suggest steroid therapy with 12mg of Betamethasone 24 hours apart Intramascular 2 doses as Steroids in preterm labour reduces morbidity and mortality due to respiratory diseases such as transient tachypnoea of new born, respiratory distress syndrome (1) . Also steroids are associated with reduction in intraventricular haemorrhages and necrotising enterocolitis. I will also start her on Normal saline infusion as this is known to inhibit Pituitary secretion of Oxytocin , there by preventing preterm labour ? evidence??? What is the evidence that pituitary oxytocin plays any role in the onset of term / pre-term labour in humans??? .
If the patient is in PTL, I will start her on tocolytic drugs according to availability in my unit. The tocolytic drugs used in UK are Nifedipine (though not licensed to use) or Atosiban. Other drugs such as Ritodrine are not in use due to side effects compared to Nifedipine or Atosiban how is this administered? .
I would start the patient on Nifedipine Oral 10mg every 15 minutes until the contractions cease. Then 20mg tds can be given for 48 hours (1) . If there’s ruptured membranes, Erythromycin 250mg tds will be given for 10 days to prevent infection ? iv?? . If there is symptoms and signs suggestive of chorioamnionitis, broad spectrum antibiotics such as Cephalexin and Metronidazole should be given (IV if fever or can not take orally due to vomiting). If there’s UTI, I will give an antibiotic such as Cephalexin or Amixycillin to treat the UTI.
Posted by PAUL A.
Pre-term delivery is the single most important determinent of adverse pregnancy outcome ? meaning?? Outcome for mother or baby? . I will ask her the duration of the pain she presented with contractions, not pain , any associated h/o ?? gush of fluid from vagina (1) to rule out preterm-prelabour rupture of membrane[pprom],color and odor.I will ask any reduced fetal movements to clinically assess fetal wellbeing is this the limit of your history in a woman who presents with contractions at 28 weeks?? .
Clinical examination include pulse rate, blood pressure and temperature measurements.Abdominal examination to know fetal lie, any uterine contrations and tenderness (1) .
A sterile speculum examination is done to look for any pool of fliud in the vagina, any odour, and color of the discharge. I will look for any cevical diatation can you assess dilatation on speculum examination? .Avoid digital examination as it may precipitate the labour and also cause risk of chorioamnionitis. Digital examination is done onlyif there is signs of immediate labour what is this? .
The initial investigation include full blood count to know infection , any leucocytosis. A high vaginal swab is taken to rule infection CRP, urine dipstix + MSU . None invasive procedure ultrasound abdomen is done to look for fetal lie, liqour volume -any oligohydramnoius.
Biophysical profile or doppler is not reqired in the first line surveillance so why write it? There is an endless number of things that are not required so why just this one? .Cardiotocography is done.
B]
Polyhydramious of any cause may lead to preterm labour. Multiple pregnacies are associated with preterm labour then singleton pregnancies.
The other factors are teenage pregancy, previos h/o preterm as if one preterm is associated with 20-40% risk of recurrence.
Preeclampia, urinary tract infection are associated with preterm you were not asked to list the risk factors for preterm labour .
C]
Tablet Erythromycin 250 mg qid is recommended to reduce the risk of preterm, infection and better neonatal outcome in a woman with threatened preterm labour??? (-1) . If Group B Streptococcous is diagnosed the question did not mention anything about GBS – so what if she had bacterial vaginosis or UTI or … are you going to address all these ‘ifs’?? and women is in labour , intrapartum dose of penicllin G is started to avoid neonatal neurological complications.
Tocolytics by itself is of no use in improving the outcome. But it is given to buy time to inject steroids and for in -utero -tranfer.
Atosiban is the recommend drug . Its side effect is nause , hypotension.
Nifedipine is not prescribed in UK. which drugs would you use, WHEN AND HOW? So when would you use tocolytics and how?
Corticosteroids should be given to reduce the risk of respiratatory distresss in newborn. Betamethasone can be given as 12 mg , 2 doses , 24 hours apart orally? . It action is best if treatment - deivery interval is 24hrs to 7 days of the first dose.Dexamethasone is the alternative steroid which can be used .
Posted by Nur Sakina K.
Fr Q A:
My initial assessment begins with a hx, examination and investigations. In the history I’d like to enquire her: LMP- is she sure of her dates?, when was her 1st dating scan. This is to assess her accurate gestational age and number of fetuses. Re the contractions; the frequency, duration and timing of her contractions to assess pattern and regularity. Is there any other associated symptoms with the contractions; ruptured membranes? If so the colour, smell and amount. This is to rule out chorioamniotis. Any associated bleeding? The amount, nature, whether mixed with mucus to elicit if an APH had occurred. If bleeding present, I’d like to ask her blood group and rhesus status as she may need anti-D. Any recent abdominal trauma/assault, urinary symptoms, chest or vaginal discharge which may suggest recent UTI, vaginal infections such as bacterial vaginosis or GBS or systemic infection that may precipitate her preterm contractions. Her current and past obstetrical hx is important. I’d enquire whether this pregnancy had any complications to date? Such as recurrent UTIs, gestational diabetes, pre-eclampsia? When was her most recent scan? I’d like to know the liquor vol for polyhydramnio, growth for IUGR and placenta location for placenta previa. Re previous pregnancies, the gestation at delivery, any previous preterm labours/deliveries and treatments, birth weight of these babies and any complications during those pregnancies. Past gynae hx is important to elicit previous smears and results, any cervical surgery or treatments such as LLETZ or cone bx. This puts her at risk of cervical incompetence. Any known uterine anomalies such as bicornuate or didelphys uterus? In previous medical hx, I’d enquire re poorly controlled hyperthyroidism or diabetes mellitus, cardiovascular disease. This is to assess any contraindications to tocolytic therapy. A social hx is important to enquire re her occupation-whether she is in a stressful, physically strenuous occupation; any recreational drugs-such as cocaine, heroine, smoking and her BMI and nutritional status. I’m aiming to identify any risk factors that may precipitate her preterm labour. I’d like to enquire re her social support at home too.
In the examination; I’d like to plapate the abdomen for fetal presentation, size, liquor vol and to assess for any abdominal tenderness- which can be due to the contractions and to exclude chorioamniotis or abruption (hard rigid abdomen). A speculum examination to assess presence of liquor leak (PPROM), bleeding, PV discharge and cervical dilatation. While doing that I’d like to take a HVS, endocervical swabs if history suggestive of vaginal infection, and swabs for fetal fibronectin. I’d like to get a urine sample to exclude UTI.

Q B:
The factors include: previous history of preterm deliveries- after 1 previous preterm birth she has an up to 20% risk recurrence. Any associated PPROM, where upto 90% usually deliver within 24 hours. A shortened cervical length less than 20mm increases the likelihood of preterm delivery. Presence of APH due to abruption, chorioamniotis or IUGR increases the likelihood of preterm delivery.

Q C:
I would administer betamethasone 12.5 mg IM 24 hours apart by 2 doses or dexamethasone 6 mg IM every 12 hourly by 4 doses immediately. This is to help fetal lung maturity. If initial assessment suggests PPROM and she is contracting regularly, I’d like to administer benzylpenicillin 3 gm i/v stat then 1.5 mg every 4 hourly til delivery. If fetal fibronectin is negative in presence of PPROM, I’d give her erythromycin 250mg qid PO for 10 days. I’d like to start tocolytic therapy to allow completion of steroid treatment or allow in utero transfer if there is no available NICU service. My drug of choice would be Atosiban, an oxytocin receptor antagonist. This is because it is associated with fewer maternal side effects compared to the beta-agonists. An initial bolus dose of 6.75 mg given over 1 min, followed by an infusion of 18 mg/hr for three hours, and then 6 mg/hr for up to 45 hours. The duration of treatment should not exceed 48 hours and the total dose given during a full course should not exceed 330mg.
Posted by Nur Sakina K.
dear paul,

i\'ve a few queries i hope u can answer:

Q A: asks INITIAL ASSESSMENT. so is performing a CTG and blood tests considered INITIAL assessement?what does INITIAL assessment in any essay q\'s usually look for? (hx, examination and ix at our initial encounter with the patient?)

