CASE

General
FY, 32 years old Gravida 1 Para 0 Chief Complaint: on and off hypogastric pain LMP - 6/11/12 PMP: 5/15/2012 AOG: 23 weeks EDC: 3/18/2013

History of Present Pregnancy

1st prenatal check up (14 weeks AOG) - usual signs and symptoms of pregnancy such as urinary frequency, breast tenderness, easy fatigability

TVS (Sept 24, 2012)

Single live intrauterine pregnancy compatible with 13 weeks and 6 days by fetal biometry, good cardiac and somatic activities - prescribed multivitamins, folic acid, calcium

 2nd prenatal check up (15 weeks aog) Pap smear - normal

HbsAg - non reactive

Vaginal candidiasis Clotrimazole 100mg/tab, 1 tablet vagina OD for 6 days

Regular intake of Multivitamins, Ferrous Sulfate and Calcium Carbonate

 3rd prenatal check up (23 weeks aog) 1 day prior to consult - Frequent uterine contractions every 10-15 minutes lasting for 30 seconds mild to moderate. No associated vaginal spotting and watery vaginal discharge

PE
General: Conscious, coherent, not in cardiorespiratory distress
BP 100/60 mmHg RR 18 cpm CR 74 bpm T 36.5 C

HEENT: Pink palpebral conjunctiva, anicteric sclerae Neck: supple, no palpable lymph nodes

PE
Chest/Lungs: symmetrical chest expansion, no retractions, vesicular breath sounds Heart: Adynamic precordium, normal rate, regular rhythm, no murmur Abdomen: Slightly globular, with a fundic height of 22 cm, fetal parts not well delineated, fetal heart tones of 120s best heard at the hypogastric area

PE
Speculum: clean looking cervix with minimal yellowish discharge non foul smelling Internal examination: normal looking external genitalia nulliparous introitus vagina admits 2 fingers with ease cervix soft closed posterior uneffaced

 Impression: Gravida 1 Para 0

pregnancy uterine 23 weeks aog

To consider Vaginitis

Threatened preterm labor

Plan
For Gram stain and Wet smear of cervicovaginal discharge

For Urinalysis
For 75 g OGTT

Start Isoxsuprine HCL 10 mg/tablet, 1 tablet q8 hours for 7 days

Labs
Urinalysis- Normal Color - Dark Yellow Transparency - Hazy PH 6.0 Sp. G. 1.030

Protein negative
Sugar - negative RBC 0 2 WBC 0 - 3

Labs
FBS - 61.58 mg/dl
1st hour 120.81 2nd hour 103.02

L
N N

(75 115 mg/dl)

(90 165 mg.dl) (76 129 mg/dl)

 Gram Stain of Cervicovaginal Discharge Nugents Score of 4 with 50 pus cells per hpf

Wet Smear

Negative for clue cells

Negative for Trichomonas Negative for Fungal Elements

PRETERM BIRTH

Introduction
small for gestational age - newborns whose birthweight is below the 10th percentile large for gestational age has been widely used to categorize newborns whose birthweight is above the 90th percentile for gestational age appropriate for gestational age designates newborns whose weight is between the 10th and 90th percentiles Low birthweight refers to births 500 to 2500 g very low birthweight refers to births 500 to 1500 g

Introduction
Preterm birth, which is defined as delivery before 37 completed weeks
late preterm births, defined as those 34 to 36 weeks gestation

THRESHOLD OF VIABILITY
births before 26 weeks, especially those weighing less than 750 g are at the current threshold of viability pose a variety of complex medical, social, and ethical considerations infants now considered to be at the threshold of viability are those born at 22, 23, 24, or 25 weeks vulnerable to brain injury because of their extreme immaturity

Policy for Threshold of Viability

all fetal indications for cesarean delivery in more advanced pregnancies are practiced in women at 25 weeks

Cesarean delivery is not offered for fetal indications at 23 weeks. At 24 weeks cesarean delivery is not offered unless fetal weight is estimated at 750 g or greater
Aggressive obstetrical management is practiced in cases of growth restriction

Reasons for Preterm Delivery

Delivery for maternal or fetal indications in which labor is induced or the infant is delivered by prelabor cesarean delivery

Spontaneous unexplained preterm labor with intact membranes

Idiopathic preterm premature rupture of membranes (PPROM) Twins and higher-order multifetal births

Medical and Obstetrical Indications

Most common indications: Preeclampsia Fetal distress SGA Placental abruption

Medical and Obstetrical Indications

Less common indications: Chronic hypertension

Placenta previa
Unexplained bleeding

Diabetes
Renal disease

Preterm Prematurely Ruptured Membranes (PPROM)

Rupture of membranes before labor and prior to 37 weeks Can result from a wide array of pathological mechanisms, including intra-amnionic infection.

