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MRCOG PART 2 SBAs and EMQs

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ESSAY 185 - PPROM

Posted by adnan S.
The risk associated are prematurity and chorioamnionitis/fetal infection.Premature birth is the major cause of neonatal mortality and morbidity.The rational for use of tocolytics are to delay delivery and gain time for corticosteroid administration /in utero transfer if NICU facilities are not available which will lead to improvement in neonatal survival and wellbeing with out causing undue risk to either the mother or fetus.Antenatal corticosteroids admnistration is associated with fetal lung maturity with significant reduction in perinatal mortalitry and morbidity with the statistical significance if corticosteroids administerd 48h-7days before delivery.No adverse effects have been identified for a single course of corticosteroids.Tocolytics decreased the risks of delivery within 7 days are betamimitics,indomethacin ,atosiban ,calcium chanel blockers like nifedipin.They are not associated with improved perinatal outcome.Maternal side effects significantly associated with tocolytics use were palpitations, nausea ,tremers ,hyperglycemia,hypokalemia rarely pulmonary oedema..Oral maintenance tocolytic therapy is ineffective.Since 40%of PPROM are associated with infection ,any delay in delivery may be detrimental to the fetus.The choice of drug remains contentious.Betamimetics are no more used as first line therapy because of side effects.Indomethacin has relatively few maternal side effects but fetal adverse effects like constriction of ductus arteriosus oligohydromnios ,necrotizing enterocolitis and intraventricular heamorrhage,hence its benefits outweigh the potential risk at gestation<32wks. Nifedipin is associated reduce incidence of RDS and admission to NICU,it is the only tocolytic currently associated with a benefit for the neonate .Atosiban have better maternal side effects ,with no improvement in perinatal outcome and high cost
Nifedipin is inexpensive ,only tocolytic shown to improve neonatal morbidity is the drug of first choice for this patient.
The management of this patient involve counseling by the neonatologist about the chances of survival which is around 74%at this gestational age of 26wks ,which deffers from hospitals to hospitals .If NICU facilities or no cots available transfer to tertiary center where facilities are available.Prophylactic antibiotics like erythromycin should be given which reduces neonatal and maternal infection ,reduction in neonatal treatment with surfactant,decreases O2dependency at 28days of age &fewer major CNS abnormalities on USS.The options available are c-section or vaginal assisted breech delivery.There is no evidences to show that c-section is associated with improved perinatal out come compare to assisted vaginal breech delivery in preterm breech presentation.C-section at 26wks is associated with technical difficulty as lower segment has not formed,low vertical incision will be needed,with the future pregnancy with scared uterus .woman is involved in the decision making regarding the mode of delivery .
Posted by Sarwa aldoori A.
The value of toccolytics lies in delaying delivery until arrangement is made for in utero transfer where avilability of special care baby unit facillities. Psycologicla support to the pateitn and detailed expalantion are very important in this case. As for the role of tocolytics ,itseffectiveness is mainly in the first 48 hours. B2 sympathomimetic as ritodrine terbutaline has been used extensively in the pasteither subcutaneously or by iv infusion , its main side effects are tacchycardia,widend pulse pressure,increased glucose ,lactateadndecreased K+ and arrhythemia. That is why it contraindicated in the presence of cardiac disease, pulmonary hypertension, uncontrolled diabetes. Calcium channel blockesr as nifedpine has been used increasingly with a loading dose of 20 mg poq30 minutes unitl uterine activity is controlledand begin maintenace dose three hrs after last loading dose,the side effects here are hpotension,tacchycardia,headaches flushing,and it is contrindicated in the presence of heart failure,aortic stenosis,impaired liver function, dut to its hypotensive effect we need to monitor BP every 15 minutesafter each loading dose.
The use of indomethacin is known for a long time ,it is prostaglandin synthetase inhibitor, given as 50 mg po then 25-50 mg po q4-6 hrto macx 300mg /24hrs.Its side effects are maternal gastric irrtiation, and fetal constriction of ductus arteriosus,it is contraindicated in bleeding diathesis,active petic ulcer, platelet disordersalso daily assesment of aminiotic fluid index is required. Magnesium sulfate is used by some given in laoding dose of 4-6 mg iv slowly then iv drip of 2 gm/he. it is calcium antagonist need to be closely monitored as there is a narrow therapeutic rand with high risk of toxicitywhich are loss of tendon refkex, respiratory depression, reduced urinarey output.it iscontraindicated in heart block,myocardial damage,impaired renal function.
The maangenet of this preterm breech start with multidisciplinary tea of neonatologist, obstetrician, specialist midwife.Detailed discussion of the situation, the prospect of this pregnancy and the likelhood of survival with no adverse handicapp. Confirm idlatation with a speculum exam and swabs to rule out chlamydial infection, gonorrhea, wet mount fo rbacterial vaginsis,as well trichomonas and treat if possible. Anorectal swabs and provision of antibiotics for group B sterp. Blood work up of full blood count, crp, platelt studies, urine exam. Strict attention to fluid balnce and provision of steroids. 12 hr apart to improve lung maturity, reduce RDS,NEC.Ultrasound exam to confirm gestational age, aminiotic fuild volume, palcental site, rule out cod compression,and survey for fetal anomaly.Theare contraindication to toccolutics in the case of fetal fetal compromise or lehtal anomaly which should be discussed in details with the aptient. The role of surfactant must be dsicussed.
Delivery of preterm breech is very controverial be it operative or vaginal and should be discussed with the patient. Also the delivery should be conducted by senior obstetrician. Other aspects are decided upon by neonatologist inters of intubation resuscitation . General practitione, comunity midwife need to be informed.
Posted by Farzana N.
Pre term prelabour rupture of membranes (pPROM) in this case puts the fetus and mother at risk of prematurity and chorioamnionitis.
Tocolytics have been proved useful in cases of preterm ROM by prolonging latency interval between ROM and delivery , thus giving opportunity for the steroids to take effect,make arrangements for NICU or inutero transfer to specialist center in case the neonatal facilities are not available.They have no proven benefit of prolonging the pregnancy or reducing perinatal mortality.In this pastient ,tocolytics should be used with great caution as the onset of contractions with pPROM commonly heralds the onset of chorioanionitis .The merits of attempting to delay delivery should be weighed against the risks of adverse neonatal and fetal outcomes in the presense of chorioamnionitis. Studies have not shown any evidence regarding the safety or benefit of using tocolytics in the settings of pPROM.
Antibiotics,Erythromycin should be given to increase the latency period and improve respiratory morbidity.
Steroids at 26wks gestation can be given if there is no evidence of chorioamninitis,but will be relatively contraindicated in suspected cases.
.Management options with preterm breech presentation are ceasarian section or vaginal breech delivery.An USS should be done to rule out any congenital abnormalities commonly associated with preterm breech. Any decision should involve the mother and her partner .Senior obstetrician and neonatologist should explain to the patient about the mortality rate. and survival. at this gestation. Her wishes should be respected. Parent will be under great stress being in this situation unexpectedly with uncertain perinatal outcome. They should be given sympathetic and supportive counseling with full opportunity to clear any doubts .Arrangements should be made for NICU.Preferrd mode of delivery in this case would be vaginal breech delivery.Studies have sown that any poor outcome of this very premature neonate would be due to complications of prematurity rather than mode of delivery.
An experienced obstetrician should supervise the vaginal delivery.Neonatologist should be present and also a senior anesthetist. An epidural should be sited and effective to prevent pushing prior to full dilatation .This will enable intradelivery manipulations,painless application of forceps to aftercoming head, or rapid recourse to operative delivery.Should the cervix clamp round the fetal head following delivery of the body ,gentle flexion by insertion of theindex finger into the fetal mouth may prove advantageous.If this does not succeed incision of the cervix should be performed.
Should ceasarian delivery be necessary,it can be performed through transverse lower abdominal incision.At this gestation the lower uterine segment would be poorly formed,so a classical uterine incision will be required..,Alternatively from the mother view point J-shaped extension to the lower uterine incision is advantageous. However with fetal mortality of upto 80% with breech presentations below 28 weeks. mothers future child bearing should not be compromised by employing classical approach.