Q: i note u replied in one of the answers, \"how do u asess cx dilatation on speculum?\" i\'ve always been taught to check with speculum examination 1st for cx dilatation and only VE if cant see cx on speculum. and yes, i\'ve been successful at assessing cx dilatation on inspection of cx via speculum examination. do u think i should include doing a VE to asess dilation in essays/clinical practise? thanks for the advise.
Posted by PAUL A.
Preterm birth is associated with significant perinatal morbidity and mortality so management aims at improving the outcome not necessary . History and examination is essential to find out cause not necessary .I will ask about rupture of membranes ,vaginal bleeding (1) [abruption],infections especially symptoms ofurinary tract infection like frequency,dysuria (1) and any bowel comlaint like diarrhoea.Any histort of vaginal discharge. whether singleton or multiple pregnancy and any fetal anomaly or polyhydramnias.I will take previous obstetric history of preterm labour (1) as it is most important predictor of recurrence-.History of previous antenatal complications like mid trimester miscarriages, preeclampsia ,IUGR [APS/thrombophilia]and pregnancy outcome.I will ask about any uterine malformation ,cervical surgery[cone biopsy]or surgical cervical dilatation as it can cause cervical incompetence. As she is healthy so medical history may be unremarkable you do not get marks for repeating the question – you are wasting your time & space .I will ask about smoking,illicit drug use,alcohol,hygiene and socioeconomic status as these are minor risk factors associated with PTL what will you do differently in a woman in social class IV compared to class I? Do you really ask for this when you see women? .In examination I will check her pulse,BP and temp.In abdominal examination I will check for fundal height, fetal lie,presentation,presence of contractions (1) ,tone,and uterine tenderness in case of abruption or chorioamnionitis.Iwill do speculum examination to identify pooling of liquor,vaginal bleeding or discharge and visual assessment for cervical dilatation how do you do this? How do you tell a cervix that is 4cm dilated from one that is 2cm dilated on speculum examination? /effacement .I will take low vaginal swabs,uretharal and rectal swabs for group B streptococcus .Per vaginal examination should be avoided as it can accelerate labour process and cause ascending infection.If done it should be limited limited to what? If you do it, it should be complete and thorough. Will you do any investigations? .
B] These include obstetric factors like previous preterm delivery as it is most important predictor of recurrence[15-20% if one and 35%-40% if previous two preterm deliveries] (1) .Multiple pregnancy and polyhydramnias cause uterine overdistention.Malformations of uterus like bicornuate ut,uterine fibroids[submucosal] and cervical incompetence.Infections like chorioamnionitis,asymptomatic bacteriuria,pyelonephritis and bacterial vaginosis either directaly cause or by releasing chemical mediators initiate preterm labour.placental abruption and previa also important factors.preeclampsia,fetal anomalies and trauma[surgical and others]can also cause it.smoking ,alcohol,recreational drugs,low BMI,low socioeconomic status can also contribute you were not asked to list the risk factors for preterm delivery. Having assessed this woman, what will make you decide she is highly likely / unlikely to deliver preterm? .
C] If it is a genuine preterm labour now do you know if it is genuine? Two women attend at 28 weeks with contractions and a closed cervix at 10am – by 2pm, one of them is delivered and the other has gone home. How do you decide at 10am which is ‘genuine’??? If you can, then you have a solution to one of the major obstetric problems and there is no contraindications to tocolysis like chorioamnionitis,abruption,fetal anomaly etc,Iwill start tocolysis.Although tocolysis itself does not improve outcome but it allows time for corticosteroids action on lungs or if in utero transfer to other hospital if required for SCBU.Ritrodine is no longer a best choicebecause of adverse maternal effects.Atosiban[oxytocin antagonist] and nifedipine[ca channel blocker]are better choices with less side effects and comparable results in delaying delivery for few days.Nifidipene is cheaper than Atosiban and can be used orally but is not licensced in uk for tocolysis so risk and benefits should be explained and informed consent should be taken before its use.Atosiban is expensive and requires intravenous administration but is licensed in uk so i will use it according to my local unit protocol (1) .Maintaience tocolytic treatement is not recommended do you gine a maintenance infusion of atosiban? .I will give two IM dosesof Betamethasone 24 hrs apart (1) because there is evidence that corticosteroids significantly reduces risk of RDS,intraventricular hemorrhage and perinatal mortality.No sideeffects with single administration.Iwill not give antibiotics if membranes are intact however if ruptured than oral tab erythromycin 250mg 8hrly is to be given (1) .If urinary tract infection or other systemic infection is suspected I will give appropriate antibiotic orally/iv depending on severity.If abruption than anti D in non sensitized women.
Posted by PAUL A.
I would start by taking a good history and a thorough examination supported by some investigations you clearly recognise that this is not part of the answer to section (a) which is below – so why write it? There is no extra space / time for anything other than the answer to the question asked .

a). History to exclude presenting complaint of vaginal bleeding, liquor drainage, vaginal discharge, foetal movements, abdominal pain, fever, dehydration, urinary symptoms the question gives you her presenting complaint – contractions. You do not get marks for writing a list

Know more about the contractions- for how often, duration, regular/irregular, becoming more severe (1) ?

Previous history of similar episodes, cervical injury including cone biopsy, trauma should be looked for.

Medical history- hypertension, Diabetes HEALTHY , past history of premature rupture of membranes,

History of smoking/ alcohol/ illegal drugs need to be excluded since these can cause preterm labour.

Any evidence of Sexually transmitted diseases since infections are a risk factor too.

On Examination- Fever, abdominal examination- size of the uterus, presentation, lie, liquor, tenderness, pulse

Sterile speculem examination for liquor and its colour and smell. If blood is present then the amount and perform Kleihaur test. If Rh negative administer Rhogam what is this?? .

Check for foetal fibonectin in the vaginal secretions. Its a sensitive test but not a very specific test test for what? Infection?? .

CTG- look for the contractions and how strong they are and the base line variability and the beat to beat variability CTG does not give you this .

USS- liquor, Biophysical profile, Estimated Foetal weight

Blood for Full blood count, CRP, Random blood sugar levels why?? , MSSU and urine for culture and sensitivity (1) will be also sent. I will make sure she has her blood group and Rh type known already if not I would order them too.


b).
Previous preterm deliveries (1) in multiparous women since they will be more likely to have another one.
cervical trauma or surgery like cone biopsy or LLEEPZ procedure may cause incompetence of the cervix.
Multiple pregnancies or increased volume of liquor as in polyhydramnios can lead to preterm labour due to overdistension of the uterus.
obesity is a known risk factor for preterm birth.
Premature rupture of membranes eventually leads to preterm delivery in most women.
Chorio amnionitis also is a cause for preterm delivery

you were not asked to list the causes of preterm labour. Just saying a is A cause of preterm delivery and B is also a cause does not amount to a discussion

c). Tocolytics- can be used for in utero transferto a tertiary unit and or for completion of steroid therapy


Atosiban- Oxytocin antagonist
Salbutamol- side effects- tachy cardia,Hypertension, Diabetogenic effect
Ritodrine- Less side effects compared to what? ,can be used orally
Nifedipine- Oral this is not a sentence and is meaningless. If the examiner wants to know if you know which drugs have a tocolytic effect, they will test this in an MCQ. They want to know if you know which of these drugs should be used, when and how.



