Preterm Labor Quiz: Neonatal Care

1. A 33-year-old woman, G2P0101, at 18 weeks' gestation presents for routine prenatal care. She has a history of pre-term labor at 32 weeks with her previous pregnancy, and she is currently receiving vaginal micronized progesterone suppositories (100 mg) daily. Transvaginal ultrasound examination demonstrates a cervical length of 16 mm and the following finding (see the attached image). She denies painful contractions, leakage of fluid, or vaginal bleeding. Which of the following is the most appropriate next step in the management of this patient?

Place patient on bedrest

Substitute 17-hydroxyprogesterone caproate for the micronized progesterone suppositories

Perform a reduction amniocentesis

Perform a cerclage

Perform a D&C to empty the uterus

In patients with a prior history of preterm labor, cervical length can be monitored by transvaginal ultrasound screening. This patient's ultrasound examination demonstrates a shortened cervix (< 20 mm) and funneling of the membranes. Given these ultrasound findings, in addition to her prior history of pre-term labor, the patient should be offered a cerclage. There is no significant difference in treatment outcomes between vaginal and IM progesterone supplementation. Reduction amniocentesis is an invasive procedure and may introduce unnecessary risk to the patient; further, there is no evidence that her amniotic fluid level is elevated. Uterine evacuation might be considered in the setting of preterm PROM at 18 weeks, but it would not be appropriate management in this patient. Contraindications to cerclage include intrauterine infection, active bleeding, active labor, premature rupture of membranes, and a fetal anomaly incompatible with life.

What is the ONLY condition in pregnancy that a patient should be placed on bedrest for?
PREECLAMPSIA!

Explanation

In patients with a prior history of preterm labor, cervical length can be monitored by transvaginal ultrasound screening. This patient's ultrasound examination demonstrates a shortened cervix (< 20 mm) and funneling of the membranes. Given these ultrasound findings, in addition to her prior history of pre-term labor, the patient should be offered a cerclage. There is no significant difference in treatment outcomes between vaginal and IM progesterone supplementation. Reduction amniocentesis is an invasive procedure and may introduce unnecessary risk to the patient; further, there is no evidence that her amniotic fluid level is elevated. Uterine evacuation might be considered in the setting of preterm PROM at 18 weeks, but it would not be appropriate management in this patient. Contraindications to cerclage include intrauterine infection, active bleeding, active labor, premature rupture of membranes, and a fetal anomaly incompatible with life.

What is the ONLY condition in pregnancy that a patient should be placed on bedrest for?
PREECLAMPSIA!

2. A bedside ultrasound examination indicates that both fetuses are in the cephalic presentation and rules out the presence of a placenta previa. A sterile speculum exam is then performed, and a vaginal swab is obtained to perform a fern test on the vaginal discharge. The fern and nitrazine tests are negative. A subsequent digital exam indicates that the cervix is 50/2–3/−3. All of the following are appropriate next steps to manage this patient except

Prep the patient for an emergent cesarean

Administer tocolytics

Administer bethamethasone

Obtain a neonatal consultation

The patient is in preterm labor, because she has a dilated
and effaced cervix in the presence of regular uterine contractions. Therefore,
treatment is aimed at delaying delivery to allow continued fetal growth
and maturity. The administration of tocolytic therapy to treat the preterm
contractions is indicated. In addition, from 24 to 34 weeks, management
also includes the administration of steroids such as betamethasone to promote
fetal lung maturity. Respiratory distress syndrome (RDS) is a sequela
of preterm neonates and occurs less often in infants given betamethasone
in utero. If delivery seems likely, intravenous antibiotics are administered
to prevent possible neonatal sepsis. If the patient’s contractions subside and
there is no evidence of infection, then the antibiotics can be discontinued.
It is advantageous to obtain a neonatology consult on any patient who
appears to be in preterm labor so the parents know what to expect if they
give birth to preterm infants. There is no need to prepare for a cesarean section
in this patient. Attempts are made to stop the labor first. If the patient
continues to progress, then a vaginal delivery is preferred since the twins
do not have a malpresentation.

Explanation

The patient is in preterm labor, because she has a dilated
and effaced cervix in the presence of regular uterine contractions. Therefore,
treatment is aimed at delaying delivery to allow continued fetal growth
and maturity. The administration of tocolytic therapy to treat the preterm
contractions is indicated. In addition, from 24 to 34 weeks, management
also includes the administration of steroids such as betamethasone to promote
fetal lung maturity. Respiratory distress syndrome (RDS) is a sequela
of preterm neonates and occurs less often in infants given betamethasone
in utero. If delivery seems likely, intravenous antibiotics are administered
to prevent possible neonatal sepsis. If the patient’s contractions subside and
there is no evidence of infection, then the antibiotics can be discontinued.
It is advantageous to obtain a neonatology consult on any patient who
appears to be in preterm labor so the parents know what to expect if they
give birth to preterm infants. There is no need to prepare for a cesarean section
in this patient. Attempts are made to stop the labor first. If the patient
continues to progress, then a vaginal delivery is preferred since the twins
do not have a malpresentation.

3. A 29-year-old G2P1001 with a twin gestation at 25 weeks presents to OB triage complaining of irregular uterine contractions and back pain. She also reports an increase in the amount of her vaginal discharge, but denies any "gush of fluid." She reports that in the morning she had some very light vaginal bleeding, but it has since resolved. She says that the babies have been active and moving as much as usual. She thinks that she may have overdone it with too much lifting as she has been rearranging the nursery to get it ready for the babies. She has no GI or urinary symptoms. She has had adequate PNC and denies any problems or complications with the pregnancy. On arrival to triage, she is placed on an external fetal monitor, which indicates uterine contractions every 2 to 4 min. She is afebrile and her vital signs are all normal. Her gravid uterus is nontender. The nurses call you to evaluate the patient. You decide to implement all of the following assessments EXCEPT which one?

Sterile digital exam

Intravenous hydration

Bedside ultrasound

Urinalysis and urine culture

Rectovaginal swab for Group B Strep

Since this patient has multiple gestation along with bleeding, cramping, and increased vaginal discharge, PTL must be ruled out. Dehydration
can be a cause of premature contractions and uterine irritability, so IVF would be appropriate here A U/A with C & S would be appropriate because UTIs can cause uterine contractions. A GBS infection can also be associated with PTL, so you should obtain a culture for this as well.
An SVE should NOT be performed until placenta previa has been ruled out by an ultrasound, since the patient reported a history of vaginal bleeding.

Explanation

Since this patient has multiple gestation along with bleeding, cramping, and increased vaginal discharge, PTL must be ruled out. Dehydration
can be a cause of premature contractions and uterine irritability, so IVF would be appropriate here A U/A with C & S would be appropriate because UTIs can cause uterine contractions. A GBS infection can also be associated with PTL, so you should obtain a culture for this as well.
An SVE should NOT be performed until placenta previa has been ruled out by an ultrasound, since the patient reported a history of vaginal bleeding.

4. The strength of using fetal fibronectin as a screening test for preterm labor is in its:

Positive predictive value

Specificity

Negative predictive value

Sensitivity

fFN has a high negative predictive value, which means if it is negative, there is a very very small chance a patient will deliver in the next 7-10 days. However, if it is positive, it does not tell you that the patient will deliver prematurely. So use it to rule OUT PTL!

Explanation

fFN has a high negative predictive value, which means if it is negative, there is a very very small chance a patient will deliver in the next 7-10 days. However, if it is positive, it does not tell you that the patient will deliver prematurely. So use it to rule OUT PTL!