Posted by raj K.
The benefits of tocolysis are that they decrease likelyhood of delivery over 48 hours, this can be used to aide transfer to a unit capable of accepting or having a place for a 26/40 baby on SCBU. It is felt that outcome is better by delivery at an appropriate unit than extra uterine transfer - in terms of fetal outcome.
It may be used in conjunction with antenatal maternal steroids to improve outcome for the fetus; (ie) less RDS, NEC, IVH, decreased perinatal morbidity or mortality.
It is a cost effective measure with decreased neonatal costs through decreased SCBU spending.
Premature rupture of membranes have subclinical chorioamnionitis as a cause in 40% of cases; suppressing delivery may be a risk in progressive chorioamnionitis- in a healthy woman with normal maternal;fetal observation - there is net benefit in suppression.
There is no evidence of benefit for suppression of labour after 48 hours, when steroids have maximum benefit.
Different tocolytics have differing side effect profiles; -
- B agonists have maternal risks of hyperglycaemia, hypokalaemia, pulmonary oedema and are poorly tolerated. They require intensive monitering and have implicatons for staff utilisation.
Nifedipine is not licensed for tocolysis, but has simaler efficacacy to B agonists, they are better tolerated and need less staff ultilisation.
Indomethasin is associated with renal function impairment in the neonate, sulindac may prove safer.

The management options are
(a) to attempt to suppress labour and give steroid cover; in the face of continued contrractions - contingency plans for delivery should be made.
(b) the lady will be in pain and may request analgesia, anesthetic consort is needed (a) for maternal pain (b) as an aide for breech delivery.
(c) paediatric awareness and availability, issues of transfer to a level 3 unit in uteros vs the risk extra uterine transfer vs risk of delivery en route need to be weighed up
(d) continuous fetal monitering, at 26/40, evidence of fetal compromise would warrant strong obstretric recommendation for caeserean delivery
(e) antibiotics, preterm delivery is a risk for GBS disease prphlaxis, with IV Benzyl penicillin warranted.