Steroids- to promote lung maturity, not if impending delivery, needs 24 hours to act
Betamethasone- 12mg daily X 2 doses,
Dexamethasone- 6mg 12 hourly X 4 doses
IV Hydrocortison- Not found to be very effective
so which of the above drugs would you use and when?
Erythromycin- to prevent ascending infection if thre is rupture of membranes how? .

Thromboprophylaxis- Low molecular weight heparin is found to be safe in pregnancy
Posted by Ron C.
RnRn

A.
In my history I’ll ask about exact nature of contractions; regularity, interval, duration & intensity. I’ll ask regarding show or leaking, as well as complaints of dysuria / frequency. I’ll inform on fetal movements, current pregnancy and presence of any problems eg hypertension, diabetes, polyhydramnion, infection, irregular antibodies, bacterial vaginosis or GBS-positive status. History of previous pregnancies, in particular premature delivery. I’ll ask regarding previous uterine instrumentation; dilatation & curettage, LLETZ or conisation. On examination I’ll assess blood pressure, pulse rate & temperature. Abdominal examination to clinically assess polyhydramnion, fetal size and presence / frequency of contractions and any tenderness. Speculum examination to assess cervix, presence of pooling liquor, vaginal swabs and fibronectin test. CTG is done to assess fetal condition and presence of any tightening / contractions. A urine sample is tested for infection. Only if cervix can’t be properly assessed and neither history or examination are suggestive for ruptured membranes I’ll consider vaginal examination for cervical assessment.

B.
Presence of regular, increasingly intense contractions with cervical shortening and / or dilation is highly suggestive for premature delivery. Likelihood is much increased in presence of ruptured membranes and / or infection. A positive history of premature delivery or cervical procedures likewise increases the likelihood. If a fibronectin test is negative, likelihood of a delivery in the next 7-10 days is very small, if positive, premature delivery is likely, keeping in mind up to 25% false-positives

C.
If based on history, examination and presence of risk factors, premature delivery is likely, I will give Beta-methasone 12 mg i.m. stat, to be repeated once more 24 hours later. This will reduce incidence of neonatal pulmonary problems. As effect of this is maximal after 48 hours, I’m keen to prolong pregnancy at least 48 hours. If I’m worried I won’t be able to postpone delivery that long, or if I need to transfer the patient due to lack of NNU capacity, I will start tocolysis. As it has less side-effects than the beta-sympathico-mimetic drugs used in the past, I will start her on Nifedipine oral tablets, 10 mg every 15 minutes till tocolysed, maximum x4, and thereafter 20-40 mg bd. If not available, Atosiban is a good (though more expensive) alternative. It is given as an i.v. bolus, followed by i.v. maintenance infusion, either till contractions have gone or till max. 48 hours. If a urinary tract infection was noted this may cause or increase uterine irritability and I will give antibiotics, such as trimethoprim 200 mg bd for 1 week. If however membranes were ruptured, I will give oral eythromycine 250 mg qid for 10 days, as this improves fetal outcome with lower risk for NEC in the neonate.
Posted by Manoj M.

(a)A history of rupture of membranes may suggest more likelyhood of preterm labour, history of bleeding may suggest an underlying cause of contractions like abruption.
History of fetal movements to assess fetal viability.
past history of previous pregnancy and outcomes may suggest increased risk for preterm labour e.g. previous previous peterm labour.
Associated urinary symptoms like dysuria and or bowel symptoms to exclude localised causes of uterine irritibility.
Social history of smoking, drug and alcohol misuse may suggest increased risk of preterm labour.
General physical examination including pulse, BP, temperature will assist in initial assessment of this patient.
Abdominal palpation to confirm palpable contraction with given history and exclude other possibilities like woody uterus with abruption. Palpation of fetal presentation and lie as imminent risk of preterm labour.
confirm fetal condition with CTG monitoring as regular contraction and likelyhood of preterm labour, if difficulty in obtaining fetal heart ultrasound to confirm fetal viability.
speculum examination to exclude rupture of membranes and if not then for fetal fibronectin testing(this has better negative predictive value plus than positive predictive value)
bimanual assessment of cervix to confirm in preterm labour and likelihood of imminent delivery and for organising care further care.

(b) A previous preterm delivery at similar gestation may suggest morelikely peterm labour.
Combination of regular contraction along with progressive cervical dilation would suggest preterm labour
A history of rupture of membranes and or vaginal bleeding is another strong factor.
Obstetric risk factors like current preeclampsia, smoking drug and alcohol misuse.
Examination findings of low presenting part with/without cervical dilation.
fetal fibronectin if negative has better prognostic value than being positive.

(c) Steroid therapy with betamethasone 12mg intramuscular injection given 12hour apart in 2 doses to reduce risk of prematurity like respiratory distress syndrome, intrventricular haemorrhage.
Tocolytics like Atosiban with loading dose followed by maintanence doses to complete steroid therapy /or for in-utero transport.
Alternative tocolytics like Nifedipine as oral tablets, but definite regimen not available for the same and Ritodrine is associated with complication like pulmonary edema.
Antibiotic therapy for preterm labour is not recommended unless evidence of rupture of membranes, then treat with Erythromicin 250mg qid for 10 days.
Simple analgesics for pain relief options e.g. paracetamol as oral tablets, if not coping alternative options include opiates and epidural anesthesia.


Posted by PAUL A.
Preterm labour is initiation of uterine contractions before 37 completed weeks. It can lead to premature delivery with its associated increased risk of perinatal mortality and morbidity you were not asked for a definition .
Initial assessment includes history, examination, & investigation waste of time & space . In the history, confirm the gestational age by reviewing the dating scan. History of the pain, any associated dysurea to rule out UTI (1) ; any associated vaginal discharge to rule out infection; Because UTI and vaginal infection can precipitate PTL. ASk about leaking to rule out PPROM (1) . Also enquire about any trauma history to rule out possibility of abruptin.
Review current pregnancy for ANC, no of fetuses,any recurrent urinary tract & vaginal infections, macrosomia, history of bleeding or threatened miscarriage, because all these factors can precipitate PTL.
Review past obstetric history, for parity, history of preterm labour and delivery (1) .
Any past history of cervical surgeries and cone biopsy.
Examine the general look of the patient, is she in pain, conscious.
Check B.P., pulse rate, temperature, & respiratory rate. Abdominal examination, check for tenderness to rule out abruption; SFH to confirm gestation; lie & presentation to determine mode of delivery if delivery is needed; and check the FHR to confirm viability and rule out distress would you palpate contractions? .
Vaginal speculum examination for cervical dilatation how do you tell if the cervix is 2cm or 4cm dilated on speculum examination? , and to rule out bleeding & leaking. Take a high vaginal swab.
Invstigations, do FBC for HB level to rule out anaemia, look for leukocytosis to rule out infection, and platelets to rule out coagulopathy. Send urine for R/M & C/S what are these? The examiner does not work in your hospital to rule out UTI.
Ultrasound is requested for gestational age are you going to request a scan at 28 weeks for gestational age??? (-1) & estimated fetal weight to inform paediatrician in case delivery is needed. Check the lie and presentation ( mode of delivery ). AFI to rule out leaking does this RULE OUT leaking?? . Do placental localization, and look for abruption if possible what will make this possible? How useful is ultrasound scanning in detecting abruption? .
CTG to confirm normality of FHR, and for contractions frequency and intensity how do you determine intensity of contractions on CTG??? (-1) .
Factors that determine delivery are maternal or fetal. Maternal factors includes active labour with dilated cervix (1) , indicating that delivery can\'t be prevented. Severe bleeding with maternal & /or fetal distress necessitating urgent delivery to save mother &/or fetal life. Associated severe abruption with maternal deterioration and fetal distress. Presence of associated medical problem like HTN, pre-eclampsia, eclampsia, or HELLP HEALTHY , with which delivery is needed to resolve the problem and save the mother\'s life.
Fetal factors include severe fetal distress, severe IUGR , with which delivery is needed to prevent fetal death. IUFD where delivery is neded to reduce maternal psychological distress.

