Essay 303 - Large for dates

c) In majority of the cases no cause is found. 

Detailed fetal anomaly scan to identify fluid in other body cavities ( ascites, pleural and peritoneal effusions) and to exclude anomalies associated with polyhydramnios ( CNS anomalies like anencephaly, upper CI atresia and diaphragmatic hernia) or placental chorioangioma. 

In case of increased BMI, or positive family history for gestational diabetes or NIDDM , glucose tolerance test i performed to exclude GDM.

Screening test for maternal infection like VDRL and screening for TORCH and parvovirus infection are usually negative and of limited value unless there is evidence of fetal infectn on ultrasound scan.

Invasive fetal testing ( amniocentesis for karyotype/ infection screen) is of value only in the presence of other anomalies.

b) Aims of the antenatal management are control of maternal symptoms and to prolong pregnancy to prevent prematurity.  Maternal risks include abdominal discomfort , breathing difficulty  and uterine irritability. There is increased risk of placental abruption. The fetal risks are prematurity and increased perinatal mortality.

Mild symptoms may not require treatment except simple analgesia.  NSAIDs are used to reduce fetal urine output there by reducing the liquor. Indomethacin use is associated with the risk of premature closure of the ductus arterioles and impaired renal function. So it should be discontinued at 32- 35 weeks or when the amniotic fluid volume is normal. Sulindac is less likely to cause constriction of the ductus arteriosus. Amnioreduction is associated with relief of maternal symptoms but the reaccumulation is common. Repeated procedures may be necessary. Nifedipine is used to reduce uterine irritability. Serial growth scans are performed to assess severity of hydramnios and to monitor fetal growth. Corticosteroids are used to improve lung maturity if she is at risk of delivery before 34 weeks. Salt restriction and diuretics are not effectve and may be harmful. 

Ultrasound scanning is performed to identify malpresentation. Induction of labour may be necessary at 37-40 weeks because of maternal discomfort but carries risk of cord prolapse and placental abruption.

 Caesarean section is offered  in the presence of severe polyhydramnios.

c) Her labour is associated with risks of cord prolapse and post partum haemorrhage. So the presence of a senior midwife and senior obstetrician is required at the time of delivery. Intravenous line is started and blood is sent for group and save. Third stage of labour should be managed actively by administration of Syntometrine as there is increased risk of post partum haemorrhage along with oxytocin infusion after delivery. Neonatologist should examine the baby for any anomalies. Oesophageal atresia should be excluded before feeding.

obgat 

(A) 

The aim of investigations is to identify the possible cause of polyhydramnios as some causes are treatable . However , in most cases , no cause is identified .

Detailed ultrasound scan is a very important investigation . it may identify congenital anomalies associated with polyhydramnios such as CNS anomalies ( e.g anencephaly ) or GIT anomalies ( e.g duodenal atresia , diaphragmatic hernia , gastroschisis ) . It may also identify fetal hydrops ( excessive fluid in one or more fetal compartments e.g pleural or abdominal space ) . It may also identify placental tumours ( chorioangioma ) .

Diabetes is a cause of polyhydramnios - offer glucose tolerance test (GTT) to exclude gestational diabetes mellitus (GDM)

If fetal hydrops is identifed on ultrasound examination , further tests are required to identify the cause . Middle cerebral artery peak systolic velocity ( MCA PSV)can identify fetal anaemia , regardless of the cause . Kleihaur test can detect fetomaternal haemaorrhage which is a cause of fetal anaemia and hydrops . Check maternal serum for antibodies against fetal cells . check maternal serum for infection e.g cytomegalovirus (CMV) , toxoplasmosis , syphilis , rubella and parvovirus B19 . Amniocentesis for fetal karyotyping and fetal infection is advised if there is fetal hydrops or congenital fetal anomalies .

(B)

The aim of antenatal managment of idiopathic polyhydramnios is to releive symptoms and prolong pregnancy .Mild asymptomatic cases can be managed conservatively with regular monitoring of amniotic fluid volume by ultrasound .