Below 26/40, the risk of prematurity is greater than risk of mode of delivery.
Under 37/40, no randomised trials have compared breech vaginal to breech CS delivery
Population data form 27 to 28 weeks show that there is a significant difference in mortality between breech born by CS vs vaginal delivery (from 73% to 83% survival)

But preterm CS may need a classical CS, which has future reproductive implications.
Posted by Srivas  P.
The main complications of preterm premature rupture of membranes at 26 weeks gestation are the possibility of having an extremely premature baby with associated poor survival and long term fetal neurological complications if she progresses in labor and delivers immediately. There are also increased fetal complications due to premature rupture of membranes like possible cord prolapse, cord compression, oligohydramnios and abruptio placenta. Delivery often occurs within 7 days in 80 % patients with PPROM.

The thrust of management in PPROM at 26 weeks, where both fetus and mother are well and healthy, is to try and prolong the pregnancy by expectant management, use of tocolytics to arrest premature contractions if there are no contraindications, administration of corticosteroids and prophylactic antibiotics. If tocolytics fail to arrest premature contractions and ensuing preterm labor, it still has a role in delaying labor so that corticoids can have effect and it also gives valuable time for transfer of this baby in-utero to the tertiary centre, well equipped in managing such premature babies and thus improve outcome.

The tocolytics mainly used are Beta sympathomimetics, NSAIDs like Indomethacin, Magnesium sulphate, Calcium channel blockers like nifedepine, Oxytocin antagonist Atosiban and Glyceryl Tinitrate. The tocolytic agents used have been only marginally efficacious in prolonging pregnancy and the serious maternal and fetal side effects preclude their long term use to prevent preterm labor. The tocolytics are used for up to 48 hours and oral tocolytics subsequently have not found to be useful. The time gained this way significantly reduces fetal morbidity like IVH, respiratory distress and thereby it is cost effective.

All commonly used tocolytics are similar in efficacy except Magnesium sulphate which has not been found useful in recent trials. The commonly used beta sympathomometics like Ritodrine can have serious maternal complications like pulm edema, myocardial ischaemia, hypokalaemia, hypergylcaemia and can precipitate ketoacidosis in diabetics. Atosiban an oxytocin antagonist is equally efficacious and with a better side effect profile. The high and prohibitive cost of atosiban still keeps Ritodrine in contention. Indomethacin can cause peptic ulceration, GI bleeding, renal failure, and thrombocytopenia in mother while fetal complications include pulm hypertension due to closure of ductus arteriosus, NEC and IVH besides causing oligohydramnios. Nitric oxide donors are still under trial. Nifedepine is as efficacious as betamimetics with better maternal side effect profile but is not licensed for this use in UK.

If this woman goes into established premature labor with breech presentation the woman should be told about the increased fetal complications due to prematurity, Breech presentation and also due to increased likelihood of congenital anomalies in breech presentations (18 % in preterm breech).There is higher incidence of IUGR. Her previous Ultrasound scan should be reviewed and if possible detailed ultrasound should be done again to look for congenital abnormalities of fetus and see placental position. Estimate of fetal weight should be done. Vaginal and urethral swabs should be taken to look for vaginal infections, GBS infection which could have caused this PPROM. Fetal prognosis should be explained to the couple which may be 40 % survival at 26 weeks gestation and 25-50 % of these survivors may have long term neurological complications and cerebral palsy.

Tocolytics should be given to delay delivery long enough for and corticoids to take effect which should also be given immediately. Corticosteroids decrease neonatal morbidity and mortality by reducing incidence of intraventricular haemorrhage and respiratory distress syndrome. The woman should be transferred, if in early labor to tertiary centre for delivery.

The intrapartum trauma to fetus is increased whether she delivers vaginally or by caesarean section. There is much controversy about optimum mode of delivery for a preterm breech. Caesarean on a preterm breech can have same complications as a vaginal delivery with difficulty in delivering the head through a poorly formed lower uterine segment. The incidence of intraventricular or periventricular hemorrhage are related to preterm delivery, immaterial of mode of delivery. No conclusive trials are available indicating preference of one over other. If there is placental abruption or cord prolapse clearly Caesarean is indicated which should be done by a senior obstetrician. She may need a J-shaped incision over lower uterine segment for extraction of baby and this is preferred to De Lee vertical incision which may get extended to a classical incision.

The mode of delivery should be discussed with the woman and her partner the risks and complications explained and there wishes should be recorded. Vaginal delivery should be conducted by experienced obstetrician. Epidural anesthesia is advised so as to prevent premature pushing in second stage, allow manipulation of breech or for rapid recourse to caesarean. There is no advantage in prophylactic forceps for after coming head. Anesthetist and senior neonatologist should be in attendance at delivery. If the aftercoming head gets stuck head, it should be flexed by suprapubic pressure and duhrrssen incision may be given at 4 and 8 ?o? clock positions to expedite delivery.

