Week 7 - Pre-term labour

Given the large volume of new information in this guideline, we will dedicate the next 3 weeks to this topic.

Question1

Which one is among the 5 most important topics that women at increased risk of pre-term labour want to know about?

A.     The risk factors for pre-term labour

B.     The options for preventing pre-term labour

C.     The signs and symptoms of pre-term labour                    

D.    The treatment options for women in pre-term labour

E.     The gestation age at which premature babies can survive

Question2

Recognised risk factors for pre-term labour include

A) Previous pre-term birth or pre-term prelabour rupture of the membranes

B) BMI below 17 or short cervix identified on trans-vaginal scan

C) Uterine fibroids and BMI over 35

D) BMI below 17 or a history of mid-trimester miscarriage

E) None of the above                  

Question3

Progestogens can be used to prevent pre-term labour in women at increased risk. To be effective, progestogens should be started

A.    Before 6 weeks gestation

B.    Before 8 weeks gestation

C.    At or before 12 weeks gestation

D.    At or before 16 weeks gestation

E.     At or before 20 weeks gestation                    

Question4

In women at increased risk of pre-term labour based on ultrasound identification of a short cervix, use of vaginal progesterone is associated with

A.    No reduction in the risk of pre-term birth

B.    A reduction in the risk of pre-term births before 28 weeks but not in the risk of pre-term births before 33 weeks

C.    A reduction in the risk of pre-term births before 33 weeks but not in risk of pre-term births before 28 weeks

D.    A reduction in the risk of pre-term births before 28, 33 and 35 weeks                     

E.     A reduction in the risk of pre-term births before 28 and 36 weeks

Question5

In women at increased risk of pre-term labour based on ultrasound identification of a short cervix, use of vaginal progesterone is associated with

A.    A significant reduction in perinatal mortality

B.    A significant reduction in neonatal mortality

C.    A significant reduction in risk of neonatal sepsis

D.    A significant reduction in the risk of broncho-pulmonary dysplasia

E.     None of the above                  

Question6

Vaginal progesterone can be used to reduce the risk of pre-term birth in women with a short cervix identified by trans-vaginal ultrasound scanning. Which group of women have been shown to benefit from this treatment?

A.    Women with cervical length below 30 mm

B.    Women with cervical length below 25 mm

C.    Women with cervical length of 21-25 mm

D.    Women with cervical length of 10-20 mm                   

E.     None of the above

Question7

Which one is an indication for prophylactic cervical cerclarge?

A.    Previous pre-term prelabour rupture of the membranes at 26 weeks

B.    Previous pre-term prelabour rupture of the membranes followed by spontaneous pre-term delivery at 28 weeks

C.    Cervical shortening on trans-vaginal ultrasound scan at 16 weeks              

D.    Previous diathermy loop excision of the cervix

E.     More than one of the above

Question8

Prophylactic cervical cerclarge is associated with

A.    No significant difference in the risk of pre-term birth in women with a previous history of pre-term birth                

B.    No significant difference in the risk of pre-term birth in women with a shortened cervix on trans-vaginal ultrasound scanning

C.    A significant increase in the risk of chorioamnionitis

D.    A significant reduction in the risk of pre-term births at or below 24 weeks

E.     A significant increase in the risk of neonatal sepsis

Question9

There are several options for preventing pre-term birth in women at increased risk. Compared to vaginal progesterone, prophylactic cervical cerclarge is associated with

A.    An increased risk of perinatal mortality

B.    A decreased risk of neonatal mortality

C.    A decreased risk of serious neonatal morbidity

D.    An increased risk of pre-term birth before 34 weeks

E.     None of the above                  

Question10

Cervical cerclarge can be used undertaken based on clinical history alone or clinical history plus cervical length measurements. Compared to history-indicated cerclarge, ultrasound-indicated cerclarge is associated with

A.    Lower perinatal mortality

B.    Lower neonatal mortality

C.    Increased risk of maternal pyrexia

D.    Lower risk of pre-term birth before 28 weeks

E.     No significant difference in perinatal mortality, neonatal mortality or risk of pre-term birth                

Question11

A healthy 32 year old woman attends the antenatal clinic at 14 weeks gestation in her second pregnancy. In her first pregnancy, she presented at 15 weeks gestation with vague abdominal pain and vaginal bleeding. Her cervix was found to be 6 cm dilated and she suffered a miscarriage 5 hours later. All investigations were negative.