Non steroidal anti-inflammatory drugs (NSAIDs ) such as indomethacin and sulindac are the medical managment of polyhydramnios as they reduce fetal urine production and consequently reduce the amniotic fluid volume and reduce the risk of preterm labour .However , they carry the risk of premature closure of ductus arteriosus if used after 32 week gestation . Sulindac may has less effect on ductus arteriosus compared to indomethacin . Diuretics and salt restriction are not recommended ( no proven benefit ) 

In severe symptomatic cases , amnioreduction is effective in reducing the amniotic fluid volume and consequently releiving symptoms and reducing the risk of preterm labour . However , reaccumulation of amniotic fluid is common and amniocentesis may need to be repeated . other risks of amniocentesis include prelabour rupture of memebranes and infection .

preterm labour is common in polyhydramnios due to uterine overdistension and measures should be taken antenataly to minimise this risk . medical (indomethacin ) and surgical ( amnioreduction) managment of polyhydramnios reduce the risk of preterm labour .Bed rest is advised . Corticosteroid therapy to enhance fetal lung maturity should be considered if preterm labour is suspected .

regarding planning timing and mode of delivery : in mild to moderate cases , labour to be induced at 39-40 weeks , although , it may be necessary to induce labour earlier at 37 -38 weeks if there is maternal discomfort .induction of labour is associated with  risk of cord prolapse and placental abruption  . In severe cases , delivery by elective caesarean section is a safer option . 

(C) 

the aim of intrapartum and postnatal intervention is to minimise the risks associated with polyhydramnios . there is increased risk of cord prolapse when the membranes rupture . For this , artificial ruprure of membranes (ARM) should be avoided if the presenting part is mobile . Alternatively , controlled ARM can be performed by a small gauge needle to puncture the fetal membranes in one or more places in the operating room . Continous electronic fetal monitoring (CEFM) is recommended during labour for early identification of changes in the fetal heart pattern suggestive of cord prolapse .

There is an increased risk pf postpartum haemorrhage (PPH) . So, maternal blood sample should be obtained for blood group and saving blood . intravenous line should be secured . Active managment of third stage is recommended as it reduces the risk of PPH .

A neonatologist should be informed to examine the baby for congenital anomalies and exclude oesophagial atresia before feeding .

blood for karyotyping 

because  it is associated with congenital anomalies of the baby

u/s  abdomen to exclude twin pregnancy , placental angioma & anomalies of the baby like sacrococcegyl carcinoma also exclude duodenal atresia & bowel obstruction  and also  to exclude odema of the fetus

 Multi disciplinary team 

 follow up her pregnancy every 2 weeks with u/s    for fetal wellbeing and amount of liqoure and doppler and follow up the baby weight

 anti d for rh -ve mother at 28th , 34 th week

 good diabetic control

review by anesthetist as she may need surgical intervention 

we can give cox 2  inhibitor to decrease amount of liqour for just 32 weeks because associated with intracranial hemorrhage, early closure of patent ductus arteriosus

if she is full term and came in laboiur we should do controlled  rupture of membrane after stabilizing the head of the baby in the pelvis  to reduce the risk of aph & cord prolapse  ,

if she is  sever polyhydrominoia discomforting the mother  go for caesarian section

a

a) Th aim of  investigation is to identify cause of polyhydramnios. I will like to do GTT  

a) The aim of investigation is to identify cause of polyhydramnios. I will like to do glucose tolerance test (GTT) to exclude diabetes as the cause more applicable if  the patient has high BMI or has first degree relative with diabetes. A detailed ultrasound (USG) is needed to rule out congenital malformations as duodenal atresia, chorioangioma, if the original USG was not meant to check that. Blood group is noted and if needed Kleihauer test is done to rule out fetomaternal haemorrhage if there is evidence of hydrops in scan. Investigations as TORCH are not offered routinely as they have limited value unless evidence of hydrops on scan. Full blood count is checked to exclude anemia as she is at high risk of postpartum haemorrhage (PPH). Serial  scans needed  for growth and liquor volume as single reading of polyhydramnios may not be significant enough.

b) The aim of antenatal management is to relieve symptoms and to make appropriate delivery plan antenatally to minimise risks associated. If polyhydramnios is mild causing minimal symptoms simple analgesics and reassurance may be enough. Mild cases could be managed midwife led but consultant led care is needed in others. She will need hospital delivery. 

    If  severe causing respiratory distress, decapacitating abdominal distension intervention is needed. Serial USG will guide regarding severity and help in assessing growth as abdominal examination will be limited. Medical measures as NSAIDS are limited in that they may cause premature closure of ductus arteriosus. Invasive measures as amniocentesis  is done to relieve pressure symptoms  but are associated with infection risk and recurrence of symptoms soon enough to limit its use to only selected severe cases as a last resort.