Woman should be given psychological support when her baby is likely to be in nursery for prolonged period. Access to nursery should be allowed to facilitate bonding with the baby. She may need help with manual expression of milk till baby is ready to suckle.

Woman should be told that risk of preterm delivery in next pregnancy is 20-30 %. She may need further investigations post delivery to look for cause of preterm delivery like congenital abnormalities of uterus, vaginal infection, cervical incompetence or maternal infections causing premature labor. Complete work up may also need inputs from neonatologist
Posted by hala M.
The rational for the use of tocolytics in this patient is to buy time for the interventions that can be done in order to improve perinatal outcome such as the steroid administration, antibiotics use and the in utero transfer to a unit with neonatal care facilities.There is no place for the long term maintenance use. Prolonging pregnancy is associated with an increase of 3% in survival for each day prolongation.
Most tocolytics used prolong pregnancy for 48 hours after its commencement and up to 7 days. Prolongation of pegnancy might be detrimental for the fetus and the mother when there is a clear indication to delivery such as infection which might be the underlying cause to the PPROM. The uterine response would be poor to tocolytics when the infection is the underlying cause.

The most commonly used tocolytics is Ritodrin which suppress uterine contraction by its sympathomemitic effect. It delays delivery within 48 hours of use and up to 7 days.
It is associated with side effect of headache, palpitation, tremor, tachycardia, nausea, vomiting, electrolyte imbalance and hypotension. The serious side effects include pulmonary oedema, cardiac ischemia and hyperglycaemia. It needs to be used with caution in multiple pregnancy and diabetes.
It is used by IV infusion ( no place for oral use) in 5% Dextrose starting at 50 ug/min to a maximum of 350. The use needs rigorous monitoring of pulse, BP( every 15 minutes), pulmonary field auscultation, blood sugar( 4 hourly ), U&E daily and in-put out- put fluid.

Indomethacin is a COX2 inhibitor and has the same efficacy like ritodrin with less minor side effects. It is associated with oligohydroamnios, premature closure of ductus arteriosus and necrotising enterocolitis in the foetus.
Atosiban ( oxytocin receptor inhibitor is as effective as ritodrin with less cardiovascular side effect). It is licensed for use but is costly. It was shown that it is associate d with increased neonatal mortality in the group below 28 weeks.
Nifidipin is a calcium channel blocker and better than ritodrin in delaying delivery by 48 hours, cheaper than atosiban but is not licensed for use in UK.


When the patient is in established labour it is necessary to counsel the about the expected outcome in term of survival and morbidity. This need to be done with the input of neonatologist if possible (survival at 26 weeks deliver is 74% with a 10- 20% risk of long term morbidity). The steroid use between 1-7 days stimulates the lung maturity and reduces neonatal mortality and morbidity. Single steroid use is not associated with increase in adverse effects. The SCBU awareness of the delivery is necessary for the neonate admission.
The antibiotic use ( Erythromycin) is associated with reduced morbidity as it treats/ prevents infection.

In this preterm breech delivery in established labour a well monitored vaginal delivery is sensible option. CS could be difficult at a small gestational age as the lower segment is not well formed with the risk of haemorrhage and upper segment scar with its implication for future pregnancies and deliveries (placenta praevia and uterine rupture). CS does not improve the outcome as the neonatal morbidity and mortality is related to the prematurity and not to the mode of delivery. Therefore the patient?s wishes need to be taken in account when taking the decision of the mode of delivery.