The drugs given include corticosteroids to enhance fetal lung maturity in case delivery is needed. It is given as dexamethasone intramuscular injection 12 mg 12 hourly for 1 day. betamethasone 12mg 24h apart
Tocolytics is given to delay delivery either to allow time for corticosteroids to work, or for in utero transfer for another center with NICU service.
Tocolytics include Atosiban, nifedipine, ritodrinr MgSo4 and others. Atosiban is given as a bolus dose followed by in fusion (1) pumb. hospital protocol for administration should be followed. Ritodrine ( B- mimetic ) is no longer recommended because of its side effects. Nifedipine can be given orally (1) ,but not licensed for use as tocolytic. Indomethacin can be given as rectal suppository but it has maternal side effects, and risk of fetal premature closure of ductus arteriosus, therefore use is limited.

Antibiotics is given if there is evidence of UTI , vaginal infection, or chorioamnionitis. Antibiotics are given orally or intravenously if severe infection.

Anti D immunoglobulin to RH negative non sesitized mothers, if there\'s associated bleeding. It is given intramuscularly after calculating the needed dose.

Treatment is also given to any associated medical condition, e.g. antihypertensives for HTN or pre-eclampsia, & insulin pump for diabetics.
Blood transusion is given if severe bleeding and after haematologist consultation.

Posted by PAUL A.
This woman may be go into preterm labour which is associated with significant perinatal mortality and morbidity.A detailed history ,clinical examination and some investigations are important in conferming diagnosis,detecting potential causes and fetal condition waste of time and space .
History includes nature of uterine contraction (regularity,intensity and duration (1) ), pervaginal passage of any water fluid or any bleeding or any foul smelling discharge to look for preterm labour or preterm premature rupture of membrane or APH or chorioamnionitis which history suggests which condition? .
Any urinary complain such as dysuria, frequency of micturation or symtoms of cystitis ,pyelonephritis should be asked (1) .
History of fever, hypertention, heart disease healthy woman , fetal movement should also be known.
General examination includes pulse, temperature,blood pressure is to be done.Abdominal examination is done for tenderness,fetal lie and position,frequency,intensity and duration of uterine contraction (1) ,fetal heart rate.
A sterile speculum examination is done to look for cervical dilatation what does a 5cm dilated cervix look like on speculum examination and can you differentiate this from one that is 3cm dilated? and any fluid comes through the cervix. A High vaginal swab is taken.
Fetal wellbeing is cheked by CTG.A ultrasound scan should be done for fetal lie and presentation. Multiple pregnancy, congenital anomaele,intrauterine fetal death, polihydromnios, placenta preaviae can also be detected by USS ? relevance to the question .
BLOOd group and save, full blood count, CRP, HVS for GBS,MSU for culture should also be done (1) .
b)
Obstetrical factors such as preterm rupture of membrane,abruptio placenta, multiple pregnancy, fetal congenitalies or death can stimulate preterm labour.
Multiple pregnancy, fetal congenitalies or death ??? can also stimulate it.
Maternal infection like chorioamnionitis,, urinary tract infection,asymtomatic bacteruria, bacterial vaginosis can facilitates it these are not recognised concepts – what does ‘stimulate’ pre-term labour mean and how is this different from ‘facilitates’ preterm labour? .
Uterine abnormality ,cervical incompetency may cause preterm delivery.
Low socioeconomic status,low prepregnancy weight,heavy smoking sometimes lead to PTD. Stimulate, facilitate, cause and lead to – what is the difference and why have you chosen these words / phrases. The aim of this question is NOT to see if you know the risk factors for preterm delivery. The examiner wants to test whether having assessed a woman, you are able to categorise her into high / low risk with respect to preterm delivery
c)
Any drugs to be used depends upon the unit protocol and the potential cause.Drugs are used to reduce perinatal mortality and morbidity.
If there is no contraindication (fetal death or gross congenital malformatio,abruptio placenta Corticosteriod should be started in form of bethametasone 12mg 24hours apart in 2 doses to reduce the risk of respiratory distress syndrome orally or iv? .
Tocolytics should be initiated to postpone delivery at least 48hours to 7days to allow time for fetal lung maturity and for in utero transfer to an appropriate SCBU unit available hospital.
The recommended tocolytic is Atosiban given in parenteral route as a loading dose followed by a maintenance for 18 hours (1) , reassessed and continued for 48 hours maximum.It is coastly and not available evrywhere.The other alternative is Nifedipine orally as a loading dose 10 mg every 15 minutes till contractions subside (1) , then maintenance dose 20-40 mg 3 times daily for 48 hours.
Erytromycine oraly (250mg qds for 10 days) should be considered if there is ruptured membranes having considered it, would you give it? .
Other antibiotics is given if there is evidence of UTI(cephalosporin) GBS (amoxicillin) is this what you will use for GBS? in appropriate dose. Anti D immunoglobulin to RH negative non sesitized mothers is given after delivery.

Posted by PAUL A.
My answer:


a) Assessment of this patient aims at diagnosis of preterm labor, identification of possible causes and their treatment to prevent preterm delivery, prematurity and its consequences of respiratory distress syndrome, intra ventricular hemorrhage and pulmonary hypoplasia waste of time & space . Information should be obtained about the frequency, intensity and regularity of uterine contractions (1) with vaginal leakage and pressure in the pelvis which indicates imminent delivery does vaginal leakage in any way indicate imminent delivery? . To confirm gestational age, menstrual cycle regularity, LMP, early dating scan reports need to be reviewed. History of previous preterm delivery (1) increases the recurrent risk. Blood pressure, pulse and temperature should be recorded and abdominal examination including FHT, liquor volume, presentation should be carried out would you palpate the contractions? .

A sterile speculum examination should be carried out for any vaginal discharge, drainage of liquor and cervical dilatation can you tell if the cervix is 3 or 5 cm dilated on speculum examination? . High vaginal swabs should be taken for culture and senstivity as infection is a possible cause. If cervix looks dilated then digital assessment for dilatation (1) and effacement should be carried out otherwise it should be avoided due to increase risk of assending infection, release of prosta glandines and initiating or accelerating further contractions.

CTG should be performed for fetal well being and ultrasound performed for fetal viability, presentation and liquor volume.

Blood should be sent for group and save antobodies, full blood count, CRP, and urine for culture and sensitivity (1) .



B) Previous history of preterm delivery (1) increases the risk of recurrent preterm delivery by 20% with one previous PTD and 35%-40% with previous two preterm deliveries. Frequency and intensity of uterine contractions if regular and painful for more than three times in ten minutes ? evidence increases the likelihood of PTD. Also rupture of membranes (1) , cervical dilatation and effacement at presentation (1) are the determinants. Non availability of treatment like tocolytics, steroids and antibiotics also increases the likelihood of imminent delivery why? Given that tocolytics do not prevent preterm delivery, why should their absence increase the likelihood? Do steroids / antibiotics prevent pre-term delivery? .