Preterm Prematurely Ruptured Membranes (PPROM)

Other factors implicated include: low socioeconomic status, low body mass indexless than 19.8, nutritional deficiencies, and cigarette smoking Increased risk for recurrence during a subsequent pregnancy Most cases of preterm rupture, however, occur without risk factors

Spontaneous Preterm Labor

Pathogenesis of preterm labor:
1. Progesterone withdrawal 2. Oxytocin initiation

3. Decidual activation

Antecedents and Contributing Factors

1. Threatened abortion 2. Lifestyle factors 3. Racial and ethnic disparity 4. Work during pregnancy 5. Genetic factors

Antecedents and Contributing Factors

6. Periodontal disease 7. Birth defects 8. Interval between pregnancies and preterm births 9. Prior peterm birth 10. Infection 11. Bacterial Vaginosis

Potential Routes of Intrauterine Infection

Diagnosis
PATIENT SYMPTOMS Braxton Hicks Contractions
- irregular, non rhythmical, painful or painless contractions

Criteria to document preterm labor

1. Contractions of 4 in 20 minutes or 8 in 60 minutes plus progressive change in the cervix 2. Cervical dilatation greater than 1cm 3. Cervical effacement of 80% or greater

Diagnosis
PATIENT SYMPTOMS
Associated with impending preterm labor: pelvic pressure menstrual-like cramps watery vaginal discharge Lower back pain signs and symptoms signaling preterm labor, including uterine contractions, appeared only within 24 hours of preterm labor

Diagnosis
CERVICAL CHANGES

1. Cervical dilatation
2. Cervical length

3. Incompetent cervix

Diagnosis
AMBULATORY UTERINE MONITORING FETAL FIBRONECTIN > 50 ng/ml

Powerful predictor of subsequent preterm birth

Prevention of Preterm birth

PROGESTERONE
-should be limited to women with a documented history of a previous spontaneous birth at less than 37 weeks

Prevention of Preterm birth

CERVICAL CERCLAGE Three circumstances when cerclage placement may be used to prevent preterm birth 1. Cerclage may be used in women who have a history of recurrent midtrimester losses and who are diagnosed with an incompetent cervix

Prevention of Preterm Birth

2. Women identified during sonographic examination to have a short cervix 3. "Rescue" cerclage, done emergently when cervical incompetence is recognized in the women with threatened preterm labor

Management of PPROM
Diagnosis A history of vaginal leakage of fluid, either as a continuous stream or as a gush, should prompt a speculum examination to visualize gross vaginal pooling of amnionic fluid, clear fluid from the cervical canal, or both

Diagnosis

Management of PPROM

Confirmation of ruptured membranes is usually accompanied by sonographic examination to assess amnionic fluid volume to identify the presenting part and if not previously determined, to estimate gestational age Amnionic fluid is slightly alkaline (pH 7.17.3) compared with vaginal secretions (pH 4.56.0)

Management of PPROM
Intentional delivery Fetal lung maturity, as evidenced by mature surfactant profiles, was present in all cases Intentional delivery reduced the length of maternal hospitalization and also reduced infection rates in both mothers and neonates

Management of PPROM
Expectant management Risks of expectant management oligohydramnios absence of fluid pockets 2 cm or larger

23 weeks or less is the threshold for development of lung hypoplasia

Management of PPROM
neonates born to women with active herpetic lesions who were expectantly managed, the infectious morbidity risk appeared to be outweighed by risks associated with preterm delivery expectant management of women with preterm ruptured membranes and noncephalic presentation had an increased rate of umbilical cord prolapse, especially before 26 weeks

Management of PPROM
CLINICAL CHORIOAMNIONITIS prolonged membrane rupture is associated with increased fetal and maternal sepsis prompt efforts to effect delivery, preferably vaginally, are initiated

Fever is the only reliable indicator for this diagnosis, and temperature of 38C (100.4F) or higher accompanying ruptured membranes implies infection

Management of PPROM
Membrane repair Tissue sealants have been used for a variety of purposes in medicine and have become important in maintaining surgical hemostasis and stimulating wound healing

Preterm Labor with Intact Membranes

Cornerstone of treatment is to avoid delivery prior to 34 weeks Corticosteroid therapy

B-adrenergic receptro agonists

Ritoridine Terbutalline Isoxuprine parenteral B-agonists to prevent preterm birth have confirmed a delay of delivery for at least 48 hours

Magnesium Sulfate
can alter myometrial contractility intravenously administered magnesium sulfatea 4-g loading dose followed by a continuous infusion of 2 g/hrusually arrests labor

Prostaglandin Inhibitors
Indomethacin 50 100 mg at 8 hour intervals not to exceed a total 24 hour dose of 200 mg Limited use to 24 48 hours because of concerns of oligohydramnios

Prostaglandin Inhibitors
Indomethacin Neonatal effects Necrotizing enterocolitis Intraventricular hemorrhage Patent ductus areteriosus

Calcium Channel Blockers

Nifedipine Safer and more effective tocolytic agents than B-agonists

Dangerous when combined with MgSO4

Recommended Management of Preterm Labor

1. Confirmation of preterm labor as detailed in Diagnosis

2. For pregnancies less than 34 weeks in women with no maternal or fetal indications for delivery, close observation with monitoring of uterine contractions and fetal heart rate is appropriate. Serial examinations are done to assess cervical changes

Recommended Management of Preterm Labor

3. For pregnancies less than 34 weeks, corticosteroids are given for enhancement of fetal lung maturation 4. Consideration is given for maternal magnesium sulfate infusion for 12 to 24 hours to afford fetal neuroprotection

Recommended Management of Preterm Labor

5. For pregnancies less than 34 weeks in women who are not in advanced labor, some practitioners believe it is reasonable to attempt inhibition of contractions to delay delivery while the women are given corticosteroid therapy and group B streptococcal prophylaxis.

Recommended Management of Preterm Labor

6. For pregnancies at 34 weeks or beyond, women with preterm labor are monitored for labor progression and fetal well-being 7. For active labor, an antimicrobial is given for prevention of neonatal group B streptococcal infection