The vaginal delivery needs to be completed by an experienced obstetrician and the labour monitored using EFM and under the epidural block with the presence of the paediatrician. The delivery of the small breech through an under dilated cervix is associated with the risk of difficult delivery of the after coming head. This needs to be managed by a careful head flexion and if this failed then the cervix can be excised at the position 4-8 O?clock carefully by an experienced obstetrician.
Posted by Sarwat F.
Obstetric management at the limits of neonatal viability raises important issues. Tocolytic use in this woman can be beneficial for gaining time to administer steroids and for in utero transfer. Betamethasone in two doses 12 hrs apart is effective in preventing respiratory distress syndrome and necrotizing enterocolitis in neonates and hence improves neonatal survival. Tocolytic are also useful if the hospital does not have SCBU facilities and in utero transfer is desired. Various options for tocolytics include atosiban, nifedipine, and ritodrine. Atosiban is oxytocin antagonist, which is beneficial as it does not have significant side effects and it is comparable to other tocolytic in term of efficacy. The problem with atosiban is its high cost and it needs to be given parenterally with proper dose calculation. Nifedipine on the other hand is cheap and can be given orally. It is equally effective as atosiban but it is not licensed for use as tocolytic and it is associated with side effects including headache and tachycardia. Ritodrine was the most commonly used drug in the past but it is associated with side effects like fluid overload, pulmonary edema, myocardial ischemia, hyperglycemia and hypokalemia. Various other tocolytics include magnesium sulphate and nitrates but their role is not established.
There is no role for long term use of tocolytics and delivery can only be postponed for 48 hrs.
Management options will be antibiotic preferably erythromycin and counselling of woman regarding mode of delivery. She will be explained about hazards of breech vaginal delivery that benefits of caesarean section far outweigh the risks of vaginal breech delivery to the baby. On the other hand neonate who is 26 weeks at the time of births may not have a good survival because of prematurity and is likely to suffer from neonatal complications like respiratory distress and neonatal encephalopathy. Caesarean section will be the favoured option after counselling woman. Counselling will also include problems expected at the time of caesarean section as lower segment will not be formed and a classical incision will be needed and this will have an impact on future pregnancies, as after a classical incision all future deliveries will be by caesarean section. A paediatrician must be present at the time of delivery. He hospital say may be prolonged because of neonatal admission in SCBU.
Posted by Aroosha B.
Preterm labor at 26 weeks of gestation is associated
with significant prenatal morbidity and mortality. Any intervention should aim to improve the survival. The role of tocolytics has not been proved to decrease prenatal mortality. The survival at 22 weeks is 8% and is 76% at 26 weeks. The aim of any tocolytic therapy is to prolong the gestation is so that the time can be gained for intervention therapy which will result in improved neonatal outcome. The various interventions which can be taken are the administration of corticosteroids which give the maximum benefit 24-48 hours until seven days after administration. The use of corticosteroids has been improved to decrease the prenatal morbidity mortality, IVH, necrotising enterocolitus and low rate of admission to NICU. The second advantage gained by use of tocolytic therapy is to facilitate in utero transfer to center with NICU facilities if these are not available as delivery in a center with NICU facilities is associated with improved outcome. However tocolytics at this gestational age are less effective in prolonging the gestational age. Although the maternal and fetal condition are normal. administration of tocolytics should be extremely careful as its use may mask the sign and symptoms of infection and result in harm rather than benefit.
There are various tocolytics which have been used but none of them is associated to decrease perinatal morbidity and mortality. Retrodine hydrochloride was the most commonly used tocolytic. However it is no more recommended because of its side effects profile on mother like tremors, palpitation, hypokalemia and rarely pulmonary odema.
Atosiban which is oxytocin antagonist is now the tocolytic of choice and is licensed for this use in pregnancy because it has same efficacy and low maternal side effects but it is expensive and is less effective at this gestational age. Nifedipine is the only tocolytic which is proved to improve prenatal outcome although not licensed for this use. MgSO4 is used as tocolytic in USA and no more is used in UK. Its administration needs careful monitoring as over dose can lead to cardiac arrest and respiratory depression.
NSAID are the only tocolytic which prolong the gestational age until 37 weeks but considerable fetal effects like oligohydroaminus constriction of ductusartieriosus.
Management options in this patient needs careful counseling of the patient and the multidisciplinary approach consisting of obstetrician, neonatologist and anesthetist. Continuous fetal monitoring is indicated in those cases where a viable fetus is expected. Its interpretation needs careful monitoring with back ground of prematurity. The neonatal unit should be informed and if it is not available transfer can be considered if a center with NICU facilities are available near by. If the labor is progressing with breech presentation and fetal monitoring is normal then a normal vaginal delivery should be anticipated as the best mode of delivery for preterm breech has not yet determined. LSCS can be considered for fetal distress. If LSCS is indicated then it should be carried out by senior obstetrician. The patient should be informed of outcome at this gestational age and a need for classical caesarean section with its subsequent effects on next pregnancy. The neonatologist should inform survival rate, short term and long term effects on survival at this gestational age in the light of unit and local area survival rate.
The patient should have opportunity to see NICU unit and aware of admission to NICU which may be prolonged. All discussion should be documented in notes and patient informed of support group and informed consent taken.
Posted by Aroosha B.
Preterm labor at 26 weeks of gestation is associated
with significant prenatal morbidity and mortality. Any intervention should aim to improve the survival. The role of tocolytics has not been proved to decrease prenatal mortality. The survival at 22 weeks is 8% and is 76% at 26 weeks. The aim of any tocolytic therapy is to prolong the gestation is so that the time can be gained for intervention therapy which will result in improved neonatal outcome. The various interventions which can be taken are the administration of corticosteroids which give the maximum benefit 24-48 hours until seven days after administration. The use of corticosteroids has been improved to decrease the prenatal morbidity mortality, IVH, necrotising enterocolitus and low rate of admission to NICU. The second advantage gained by use of tocolytic therapy is to facilitate in utero transfer to center with NICU facilities if these are not available as delivery in a center with NICU facilities is associated with improved outcome. However tocolytics at this gestational age are less effective in prolonging the gestational age. Although the maternal and fetal condition are normal. administration of tocolytics should be extremely careful as its use may mask the sign and symptoms of infection and result in harm rather than benefit.
There are various tocolytics which have been used but none of them is associated to decrease perinatal morbidity and mortality. Retrodine hydrochloride was the most commonly used tocolytic. However it is no more recommended because of its side effects profile on mother like tremors, palpitation, hypokalemia and rarely pulmonary odema.
Atosiban which is oxytocin antagonist is now the tocolytic of choice and is licensed for this use in pregnancy because it has same efficacy and low maternal side effects but it is expensive and is less effective at this gestational age. Nifedipine is the only tocolytic which is proved to improve prenatal outcome although not licensed for this use. MgSO4 is used as tocolytic in USA and no more is used in UK. Its administration needs careful monitoring as over dose can lead to cardiac arrest and respiratory depression.
NSAID are the only tocolytic which prolong the gestational age until 37 weeks but considerable fetal effects like oligohydroaminus constriction of ductusartieriosus.
Management options in this patient needs careful counseling of the patient and the multidisciplinary approach consisting of obstetrician, neonatologist and anesthetist. Continuous fetal monitoring is indicated in those cases where a viable fetus is expected. Its interpretation needs careful monitoring with back ground of prematurity. The neonatal unit should be informed and if it is not available transfer can be considered if a center with NICU facilities are available near by. If the labor is progressing with breech presentation and fetal monitoring is normal then a normal vaginal delivery should be anticipated as the best mode of delivery for preterm breech has not yet determined. LSCS can be considered for fetal distress. If LSCS is indicated then it should be carried out by senior obstetrician. The patient should be informed of outcome at this gestational age and a need for classical caesarean section with its subsequent effects on next pregnancy. The neonatologist should inform survival rate, short term and long term effects on survival at this gestational age in the light of unit and local area survival rate.
The patient should have opportunity to see NICU unit and aware of admission to NICU which may be prolonged. All discussion should be documented in notes and patient informed of support group and informed consent taken.
Posted by Vaani M.
Premature PROM is associated with neonatal morbidity and mortality. The use of tocolytics in this woman would only be indicated for the administration of corticosteroids for fetal lung maturity and for the transfer of the mother to a unit with facilities for delivery and care of a 26 week neonate if not available. The tocolytics would help delay delivery from one to 7 days after administration. The drugs of choice would be ritodrine, nifedepine, or atosiban as per the local protocol and availability of drug. Ritodrine is a beta agonist associated with maternal side effects as hyperglycaemia, hypokalaemia, fluid retention, and pulmonary oedema but no neonatal benefits. Nifedepine is associated with very few side effects as tachycardia and headache for the mother and improves neonatal outcome. Atosiban needs to be administered parenterally and is expensive but the only licensed drug for use as a tocolytic.