C) Drugs used in preterm labour includes tocolytics to decrease frequency and intensity of uterine contractions, steroids that is beta methasone for fetal lung maturity and antibiotics if membranes are ruptured. Tocolytics drugs are given to delay delivery upto few days for the effect of steroids or in utero transfer. Commonly used drugs are Atosiban which is oxitocin receptor inhibitor and Nifedepine which is calcium channel blocker. Both are effective with minimal side effects as compared to Beta agonists like Ritordine. Atosiban is expensive and Nifedipine is not licensed in the UK. After discussing with the patient and giving her full information about the drug efficacy, side effects, these may be initiated. Atosiban (1) given intravenusly in three steps:
A bolus dose of 6.75 miligrams over two minutes.
Then eighteen miligram per hour for three hours.
Followed by six miligrams per hour for a total of fortyfive hours.

Nifedipine is given as ten miligram sublingually. Every 15 minuted for one hour. Then 60-160 mili grams per day (1) . Other tocolytics like indomethacin which causes premature closure of ductus arteriosus, magnesium sulphate and nitric oxide donors has been used successfully but not recomended due to adverse side effects.

Erythromycin 250 miligrams six hourly for 10 days, if membranes are ruptured and expectant management is decided iv?? .

Thanks
Posted by PAUL A.
Fr Q A:
My initial assessment begins with a hx, examination and investigations waste of time & space . In the history I’d like to enquire her: LMP- is she sure of her dates?, when was her 1st dating scan. This is to assess her accurate gestational age and number of fetuses take the question at face value – she is 28 weeks and does not have twins or placenta previa or any other condition . Re the contractions; the frequency, duration and timing of her contractions to assess pattern and regularity (1) . Is there any other associated symptoms with the contractions; ruptured membranes how will she know if she has ruptured membranes? You ask about fluid loss ? If so the colour, smell and amount. This is to rule out chorioamniotis. Any associated bleeding? you are answering the question – do not ask the examiner questions The amount, nature, whether mixed with mucus to elicit if an APH had occurred. If bleeding present, I’d like to ask her blood group and rhesus status as she may need anti-D. Any recent abdominal trauma/assault, urinary symptoms ? urinary stress incontinence?? , chest or vaginal discharge which may suggest recent UTI, vaginal infections such as bacterial vaginosis or GBS or systemic infection that may precipitate her preterm contractions. Her current and past obstetrical hx is important what exactly about her past obs Hx? Such generalisations do not earn marks . I’d enquire whether this pregnancy had any complications to date? Such as recurrent UTIs, gestational diabetes, pre-eclampsia? When was her most recent scan? I’d like to know the liquor vol for polyhydramnio, growth for IUGR and placenta location for placenta previa you could spend the entire essay wanting to know about all obstetric conditions – you will not get any marks. The woman has the condition in the question and nothing else . Re previous pregnancies, the gestation at delivery, any previous preterm labours/deliveries (1) and treatments, birth weight of these babies and any complications during those pregnancies. Past gynae hx is important to elicit previous smears and results, any cervical surgery or treatments such as LLETZ or cone bx. This puts her at risk of cervical incompetence. Any known uterine anomalies such as bicornuate or didelphys uterus? In previous medical hx, I’d enquire re poorly controlled hyperthyroidism or diabetes mellitus, cardiovascular disease read the question – HEALTHY woman . This is to assess any contraindications to tocolytic therapy. A social hx is important to enquire re her occupation-whether she is in a stressful, physically strenuous occupation; any recreational drugs-such as cocaine, heroine, smoking and her BMI and nutritional status. I’m aiming to identify any risk factors that may precipitate her preterm labour. I’d like to enquire re her social support at home too You have presented the history of a medical student – you are expected to look at the question and present a focused history .
In the examination; I’d like to plapate the abdomen would you check her temp and pulse? for fetal presentation, size, liquor vol and to assess for any abdominal tenderness- which can be due to the contractions and to exclude chorioamniotis or abruption (hard rigid abdomen). A speculum examination to assess presence of liquor leak (PPROM), bleeding, PV discharge and cervical dilatation how do you assess cervical dilatation on speculum examination? . While doing that I’d like to take a HVS, endocervical swabs if history suggestive of vaginal infection, and swabs for fetal fibronectin (1) . I’d like to get a urine sample to exclude UTI (1) .

Q B:
The factors include: previous history of preterm deliveries- after 1 previous preterm birth she has an up to 20% risk recurrence (1) . Any associated PPROM, where upto 90% usually deliver within 24 hours this is incorrect – 50% deliver within 7 days and thereafter 50% every 7 days . A shortened cervical length less than 20mm presence of cervical change increases the likelihood of preterm delivery. Presence of APH (1) due to abruption, chorioamniotis or IUGR increases the likelihood of preterm delivery. why did you do a fibronectin test if the results do not alter the likelihood of preterm delivery??

Q C:
I would administer betamethasone 12.5 mg IM 24 hours apart by 2 doses or dexamethasone 6 mg IM every 12 hourly by 4 doses immediately which one will you use? Are these drugs identical? . This is to help fetal lung maturity. If initial assessment suggests PPROM and she is contracting regularly, I’d like to administer benzylpenicillin 3 gm i/v stat then 1.5 mg every 4 hourly til delivery. If fetal fibronectin is negative in presence of PPROM do you do this test in the presence of PPROM?? (-1) , I’d give her erythromycin 250mg qid PO for 10 days (1) . I’d like to start tocolytic therapy to allow completion of steroid treatment or allow in utero transfer if there is no available NICU service. My drug of choice would be Atosiban, an oxytocin receptor antagonist. This is because it is associated with fewer maternal side effects compared to the beta-agonists. An initial bolus dose of 6.75 mg given over 1 min, followed by an infusion of 18 mg/hr for three hours, and then 6 mg/hr for up to 45 hours (1) . The duration of treatment should not exceed 48 hours and the total dose given during a full course should not exceed 330mg.
Posted by Sahithi T.
) Initial assessment should be aimed to rule out differential diagnosis of abdominal pain at 28 weeks. The history of regular periodic pain with increasing intensity associated with abdominal tightening points towards uterine activity of preterm labour whereas dull aching continuous pain or backache suggests ligament stretching or pain due to other reasons. History of constipation or any urinary complaints should be enquired which are again associated with abdominal pain. Urinary tract infection can cause preterm labour. History of any blunt trauma should be asked. History of any medical disorders, previous preterm labour and second trimester miscarriages, any obstetrical complications during previous and present pregnancy should be enquired. Early pregnancy bleeding episodes are associated with preterm labour. History of breakage of water should be asked to rule out rupture of membrane. History of any other presenting complaint such as fever or vomiting may point towards infection or any other cause of preterm labour. On examination one should do abdominal examination to determine gestational age, presentation, uterine activity and foetal heart rate monitoring. Precaution should be taken not to use any gel to lubricate speculum. Water should be used to lubricate speculum as it does not interfere fibronectin results. On speculum leaking, cervical dilation and cervical states should be examined. At same time foetal fibronectin sample should be taken if there is no history of recent sexual intercourse(in last 24 hours), no evidence of bleeding or rupture of membrane. Endocervical and high vaginal swabs should be taken to rule out infections. Vaginal examination is avoided if there is no evidence of cervical dilation. Urine sample should be obtained for dipstick test and then MSU should be sent for culture if infection is suspected.