A.    Recommend prophylactic cervical cerclarge

B.    Recommend serial ultrasound cervical length measurements from 20 – 28 weeks

C.   Offer serial ultrasound cervical length measurements from 16 – 24 weeks                      

D.   Offer vaginal progesterone

E. Offer vaginal progesterone or prophylactic cervical cerclarge

Question12

A healthy 23 year old woman has been referred to the antenatal clinic at 20 weeks gestation in her first pregnancy. During the anomaly scan, the sonographer thought that the cervix appeared shortened on trans-abdominal scanning. Trans-vaginal scanning was therefore performed and the cervical length was 22 mm. The pregnancy has so far been uncomplicated and there is no history of cervical surgery or trauma.

A.    Offer prophylactic cervical cerclarge

B.    Repeat trans-vaginal scan in 2 weeks

C.    Offer vaginal progesterone                

D.    Offer prophylactic cervical cerclarge or vaginal progesterone

E.     Reassure the woman

Question13

A healthy 35 year old woman is undergoing serial trans-vaginal scanning to measure cervical length. The cut-off at which treatment should be offered or considered is

A.    25 mm              

B.    20 mm

C.    15 mm

D.    variable depending on the previous history

E.     variable depending on gestation age

Question14

A 36 year old woman attends the antenatal clinic at 10 weeks in her first pregnancy. In her first pregnancy, she went into spontaneous labour at 35 weeks gestation and had an emergency caesarean section because of a breech presentation. The baby spent 2 weeks on the neonatal unit but is alive and well. There are no other risk factors.

A.    Offer serial cervical length measurements from 14 - 24 weeks

B.    Offer serial cervical length measurements from 16 – 24 weeks

C.    Offer serial cervical length measurements from 16 – 28 weeks

D.    Reassure                                

E.     Offer prophylactic vaginal progesterone

Question15

A healthy 23 year old woman attends the antenatal clinic at 20 weeks gestation following an anomaly scan and trans-vaginal scan to measure cervical length. She has a history of spontaneous miscarriage at 18 weeks. The anomaly scan is normal and the cervical length is 18 mm with no funneling.

A.    Repeat cervical length in 1-2 weeks

B.    Offer prophylactic cervical cerclarge

C.    Offer vaginal progesterone

D.    Offer prophylactic cervical cerclarge or vaginal progesterone                     

E.     Reassure

Question16

A healthy 39 year old woman attend the antenatal clinic at 12 weeks gestation in her first pregnancy. She has a history of CIN 3 treated by laser cone biopsy 10 years ago. Her subsequent cervical smears have been negative.

A.    Offer prophylactic cervical cerclarge

B.    Offer vaginal progesterone

C.    Offer prophylactic cervical cerclarge or vaginal progesterone

D.    Offer serial cervical length measurements                 

E.     Offer speculum examination to assess cervical length

1e 2a 3e 4d 5b 6d 7e 8d 9e 10e 11d 12e 13d 14d 15d 16b 

ANSWERS

1)   C

2)   E

3)   E

4)   D

5)   E

6)   D

7)   C

8)   A

9)   E

10)                  E

11)                  C

12)                  C

13)                  A

14)                  D

15)                  D

16)                  D

To Dr Paul

question 6 has answer D,but nice guidelines of 2015 on preterm labour informs that offer prophylactic vaginal progesterone ,if trans vag usg between 16 and 24 weeksshows cervical length less than 25 mm.Should not the correct answer be 6 B?

Women with ultrasound identified short cervix

·       Women who received vaginal progesterone have significantly fewer preterm births under 28, 33 and 35 weeks compared with those who received placebo.

·       There was no strong indication that some subgroups based on the cervical length benefit either more or less from the intervention of progesterone.

·       However, there was some indication that there may be a significantly lower risk of preterm birth in women with cervical length of 10–20 mm who received progesterone compared with those who received placebo.

·       There was no evidence of benefit for the subgroups of less than 10 mm or between 21 mm and 25 mm.

·       This IPD meta-analysis also showed no significant differences between the 2 treatment groups for perinatal mortality, intrauterine fetal death, neonatal death, preterm birth under 37 weeks, bronchopulmonary dysplasia or neonatal sepsis