Since maternal and fetal observations are normal with uterine contractions and early labour pains, her management would include immediate administration of betamethasone for fetal lung maturity and tocolytics to delay delivery. Antibiotics as erythromycin should be given. Her condition needs to be monitored by daily assessment of full blood count for leucocytosis, C-reactive protein, CTG, and biweekly ultrasound for biophysical profile and to assess liquor volume. If all were observed as normal she could be allowed to progress to 34 weeks prior to deciding for delivery. If she develops chorioamnionitis with fever, leucocytosis, she needs to be delivered immediately. The mode of delivery for a 26 week fetus in breech is controversial. ECV could be tried under tocolysis but with contractions and ruptured membranes chances of success is very limited. Preterm breech would be best delivered by caeserean although the prognosis for a 26 week neonate could be poor with immature lung development and neurodevelopmental delay. The caeserean could be difficult with decreased liquor and need for a classical scar necessisating further caesereans in future. Vaginal delivery for a breech further compromises the neonatal prognosis in addition to the poor prognosis of the preterm neonate. A detailed discussion with the neonatologist and the couple is necessary with explanation about her status and neonatal prognosis as per facilities available prior to deciding mode of delivery. The woman and her partner should be given the choice to decide their choice regarding mode of delivery.
Posted by Sreekala S.
There is no clear evidence to suggest that tocolytics improve the outcome in preterm labour. But, Tocolytics should always be considered to gain some time for the intra uterine transfer to a tertiary level neonatal unit and to complete the course of corticosteroids to enhance fetal lung maturity. Generally Tocolytics are indicated for use only for 48hrs within which measures can be taken for the intra uterine transfer or for steroids to act.
Ritodrine is no longer the tocolytic of choice because of its unpleasant side effects like palpitations, tremor, chest pain, headache, nausea and pulmonary edema.
Atosiban or Nifedepine are preferred as they have fewer side effects and comparable effectiveness. Atosiban is licensed for its use in the UK but not nifedepine for use as a tocolytic. Atosiban is associated with nausea and vomiting. The main disadvantage with atosiban is that it is very expensive. Nifedepine has the advantage that it can be taken orally and is cheap. It is associated with side effects like headache, flushing, tachycardia, palpitations, hypotension.
Indomethacin is a NSAID which is not commonly used as a tocolytic. It is associated with premature closure of the Patent ductus areteriosus, renal and cerebral vasoconstriction and necrotising enterocolitis.
Magnesium sulphate and Glyceryl trinitrate are not commonly used.
Maintenance tocolysis is not commonly recommended.
In view of the lack of substantive evidence to support the use of tocolytics and due to their potential side effects the woman and her partner should be involved in decision making about the use of tocolytics.
She should be counselled that there is a high probability of delivering the baby preterm. NICU staff should be alerted and paediatric team made to speak to the couple about the prognosis of the baby.