   Inform her the risks associated as cord prolapse, PPH, abruption, unstable lie, preterm labour so she is aware when and how soon to report if symptoms occur.

Detailed delivery plan is made in advance if possible. She will need early intravenous access and group and save &  active management of 3rd stage of labour as she is at risk of PPH. If unstable lie she will need admission to hospital specially if she stays far from hospital and she is alone at home. If Breech presentation offer of ECV depends on availability of expertise and severity of polyhydramnios however there is a risk of abruption involved. If risk of preterm labour prior to 36 weeks gestation tocolysis will be needed to get 2 doses of steroid inorder to assist in maturing the lung. Aim to deliver around 39-40 weeks unless symptoms necessitate early delivery when induction could be offered which has a risk of causing abruption.

c) She will need early Iv line, group save in labour. Presentation should be confirmed with USG if needed. If breech offer of ECV based on expertise available but could be offered only if membranes intact . Her wishes and attitute towards risks involved should be considered. Avoid spontaneous rupture of menbranes specially when presenting part not fixed rather offer controlled ARM once in labour and if progress is slow. Continuous CTG monitoring is needed. Inform paediatrician as there is risk of operative intervention and to rule out anomalies.

a) Perform a detailed ultrasound scan to investigate for the possible causes of polyhydramnios. Look for chromosomal abnormalities including oesphageal atresia and skeletal dysplasia, hydrops, signs of fetal infection and placental chorioangioma. Exclude a monochorionic twin pregnancy. Perform a oral glucose tolerance test to exclude maternal diabetes and thyroid function tests to exclude thyroid disease like Grave's. Other investigation depends on findings on the ultrasound scan. If there is presence of hydrops, perform haemoglobin electrophoresis to exclude thalassaemia, kleihauer test to exclude maternal fetal haemorrhage. If there are signs of fetal infection, do TORCH screen and check for parvovirus, syphilis infection in the mother.If there signs of chromosomal abnormalities, consider amniocentesis for karyotyping.

b) She should referred to a fetal maternal medicine specialist as her pregnancy is high risk. Main aim of antenatal management is to reduce risk of preterm delivery and treat her symptoms, as polyhydramnios may be associated with uterine overdistension, abdominal pain and difficulty breathing. Treat pain and discomfort with simple analgesia like paracetamol. Given Nifedipine to reduce uterine irritability. Indomethacin can be given at less than 32 weeks due to its risk of premature closure of the ductus arteriosis,  which can help to reduce amniotic fluid volume. In case of severe polyhydramnios, amnioreduction may be considered to help reduce symptoms in an attempt to prolong pregnancy. However, this is associated with a risk of reaccumulation and need for repeated procedures. Give corticosteroids as patient is at risk of preterm delivery. Perform serial ultrasound scans to monitor fetal growth and severity of polyhydramnios. Close to delivery, perform an ultrasound scan to check fetal lie as polyhydramnios is associated with a risk of malpresentation. Advise delivery in a consultant led maternity unit with neonatal facilities on standby. Discuss mode and timing of delivery at 36 weeks, allowing normal vaginal delivery and caesarean section for obstetric indications. Discuss the role of induction of labour if patient symptomatic, but explain risks of abruption and cord prolapse.

c)Inform the multidisciplinary team including consultant, neonates and senior midwife. Perform an abdominal and vaginal examination to determine position, lie and enagagement of the fetus. Use an ultrasound if needed to confirm fetus is in a cephalic position as risk of malpresentation is high. Suggest caeserean section if non-cephalic presentation. Do not rupture the membranes if the head is not well engaged to due increased risk of cord prolapse. Do full blood count and type and screen as patient is at risk of postpartum haemorrhage.  She needs continuous cardiotocogram in labour as  she is at higher risk of complications including cord prolapse and fetal distress, abruption and uterine rupture. Use synotocinon for augmentation of labour judiciously with close monitoring of progress of labour on a partogram. Manage third stage of labour actively due to the higher risk of postpartum haemorrhage.