B) History suggestive of periodic regular abdominal pain which is gradually increasing in intensity and associated with abdominal tightening strongly suggests preterm delivery. History of previous preterm delivery increases risk of recurrent preterm labour in 15% of women. Any history of precipitating cause like urinary tract or systemic infection increases like hood of preterm labour. On examination palpable regular uterine contractions indicates preterm delivery. Cervical softening, cervical status, presence of show determines like hood of preterm labour. Positive fibronectin test predicts potential for preterm delivery but when it has strong negative predictive value than positive. It forms basis for in patient admission in many units.

C) The role of tocolysis for preterm delivery is limited. The indication to start tocolysis is with diagnosis of preterm delivery. Atosiban, an oxytocin antagonist and nifedipine are widely used tocolystics at present. Atosiban is licensed in UK for this indication where as nifedipine is not licensed yet. Atosiban drip should be started in delivery suit under continuous monitoring. The tocolytics helps to buy time to complete steroid therapy or time for in utero transfer. Betamethazone should be given dose of 12 mg as soon as possible and repeated after 24 hours. Evidence conclusively proved beneficial effects of steroids in preterm labour. Betamethazone is preferred over dexamthazone as Betamenthazone has additional benifical effect to prevent neonatal intra cranial haemorrhage. The recent evidence shows no beneficial effect of antibiotics in preterm labour. But antibiotics should be started if there is prolonged preterm rupture of membrane, urinary tract infection or strong clinical evidence of vaginal infection. Erythromycin 250 mg QID is preferred. Hence tocolytics upto 48 hours, betamethazone in 2 doses 24 hours apart and antibiotics if indicated, are the medications used in this condition.
Posted by H H.
A I should know that preterm labour is associated with increased perinatal mortality and morbidity.I would ask of frequency of uterine contractions and if associated with constant pain and vaginal bleeding which may point to placental abruption.I will ask if she brooke her waters and when this happened.I will confirm date by asking of her LMP and see her notes for early dating scan,this will tell me also if has twins.Will see her parity and if any previous preterm deliveries or previous abdominal delivery.Any surgical history on the cervix as cone biopsy or LLETZ, or if she had a cervical suture in this prgnancy.Will ask of her social history including smoking and alcohol intake or illicit drugs.Will ask if had previous vaginal discharge and if treatment given (bacterial vaginosis) .
Will see her pulse, bld pressure and temp ,abd exam for frequency of uterine contractions, fundal level(hydramnios twins),fetal lie , tenderness(generalized or localized), presence of woody hard tender uterus(abruption), ease of feeling fetal parts and fetal movement .Speculum exam if has vag bleeding to exclude local cause or if has rupture memb to confirm diagnosis,in absence of both will do digital exam for cervical dilatation and effacement .

B) Main factor is finding of cervical dilatation and effacement specially if more than 4 cm.If membranes has ruptured 50% will deliver within 7 days ,most of these in 1st 24 hrs.If she has vaginal bleeding and placental abruption she is more likely to deliver prematurely.If she has previous preterm deliveries,or is pregnant in twin , a scan showing funnlling and shortning of cervix, will point to her likely to deliver early. Patients with bacterial vaginosis are at increased risk.Presence of fetal fibronectin in vagina will point to likely to deliver.Most of the cause are unknown and evidence based studies will be needed to confirm causation

C0 If preterm labour is diagnosed corticosteroids are given for fetal lung maturity.Betamethasone given intramuscularly 12 mg ,2 doses 24 hr apart.Need 48 hr to act,so tocolytics given to delay delivery if possible.Better than Dexamethasone as less periventricular leucomalacia in baby
Nefidipine ,oral tocolytic, not licensed inUK for this indication, cheap less side effects than B mimetics. Atosiban ,oxytocin antagonist, tocolytic ,licensed in uk, expensive ,given IV. Less side effects.Beta mimetics given iv infusion of ritodrine ,not widely used now for side effects.

If has rupture memb erythromycin given 250mg oral 4 times daily for 10 days ,will prevent and treat infection and prolong pregnancy(Oracle trial), so decrease perinatal mort and morbidity.
Posted by Prem S.
a) Severity ( intensity and frequency) of uterine contractions should be assessed as it might need inutero transfer if NNU cot not available. History of rupture of membranes should be assessed as there is risk of ascending infection and sepsis to mother and baby. Pv bleed needs intensive monitoring until stabilised. Good fetal movements indicate fetal wellbeing. Parity and any previous caesaren influence mode of delivery. Previous preterm delivery, cone biopsy, urinary tract infections, medical disorders like preeclampsia, autoimune disorders, sickle cell disease carries high risk of preterm delivery.
General examination- maternal tachycardia, high temperature suggestive of infection. Abdominal examination inlcudes any palpable contractions, tensed uterus between contractions suggestive of abruption, difficult to assess presentation due to prematurity, therefore needs scan to check presentation. Speculum examintaion to check any pooling or leakage of liquor, any bleeding, cervical dilatation and effacement best assessed by digital examination provided there is no SROM and placeta not low lying. Fetal fibronectin should be taken as it has high negative preditive value. Check urine dipstick to look for any signs of infection . CTG to assess fetal wellbeing.

b) Factors that increase the likelihood of preterm delivery are previous preterm delivery, urinary tract infection especially pyelonephritis, any other systemic illness, previous cone biopsy on cervix, multiple pregnancy, positive fetal fibronectin and medical disorders like preeclampsia, uncontrolled autoimmune and endocrine disorders.

c) Steroids if fetal fibronectin positive or clinicaly strong uterine contractions is given for fetal lung maturity in the form of Betamethasone 12mg intramuscularly and 2 doses given in 24 hours apart. Tocolysis either atosiban or nifedipine is preferrred to buy some time for steroid course completion or inutero transfer. For both atosiban and nifidipine, bolus and maintainence dose is given according to hospital policy. Patient needs to be aware that nifedipine is not licensed in UK for this purpose.Routine anitbiotic for threatened preterm labour is not recommended as it does not improve neonatal outcome and recent study showed it is associated with cerebral palsy. If SROM is confirmed then erythromycin 250 mg qds for 10 days is recommended.
Posted by PAUL A.
RnRn

A.
In my history I’ll ask about exact nature of contractions; regularity, interval, duration & intensity (1) . I’ll ask regarding show or leaking, as well as complaints of dysuria / frequency (1) suggestive of UTI . I’ll inform on fetal movements ? meaning , current pregnancy and presence of any problems eg hypertension, diabetes, polyhydramnion, infection, irregular antibodies, bacterial vaginosis or GBS-positive status whenever you find yourself writing a list, you should know that you will not get any marks . History of previous pregnancies, in particular premature delivery as this is associated with increased risk of recurrence – you must explain why / how this is relevant . I’ll ask regarding previous uterine instrumentation; dilatation & curettage, LLETZ or conisation. On examination I’ll assess blood pressure, pulse rate & temperature. Abdominal examination to clinically assess polyhydramnion, fetal size and presence / frequency of contractions and any tenderness (1) . Speculum examination to assess cervix, presence of pooling liquor, vaginal swabs and fibronectin test (1) . CTG is done to assess fetal condition and presence of any tightening / contractions. A urine sample is tested for infection. Only if cervix can’t be properly assessed and neither history or examination are suggestive for ruptured membranes I’ll consider given the conditions that you have outlined, will you do a VE or consider it? What more is there to consider? vaginal examination for cervical assessment .