The woman and her partner should be informed of the different options of delivery and the potential risks. The baby can be allowed to deliver vaginally either by a spontaneous breech vaginal delivery or an assisted vaginal breech delivery. With a Vaginal delivery the baby has the advantage of an improved respiratory outcome than that with a caesarean section as the stress of labour reduces the respiratory morbidity and gives a reasonable chance of a vaginal delivery for her next time. The main disadvantage may be with the delivery of the after coming head and needs the presence of experienced staff trained in vaginal breech delivery.
ECV is a manouvre that is performed to get the breech presentation into the favourable cephalic presentation to enable her to have a vaginal delivery. It should be attempted after proper counselling of the couple under continuous electronic fetal monitoring by trained staff with preparation for an emergency caesarean section in the event of signs of fetal distress. Tocolytics and IV sedation may be needed. ECV carries the risks of failure of the procedure, need to deliver the baby by an emergency caesarean section.
Emergency Caesarean section is another option but carries the risks of injury to bowel, bladder, infection, haemorrhage, DVT/PE and reduces the chances of a vaginal delivery next time.
The different options should be discussed with the couple and an informed decision taken. The discussion should be well documented. Trained paediatric team should be present at delivery.
Posted by BAHAA-Uddin BOR B.
The use of tocolytics in this particular patient allows for the administration of corticosteroids and in-utero transfer to a unit with neonatal facilities .( SCUB).
Its effectiveness may be reduced when used in PPROM but they are not contraindicated. A wide variety of agents have been advocated as suppressing uterine contractions.Three classes of proven tocolytic are available : beta-adrenoceptor agonists, non-steroidal ant-inflammatory drugs, and calcium-channel antagonists.
B-mimetics have been the most commonly used drugs in UK.Although its use is associated with significant adverse effects,such as palpitation ,tremor, chest pain ,cardiac arrythmias, nausea ,vomiting, headache, hyperglycaemia , pulmonary oedema and also maternal death. Short-term fetal effects include tachycardia and increased cardiac output .Atosiban-an oxytocin antagonist , has a better maternal cardiac adverse effect profile than B-mimetics.It is now proven to be an effective tocolytic ,it is licensed for use, but it is more expensive when compared to Ritodrine and Nifedipine.
Nifedipine, a calcium channel blocker has the advantage of oral use and it is cheap.
A recent metanalysis has shown that it appear to be more effective than B-mimetics for tocolysis and has a better side effect profile . It is NOT licensed in the UK for use as tocolytic . Its side effects include headache,nausea and gastrointestinal symptoms.
Dosage in the largest trial was 10mg. SL.every 15min. for the first hour, until contractions stopped ,then 60-160 mg /day of slow release nifedipine depending on uterine activity. Indomethacin ,(NSAI),has a relatively few maternal advers effects but its use has been limited by potential fetal adverse effects,such as,premature closure of ductus arteriosus ,oligohydramnios, necrotising enterocolitis and impaired fetal renal function.The use of any tocolytic should be carefully considered in terms of
Available evidence on potential benefit and possible hazards and fully discussed with the patient and the partner before treatment is started.
Management options depends on several factors including the availability of neonatal (NICU)facilities,perceived chances of survival , and the most important is the woman whishes , which accordingly should be discussed ,explained to her ., the hazards at delivery ,and the preterm breech fetus faces considerable problems whatever the mode of delivery,but caesarean section confers considerable extra morbidity on the woman.
Management depends mainly on presence of senior obstetrician, neonatologist and senior anaesthist. Frequent assessment of fetal heart rate, careful ultrasound examination may be useful to exclude placenta praevia , fetal anomalies, estimate of fetal weight. All procedures should be under complete aseptic precautions, I/V Erythromicin should be started,also the risk of placental abruption should be considered whenever blood loss or abdominal pain occur.
Vaginal delivery should be attended by a senior obstetrician.It is preferably conducted with an effective epidural block.If the fetal head become entrapped behind the incompletely dilated cervix,it should be carefully flexed, failing this, the cervix should be incised at 4 and 8 o\'clock., the head will deliver.
Caesarean section ,if the woman\'s wishes or for apparent obstetric indications, like placental abruption, or cord prolapsed .and caesarean section may be the only option ,CS through a Pfannensteil incision will be adequate for LSCS, but a classical or De Lee incision will require a vertical midline incision..The management of this patient therefore poses several problems which must be discussed and the woman and partner are involved in the decision making regarding the mode of delivery.

Posted by M H.
Management in this lady would constitute a balance between the benefits of prolonging the pregnancy for foetal benefit and the ricks of infection, chorioamnioitis. The use of tocolytics in this lady may delay delivery to enable administration of antenatal corticosteroids to facilitate foetal lung maturity and also transfer to a unit with neonatal intensive care back up if necessary. Due to severe prematurity of 26W, prolongation of pregnancy would also improve outcome by about 3% per day.