a)    I would repeat the ultrasound scan in a fetal medicine clinic and classify polyhydramnios as mild 8-12cm, moderate 12- 15cm severe 12-15cm as this will affect monitoring. I perform a detailed USS to look for fetal anomalies: neural tube defect including anencephaly. I would also look for swallowing movements, and swallowing movements and and a structural, neurological or muscular cause if they are impaired, such as oesophageal atresia, diagraphagmatic hernia, GI obstruction or gastroschisis.  I would look for any other markers of abnormality for trisomy 21, 18, 13 or achondroplasia, and consider invasive testing if there is evidence of abnormalities. I would ask the mother about any recent viral illnesses, and consider screening for TORCH, parvovirus or hepatitis, and ceck the booking bloods for sypillis screening and paired IgG smaples, as these are all possible causes. I would exclude free fluid in other spaces- pericardial, pleural and acites to exclude hydrops fetalis, as this would warrant further investgations, such as cardiac failure, anaemia or immune hydrops. Maternal investigations would involve a glucose tolerance test  to exclude maternal diabetes. I would also screen for maternal antibodies as a cause of immune hydrops and consider a TORCH screen if there was a history of infection, as a cause of polyhydramnios.

b)    If no cause has been found I would counsel the patient that this is a common occurrence, however she is at risk of preterm labour, malpresentation and cord proplapse, placental abruption and post-partum haemorrhage and to present to hospital urgently if her membranes rupture or she suspects any of the above. I would check for any abdominal pain, discomfort or respiratory compromise, in particular if there are maternal commobridities.

I would see her in ANC every 4 weeks with a growth scan. For mild polyhydranios USS monitoring every 4 weeks and expectant management is sufficient. For moderate or severe polyhydramnios, I would advise and USS to check for growth every 4 weeks. Therapeutic options can be considered: Amnioreduction, NSAIDS and sulindac acid, however the risks need to be considered (infection, PROM, renal or cerebral impairement, premature closure of the patent ductus arteriosus).  For moderate or severe polyhydramnios, I would offer a caesarean section at 39 weeks. Severe or moderate polyhydramnios may warrant induction of labour before 39 weeks for maternal discomfort/ respiratory difficulty.

c) I would admit her to labour ward for care by the mutlidisciplinary team: Paediatricians, obstetricians and experienced midwive, and consider her previous obstetric history and other risk factors- previous labours. She will require continuous CTG monitoring due to risk of abruption and perinatal mortality and morbidity. If she requires an artificial rupture of membranes this should be done in a controlled way to prevent cord prolapse, and after checking that the presentation is cephalic and the head is engaged. I would check presentation by USS to exclude malpresentation, and offer caesarean if malpresentation. I would actively manage the third stage with 10 units im syntocinon, 40 units of a syntocinon infusion and syntometrine if none contraindicated. I would ensure iv access and a valid FBC and G+S are available in case of post-partum haemorrhage. Paediatricians would need to be present at delivery, and check for gasto-obstruction before feeding.  

a)

Polyhydramnios is not uncommon and often leads to anxiety to patients & clinicians.

For the woman who has been referred to antenatal clinic for first time for polyhydramnios on the ultrasound scan, detail history should be obtained, including obstetric history, medical history to rule out preexistent or gestational diabetes, past history and medication history.

Most often the condition is idiopathic and one should direct the investigations to rule out the cause and to monitor the condition.

One should carefully review the ultrasound scan, whether its a single gestation or Twins with Twin-Twin transfusion syndrome, fetal anomalies- especially for upper GI atresia/fistulae/ obstruction due to any mass, open neural tube defect, syndromic manifestation, any other structural anomalies, features of hydrops fetalis, suspicious lesions of congenital infection. When in doubt, it is preferable to repeat the ultrasound with expert, fetal medicine specialist if possible.

One should rule out diabetes by performing GTT. Other investigations like - tests for chromosomal / structural anomalies can be performed if suspected.

It is preferred to repeat the ultrasound scan after every 2- 4 weekly along with the doppler velocity depending upon the severity, to judge the progress of the condition.

One should take into account, womans anxiety & her wish before the investigations being carried out.

b)

Management should take place in multidisciplinary setting, involving Senior obstetrician, Fetal medicine expert, sonologist, neonatologist, anaesthetist.

When no underlying cause is identified, one should carefully counsell & reassure the woman. Owing to her anxiety and the nature & severity of the condition, this couselling can be offered by fetal medicine expert.