B.
Presence of regular, increasingly intense contractions with cervical shortening and / or dilation is highly suggestive for premature delivery (1) . Likelihood is much increased in presence of ruptured membranes (1) and / or infection. A positive history of premature delivery (1) or cervical procedures likewise increases the likelihood. If a fibronectin test (1) is negative, likelihood of a delivery in the next 7-10 days is very small, if positive, premature delivery is likely, keeping in mind up to 25% false-positives good answer

C.
If based on history, examination and presence of risk factors, premature delivery is likely, I will give Beta-methasone 12 mg i.m. stat, to be repeated once more 24 hours later (1) . This will reduce incidence of neonatal pulmonary problems. As effect of this is maximal after 48 hours, I’m keen to prolong pregnancy at least 48 hours. If I’m worried I won’t be able to postpone delivery that long, or if I need to transfer the patient due to lack of NNU capacity, I will start tocolysis. As it has less side-effects than the beta-sympathico-mimetic drugs used in the past, I will start her on Nifedipine oral tablets, 10 mg every 15 minutes till tocolysed, maximum x4, and thereafter 20-40 mg bd (1) . If not available, Atosiban is a good (though more expensive) alternative. It is given as an i.v. bolus, followed by i.v. maintenance infusion (1) , either till contractions have gone or till max. 48 hours. If a urinary tract infection was noted this may cause or increase uterine irritability and I will give antibiotics, such as trimethoprim 200 mg bd for 1 week. If however membranes were ruptured, I will give oral eythromycine 250 mg qid for 10 days (1) , as this improves fetal outcome with lower risk for NEC in the neonate.

good answer
Posted by PAUL A.
(a)A history of rupture of membranes may suggest more likelyhood of preterm labour (1) , history of bleeding may suggest an underlying cause of contractions like abruption.
History of fetal movements to assess fetal viability.
past history of previous pregnancy and outcomes may suggest increased risk for preterm labour e.g. previous previous peterm labour (1) .
Associated urinary symptoms like dysuria (1) and or bowel symptoms to exclude localised causes of uterine irritibility.
Social history of smoking, drug and alcohol misuse may suggest increased risk of preterm labour.
General physical examination including pulse, BP, temperature will assist in initial assessment of this patient.
Abdominal palpation to confirm palpable contraction with given history and exclude other possibilities like woody uterus with abruption. Palpation of fetal presentation and lie as imminent risk of preterm labour (1) .
confirm fetal condition with CTG monitoring as regular contraction and likelyhood of preterm labour, if difficulty in obtaining fetal heart ultrasound to confirm fetal viability.
speculum examination to exclude rupture of membranes and if not then for fetal fibronectin testing (1) (this has better negative predictive value plus than positive predictive value)
bimanual do you do a bimanual examination at 28 weeks? assessment of cervix to confirm in preterm labour and likelihood of imminent delivery and for organising care further care.

(b) A previous preterm delivery (1) at similar gestation may suggest morelikely peterm labour.
Combination of regular contraction along with progressive cervical dilation (1) would suggest preterm labour
A history of rupture of membranes and or vaginal bleeding is another strong factor (1) .
Obstetric risk factors like current preeclampsia, smoking drug and alcohol misuse.
Examination findings of low presenting part with/without cervical dilation.
fetal fibronectin if negative has better prognostic value than being positive ? meaning .

(c) Steroid therapy with betamethasone 12mg intramuscular injection given 12hour apart in 2 doses to reduce risk of prematurity like respiratory distress syndrome, intrventricular haemorrhage 24h apart .
Tocolytics like Atosiban with loading dose followed by maintanence doses to complete steroid therapy /or for in-utero transport. how? Orally??
Alternative tocolytics like Nifedipine as oral tablets, but definite regimen not available for the same so how would you give it? and Ritodrine is associated with complication like pulmonary edema.
Antibiotic therapy for preterm labour is not recommended unless evidence of rupture of membranes, then treat with Erythromicin 250mg qid for 10 days iv? .
Simple analgesics for pain relief options e.g. paracetamol as oral tablets, if not coping alternative options include opiates and epidural anesthesia. see good answer above – you were specifically asked: which drug? When? How? Your answer should follow that pattern – this drug… this is when I will give it ….this is how I will give it
Posted by PAUL A.
) Initial assessment should be aimed to rule out differential diagnosis of abdominal pain READ THE QUESTION – Contractions NOT abdominal pain at 28 weeks. The history of regular periodic pain with increasing intensity associated with abdominal tightening points towards uterine activity of preterm labour whereas dull aching continuous pain or backache suggests ligament stretching or pain due to other reasons. History of constipation or any urinary complaints should be enquired which are again associated with abdominal pain. Urinary tract infection can cause preterm labour. History of any blunt trauma should be asked. History of any medical disorders, previous preterm labour and second trimester miscarriages, any obstetrical complications during previous and present pregnancy should be enquired. Early pregnancy bleeding episodes are associated with preterm labour. History of breakage of water should be asked to rule out rupture of membrane (1) . History of any other presenting complaint such as fever or vomiting may point towards infection or any other cause of preterm labour. On examination one should do abdominal examination to determine gestational age ? value at 28 weeks , presentation, uterine activity and foetal heart rate monitoring. Precaution should be taken not to use any gel to lubricate speculum. Water should be used to lubricate speculum as it does not interfere fibronectin results. On speculum leaking, cervical dilation and cervical states should be examined. At same time foetal fibronectin sample (1) should be taken if there is no history of recent sexual intercourse(in last 24 hours), no evidence of bleeding or rupture of membrane. Endocervical and high vaginal swabs should be taken to rule out infections. Vaginal examination is avoided if there is no evidence of cervical dilation (1) . Urine sample should be obtained for dipstick test and then MSU should be sent for culture (1) if infection is suspected.

B) History suggestive of periodic regular abdominal pain which is gradually increasing in intensity and associated with abdominal tightening strongly suggests preterm delivery. History of previous preterm delivery (1) increases risk of recurrent preterm labour in 15% of women. Any history of precipitating cause like urinary tract or systemic infection increases like hood of preterm labour. On examination palpable regular uterine contractions indicates preterm delivery do they? Have you ever seen women with palpable contractions at 28 weeks who go on to deliver at term? . Cervical softening, cervical status (1) , presence of show determines like hood of preterm labour. Positive fibronectin test predicts potential for preterm delivery but when it has strong negative predictive value than positive (1) . It forms basis for in patient admission in many units.