However, it is well documented that rupture of membranes is associated with infection and in these instances, prolongation of the pregnancy may be detrimental to both foetus and mum. Tocolytics on their own have not been shown to reduce incidence of perinatal mortality, morbidity are preterm delivery. There are also the potential effects of tocolytics on the foetus (NSAIDS have been associated with necrotising enterecolitis, oligohydramnios and intraventricular haemorrhage).

The mode of delivery for a preterm breech is still controversial. To facilitate counselling and decision making, the nature of the breech presentation and the position of the cord should be ascertained. If there is time, an ultrasound should be done to look for associated foetal anomalies. The lady should ideally be in a centre with operative and neonatal intensive care facilities and a neonatologist should be consulted. If elected to proceed for a vaginal deliver (in event of an extended or frank breech), the delivery should be attended to by the most senior and experienced obstetrician with the neonatologist nearby to attend to the baby on delivery. However, vaginal delivery has been associated with intraventricular haemorrhage, damage to internal organs and entrapment of head but there is no evidence that conclusively show that a caeseran section would avoid all these problems.

At 26 weeks, the lower segment may not be well formed and she may require a classical section. To enable future pregnancy safely, a J incision would be better. The morbidity rate is higher for the lady with a caeseran section and there may not be any extra benefit to the foetus.

As there is absence of eveidence that a preterm baby should be delivered by Caeseran Section, the decision regarding mode of delivery should be made in conjuction with the parents. Counselling should be carried out by the most experienced person in a non directed manner to deliver evidence based information to enable the couple to make an informed choice. They should be allowed to ask questions and be given time to make a decision. Post delivery, they will need additional support, another session should be arranged to tackle any issues, referral to a support group should be made. Breastfeeding should be encouraged
Posted by Aroosha B.
Dear DR Paul
I have a quairy regarding second part the mangement option r vaginal delivery versus LSCS .We have informed the patient of pros and cones and a survival rate of 76 percent,the fetus is normal.We know interpretation of CTG at this gestational age but how we will know that stressof labour is not affecting this premature fetus, Imean how we will monitor labour































































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Posted by SWATI M.
Aim of use of tocolytic drugs is to delay the delivery and improve neonatal outcome.

Tocolytic drugs delay delivery from 48 hours upto 7 days .When used alone they are not associated with improved neonatal outcome but this time interval can be utilized to administer corticosteroids which enhance fetal lung maturity and associated with reduction in the incidence of RDS , IVH and necrotising enterocolitis .This improves neonatal outcome and also there is reduction in cost of NICU facilities due to reduced stay,less requirement of surfactant and oxygen use.Maximum benefit of corticosteroids use will be established after 24 hours of the first dose.

The effectiveness of tocolytics in this woman will be reduced due to spontaneous rupture of the membranes and presence of the uterine contractions and moreso if she has vaginal bleeding too.Still delay of labour upto 24 hours can be helpful to establish action of corticosteroids and should be recommended.Transfer to the centre where NICU fascilities are better available will be desirable .Since she has regular contractions,ex-utero transfer may be appropriate after initial neonatal stabilization.

Nifedipine and atosiban are equally effective and has less side effects than B-agonists. Nifedipine can be given orally ,it is cheap but not licensed as a tocolytic and no consensus about appropriate doses.Atosiban is associated with fewer maternal cardiovascular side effects than B agonists but needs to be administred intravenous and more expensive.Its side effects are nausea and vomiting.B-agonists are widely used but has significant side effects such as palpitations,chest pain, pulmonary edema and hyperglycaemia.
In her case nifedipine or atosiban will be preferred according to the availability.
Indomethacin will not be preferred in her case as she is likely to deliver and can cause PDA in neonate.

Aim of management in established labour with breech presentation is to ensure safe delivery minimizing neaonatal trauma and less maternal morbidity.

Vaginal delivery should be allowed if she is in advanced labour ,cord prolapse has been ruled out and fetal condition is good .Ensure presence of the skilled personnel in vaginal breech delivery at delivery time ,also the neonatologist .Recommend continuous CTG monitoring during labour but interpretation of CTG at this gestation is more difficult and senior input is vital .Emergency caesarean section may be needed if fetal distress or cord prolapse occur during labour.There is risk of entrapment of head and fetal hypoxia with expulsion of fetal leg/breech through partially dilated cervix needing cervical incisions to deliver fetal head and these incisions are associated with more bleeding.

There is no evidence that caesarean delivery in all preterm breeches is associated with better outcome.Caesarean section is recommended if fetal distress ,cord prolapse or footling breech presentation. CS will be associated with more maternal morbidity due to haemorrhage as lower segment is not well formed ,need classical vertical uterine incision.This has implications on mode of delivery in future pregnancies.There is potential for fetal trauma during delivery as uterine wall is thick at this gestation and most of liquor is drained due to ruptured membrane.
Decision of mode of delivery will depend upon type of breech ,cord prolapse,fetal condition and maternal wishes.