She should be offered support & written information about the condition, causes & its impact. Simple measures like propped up position, breathing exercises will alleviate her respiratory dyscomfort, analgesia for her musculoskeletal pain due to overstretching.

She should be monitored in consultant led clinic with regular Ultrasound exams - to assess the progress & severity. Woman should be instructed to look for warning signs- like leaking of liquor, as high chances of cord prolapse, onset of preterm labour pains.

Fetal medicine expert can further decide for any medical or invasive procedure for very severe polyhydramnios.

Hospitalised vaginal delivery should be aimed and caeserean section is reserved for obstetric indication.

c)

Ideally there should be documented birth plan for such case, including emergency situations and she should have easy access & contact numbers of the maternity unit.

One should assess the woman, if she presents in labour at 36 weeks. Abdominal palpation for confirmation of presentation, speculum examamination & vaginal examination to rule out ruptured membranes & cord prolapse and the phase of labour. Continuous electronic fetal heart monitoring is essential. If fetal distress/cord prolapse occurs, then delivery should be expeditated either vaginally or by emmergency caeserean section.

For uncomplicated cases, she should be allowed to deliver vaginally, with proper monitoring & support. Controlled artificial rupture of membranes with judicial use of oxytocin is recommended to prevent cord prolapse.

Active management of third stage of labour is important, as there is risk of PPH. Controlled cord traction for placental delivery and prompt use of oxytocic drugs to prevent uterine atonicity, are useful strategies. She should be monitored postnatally for atonic PPH.

Routine postnatal advise including breastfeeding and contraception should be offered.

a) I will do an oral glucose tolerance test to look for underlying diabetes mellitus as a cause of a fetus that is larger than dates and polyhydramnios. I will perform a detailed fetal anomaly scan to look for evidence of structural anomalies such as esophageal atresia, bowel obstruction, congenital diaphragmatic hernia which are associated with polyhydramnios. I will also look for features of Beckwidth Wiederman syndrome such as macroglossia, and hepatomegaly. Amniocentesis can be performed for karyotyping if there are structural anomalies present. The scan will also determine presence of fetal hydrops. If fetal hydrops is present, I will do a TORCH screen and also screen for possible infections such as toxoplasma, cytomegalovirus and parvovirus, as well as investigate for possible causes of hydrops.

b) Management will be in conjuction with a neonatologist and fetal medicine specialist. The mother will have to be counselled on the risks of a large for dates fetus and polyhydramnios. These include preterm labour, premature rupture of membranes, placental abruption, shoulder dystocia, risk of induction of labour and caesarean section and postpartum hemorrhage. Fetal growth will be monitored regularly by fetal growth scans, with consideration for induction of labour if fetal macrosomia ensues and the fetus is mature. Amniotic fluid index should be monitored. If polyhydramnios is severe and resulting in respiratory embarrassment in the mother, amnioreduction may be performed. Fetal presentation should be determined at 36 weeks gestation in view of the increased risk of malpresentation, so as to determine mode of delivery. The mother should be advised to return to the hospital as soon as possible in the event of contractions or rupture of membranes, as there is an increased risk of cord prolapse in an unstable lie which is more likely in polyhydramnios.

c) This patient should be delivered in a hospital with a neonatal unit, under the care of a consultant obstetrician, anaesthetist, senior midwife and neonatologist. Continuous electronic fetal monitoring should be in place in view of risk of fetal distress and placental abruption. Fetal presentation and estimated fetal weight should be confirmed to be cephalic before trial of normal vaginal delivery. Intravenous canula should be sited and blood taken for full blood count and group and save in view of risk of caesarean section and postpartum hemorrhage. If her membranes have ruptured, vaginal examination should be performed to ensure there is no cord prolapse. Should she require amniotomy, this should be performed in a controlled fashion, to prevent cord prolapse in view of polyhydramnios. Shoulder dystocia precaution measures should be in place and the senior obstetrician and neonatalogist should be present at delivery. Active management of the third stage of labour is essential in view of the risk of postpartum hemorrhage. A oxytocin infusion can be started after delivery. The neonate should be reviewed by the neonatologist postdelivery for a full assessment and investigations for possible underlying syndromes or metabolic disorders.