C) The role of tocolysis for preterm delivery is limited. The indication to start tocolysis is with diagnosis of preterm delivery you diagnose preterm delivery when the baby is delivered . Atosiban, an oxytocin antagonist and nifedipine are widely used tocolystics at present. Atosiban is licensed in UK for this indication where as nifedipine is not licensed yet. Atosiban drip how? should be started in delivery suit under continuous monitoring. The tocolytics helps to buy time to complete steroid therapy or time for in utero transfer. Betamethazone should be given dose of 12 mg orally? HOW? as soon as possible and repeated after 24 hours. Evidence conclusively proved beneficial effects of steroids in preterm labour. Betamethazone is preferred over dexamthazone as Betamenthazone has additional benifical effect to prevent neonatal intra cranial haemorrhage. The recent evidence shows no beneficial effect of antibiotics in preterm labour. But antibiotics should be started if there is prolonged preterm rupture of membrane do you have to wait till it is prolonged? , urinary tract infection or strong clinical evidence of vaginal infection. Erythromycin 250 mg QID is preferred for UTI or vaginal infection or both? Do you give it iv? HOW . Hence tocolytics upto 48 hours, betamethazone in 2 doses 24 hours apart and antibiotics if indicated, are the medications used in this condition you were not just asked about the drugs used – you were asked to indicate WHEN and HOW you would initiate therapy .
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A I should know that preterm labour is associated with increased perinatal mortality and morbidity not necessary .I would ask of frequency of uterine contractions and if associated with constant pain and vaginal bleeding which may point to placental abruption.I will ask if she brooke her waters and when this happened (1) .I will confirm date by asking of her LMP and see her notes for early dating scan,this will tell me also if has twins.Will see her parity and if any previous preterm deliveries (1) or previous abdominal delivery.Any surgical history on the cervix as cone biopsy or LLETZ, or if she had a cervical suture in this prgnancy.Will ask of her social history including smoking and alcohol intake or illicit drugs.Will ask if had previous vaginal discharge and if treatment given (bacterial vaginosis) .
Will see her pulse, bld ?? pressure and temp ,abd exam for frequency of uterine contractions (1) , fundal level(hydramnios twins),fetal lie , tenderness(generalized or localized), presence of woody hard tender uterus(abruption), ease of feeling fetal parts and fetal movement .Speculum exam if has vag bleeding to exclude local cause or if has rupture memb to confirm diagnosis,in absence of both will do digital exam for cervical dilatation and effacement you will do speculum examination in the absence of bleeding or suspected ROM – you may find the cervix is long and closed and therefore avoid a VE. You will also need fetal fibronectin test .

B) Main factor is finding of cervical dilatation and effacement (1) specially if more than 4 cm.If membranes has ruptured 50% will deliver within 7 days (1) ,most of these in 1st 24 hrs.If she has vaginal bleeding and placental abruption she is more likely to deliver prematurely.If she has previous preterm deliveries (1) ,or is pregnant in twin , a scan showing funnlling and shortning of cervix, will point to her likely to deliver early. Patients with bacterial vaginosis are at increased risk.Presence of fetal fibronectin in vagina will point to likely to deliver should appreciate that a negative test is more valuable .Most of the cause are unknown and evidence based studies will be needed to confirm causation ? meaning

C0 If preterm labour is diagnosed will you give for threatened preterm labour or you will wait till she is in labour? corticosteroids are given for fetal lung maturity.Betamethasone given intramuscularly 12 mg ,2 doses 24 hr apart (1) .Need 48 hr to act,so tocolytics given to delay delivery if possible.Better than Dexamethasone as less periventricular leucomalacia in baby
Nefidipine ,oral tocolytic, not licensed inUK for this indication, cheap less side effects than B mimetics. Atosiban ,oxytocin antagonist, tocolytic ,licensed in uk, expensive ,given IV these are not sentences. You need more details about WHEN & HOW . Less side effects.Beta mimetics given iv infusion of ritodrine ,not widely used now for side effects.

If has rupture memb erythromycin given 250mg oral 4 times daily for 10 days (1) ,will prevent and treat infection and prolong pregnancy(Oracle trial), so decrease perinatal mort and morbidity this is prophylaxis – reduces risk rather than prevent and DOES NOT TREAT infection .
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a) Severity ( intensity and frequency) of uterine contractions should be assessed (1) as it might need inutero transfer if NNU cot not available. History of rupture of membranes (1) should be assessed as there is risk of ascending infection and sepsis to mother and baby. Pv bleed needs intensive monitoring until stabilised. Good fetal movements indicate fetal wellbeing. Parity and any previous caesaren influence mode of delivery. Previous preterm delivery (1) , cone biopsy, urinary tract infections, medical disorders like preeclampsia, autoimune disorders, sickle cell disease HEALTHY woman carries high risk of preterm delivery.
General examination- maternal tachycardia, high temperature suggestive of infection. Abdominal examination inlcudes any palpable contractions (1) , tensed uterus between contractions suggestive of abruption, difficult to assess presentation due to prematurity, therefore needs scan to check presentation. Speculum examintaion to check any pooling or leakage of liquor, any bleeding, cervical dilatation and effacement best assessed by digital examination provided there is no SROM and placeta not low lying (1) . Fetal fibronectin should be taken as it has high negative preditive value (1) . Check urine dipstick to look for any signs of infection (1) . CTG to assess fetal wellbeing.

b) Factors that increase the likelihood of preterm delivery are previous preterm delivery, urinary tract infection especially pyelonephritis, any other systemic illness, previous cone biopsy on cervix, multiple pregnancy, positive fetal fibronectin and medical disorders like preeclampsia, uncontrolled autoimmune and endocrine disorders you were not asked to LIST .

c) Steroids if fetal fibronectin positive or clinicaly strong uterine contractions is given for fetal lung maturity in the form of Betamethasone 12mg intramuscularly and 2 doses given in 24 hours apart (1) . Tocolysis either atosiban or nifedipine is preferrred to buy some time for steroid course completion or inutero transfer. For both atosiban and nifidipine, bolus and maintainence dose is given according to hospital policy do you give both drugs orally or iv or do they have different routes of administration? . Patient needs to be aware that nifedipine is not licensed in UK for this purpose.Routine anitbiotic for threatened preterm labour is not recommended as it does not improve neonatal outcome and recent study showed it is associated with cerebral palsy. If SROM is confirmed then erythromycin 250 mg qds for 10 days is recommended HOW? iv?? .
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A good answer should contain the following

History
• Severity and frequency of contractions (1 mark)
• History of vaginal loss – liquor / bleeding (1 mark)
• Find out how the woman is coping with pain and her plans for pain relief. Read her birth plan if available (1 mark)
• Past obstetric history especially history of previous pre-term delivery or second trimester miscarriage – increases risk (1 mark)
• Symptoms of UTI – can precipitate pre-term labour (1 mark)

Examination
• Temp, pulse, BP. Uterine contractions, fetal heart (1 mark)
• Offer vaginal assessment – speculum examination +/- vaginal examination (1 mark)

Investigations
• Test for infective cause - urine dipstix for evidence of UTI, vaginal swabs, FBC & CRP (1 mark)
• Fetal fibronectin test (1 mark)
(b)

Factors determining likelihood of pre-term delivery
• Most important predictor is history of previous pre-term delivery (1 mark)
• Presence of cervical change at presentation (1 mark)
• Fetal fibronectin test – most accurate in predicting delivery within 7-10 days of testing. Negative test more valuable (1 mark)
• Other complications like ruptured membranes and antepartum haemorrhage increase the likelihood of preterm delivery (1 mark)

(c)

Use of tocolytics
• Use Nifedipine or atosiban – Use drug which the unit has most experience with and follow unit guidelines (1 mark)
• Use in women with positive fibronectin test to delay delivery and enable corticosteroid administration (1 mark)
• Also used to cover in-utero transfer to another unit (1 mark)
• Nifedipine administered orally; atosiban administered iv. Loading dose followed by maintenance infusion for 24-48h (1 mark)

Use of corticosteroids
• To promote fetal lung maturity – betamethasone 12mg im 24h apart (1 mark)

Use of antibiotics
• Only if ruptured membranes. Erythromycin orally for 10 days (1 mark)

References
1) Tocolytic drugs for women in preterm labour. RCOG Clinical Guideline No. 1B (Oct 2002). http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT1BTocolyticDrug2002.pdf

2) Intrapartum care - management and delivery of care to women in labour. Sept 2007. NICE. http://www.gserve.nice.org.uk/nicemedia/pdf/IntrapartumCareSeptember2007mainguideline.pdf
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