(a) Maternal investigations I would perform are to check her urine for glycosuria.  I would check her blood pressure to exclude hypertension.  I would arrange for a 75mg oral glucose tolerance test to exclude development of gestational diabetes.  I would also perform a TORCH screen on the mother to exclude the presence of infections which may cause polyhydramnios.  Regarding the fetus I would refer the mother to a fetal medicine specialist for a detailed scan, in order to exclude fetal causes of polyhydramnios (tracheo-oesophageal fistula/diaphragmatic hernia/duodenal atresia).

(b) The subsequent antenatal management would centre around managing maternal discomfort from the polyhydramnios. I would arrange regular scans (every 3 weeks) to assess the liquor volume.  I would counsel the woman with regard to fetal movements and the fact that she may not be able to feel them as much.  I would advise her to come to hospital if she felt they were reduced.  I would counsel her regarding the risk of cord prolapse in the event of membrane rupture and to come in immediately if that should happen.  If she lived in a remote area I might suggest elective admission from 36 weeks.  I would consider NSAIDS if tense polyhydramnios develops to reduce fetal urine production.  There is no good evidence to support amnioreduction.

(c) Maternal interventions I would perform are to secure IV access and take blood for an FBC and group & save.  This is because there is a high risk of cord prolapse when the membranes rupture.  I would ensure that the mother has adequate analgesia.  If there is tense polyhydramnios with the presenting part either free or high above the ischial spines I would recommend an epidural.  I would then perform amniotomy, in theatre with an assistant stabilising the fetal lie.  Before doing this I would perform a vaginal examination to exclude cord presentation.  I would use continuous electronic fetal monitoring throughout. When the baby is born I would ask the paediatrician to examine the baby and consider passing a nasogastric tube to exclude tracheo-oesophageal fistula.

The majority of cases is idiopathic in nature. In order to identify the cause of Polyhydramnios in healthy 35 y.o. woman, it would be necessary to request  further inverstigations, including GTT to look for hidden insulin deficiency or gestational onset of NIDDM type 2. The target fetal assesment which will include the detailed USS of fetus by expert to exclude fetal malformations/anomalies such as anencephaly, oesophageal or duodenal atresia, open neural tube defect, sacrococcygeal teratoma, also some placental causes may be relevant in this scenario (placental chorioangioma). The presence of fetal hydrops might be coexisting to polyhydramnios due to variety of causes, such as parvovirus 19 infection or alloimmunisation. TORCH (CMV, hepatitis B,C, parvovirua19, syphilis) screen will be required to look for a possible infection. TORCH (CMV, hepatitis B,C, parvovirua19, syphilis) screen will be required to look for a possible infection.

b) If no cause was found after all above investigations, the management will be depends on several factors, such as severity of polyhydramnios, patient's symptoms, effectiveness of offered treatment. Close fetal surveillance will required up to the rest of the preganancy. Regular USS for growth, LV, Dopplers every 2/52 with reviews in Consultant's led antenatal clinic. In cases of severe polyhydramnios one should consider pharmacological or surgical methods of reduction of excessive Amniotic fluid. Indometacin, a cyclo-oxygenase inhibitor or Sulindac were used in certain cases with success, but it cannot be used beyond 32/40 as the risk of premature closure of Ductus Arteriosus in the fetus. Steroids for expidating the fetal lung maturity needs to be discussed and given to the patient before 34+6/40 due to increased risk of preterm labour and accosiated prematurity and perinal morbidities and mortality. Thromboprophylaxis with TED's stockings and in case of inpatient admission with Clexane should be considered. The delivery and mode of delivery will be based on individual performance, normally by 38/40. Watching for malpresentaions, unstable lie as polyhydramnios could give an extra mobility to the fetus. In cases of unstable lie or high head after 36/40 the inpatient admission could be considered with awareness of risk of cord prolapse and placenta abruptio.

c) In case of spontaneous onset of labour at 36/40, the fetal presentation on arrival should be confirmed clearly, if ARM is planned - a Controlled ARM by experienced obstetrician as patient at incresed risk of cord prolapse. IV access and Group and Save send to the laboratory as a risk of PPH is also increased, active management of third stage would be required and should be discussed with patient due to uterine overdistension. In rare occasions the cases of Amniotic Fluid embolism and placental abruption were descibed in literature in women with polyhydramnios and rapid decompression of uterus after SROM or ARM. Neonatal team to be presented at preterm delivery and be available for detailed newborn's check. Continious Electronic Fetal Monitoring to be established on arrival, FSE clip may be required if abdominal monitoring is failed.