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Preterm Labour and PPROM - Coggle Diagram

- - - - Regular uterine contactions with progressive cervical dilation at less than 37 weeks gestation
    - - Delivery of a baby before 37 weeks gestations
  - - - Assited reproduction
      - ↑ Maternal age
      - ↑ Chronic disease due to obesity
      - Progress in intensive care
      - Early planned delivery - maternal / fetal indication
  - - - < 28 weeks
    - - 28- < 32 weeks
    - - 32- < 37
    - - 23 - 24+6
  - - - 1. Hx of spontaneous preterm birth
      - Lifestyle : smoking, drugs, dress, DM, poor nutrition
      - Low BMI
      - Age <18, >35
      - Assisted reproductive tx
      - Chronic maternal medical conditions
    - - PPROM
      - Infection - chorioamniotis, BV, UTI
      - Incompetent cervix / cervical trauma / surgical procedures of cervix
      - APH / 2nd trimester vaginal bleeding
      - Placenta praevia
      - Placenta abruptio
      - Uterine abnormality
      - Uterine overdistension - polyhydramnios, multiple pregnancy
      - Fetal anomaly
      - Fetal growth restriction
  - - - ↑ Risk of CVS morbility and mortality
    - - Necrotising enterocolitis NEC
      - Retinopathy of prematurity ROP
      - Intraventricular haemorrhage IVH
      - Bronchopulmonary dysplasia
      - Feeding problems / Failure to thrive FTT
    - - Risk 1/ ∝ Gestational Age
      - Neuro
        
        Impaired cognitive abilities
        
        Motor deficits
        
        Cerebral palsy
        
        Vision / hearing losses
      - Behavioural
        
        Anxiety
        
        ASD
        
        ADHD
  - - - 23+0 - 24+6
      - Ethical challenge
    - - 22 weeks no hope of survival
- - - - Progressive cervical dilation from 4cm with regular contractions
    - - Reported symptoms + clinical assessment that confirms possibility of PTL- rules out established labour
    - - CL > 15mm
        
        Unlikely - d/c home
      - CL < 15mm
        
        Diagnostic of PTL
      - Consider at 30+0 or more
    - - Negative (<50ng/ml)
        
        PTL unlikely - d/c home
      - Positive (>50ng/ml)
        
        Diagnostic of PTL
  - - - Bleeding
      - Infx
    - - Oxyctocin receptor antagonist : Atosiban
    - - GA 24+0 to 33+4
      - Benefit of corticosteroids
      - Availability of approapriate neonatal care
      - Preference of woman
  - - - Discuss with woman and MDT
    - - Offer corticosteroids
    - - Not routinely recommended
    - - Consider single repeat course If:
        
        One course more than 7 days ago AND
        
        High risk of birth in 48h
        
        Less than 20+0 weeks or suspected growth restriction
    - - Dexamethasone
    - - For lungs to survive
        Before 35
        Give corticoids 2 tries
  - - - All women in preterm labour with intact membranes
    - - GBS prophylaxis
    - - Benzylpenicillin
        3g IV STAT loading dose
        1.8 g IV 4hrly until delivery
      - Pencillin allergy
        
        Cephalosporin
        
        Vancomycin
  - - - 23+5 to 32
        
        Offer IV MgSO4 if in established PTL / planned preterm birth within 24 hrs
        
        Risk of CP decreases aft 32 weeks
    - - 4g IV bolus over 15min
      - Follow with 1g/h IV until birth or until 24hr (whichever is first)
    - - Every 4 hr
      - Pulse
      - BP
      - RR
      - Deep tendon reflexes
      - Oligouria / renal failure
    - - Reduce / Stop
      - Monitor more frequently
    - - Foetal neuroprotection - prevent CP
    - - MgSO4
        32-4-4
        
        Use up to 32 weeks
        4g bolus
        Monitor every 4 hr
      - From 23+5, the brain’s alive,
        At 32, Mg’s through!
  - - - Normal CTG reassuring
      - Abnormal not diagnostic of hypoxia / acidosis
    - - C/i before 34 weeks
  - - - Use
        
        Between 16+0 and 27+6 with dilated cervix and exposed, intact foetal membranes
      - C/I
        
        Signs of infx
        
        Active vaginal bleeding
        
        Uterine contractions
      - Memory Aid
        
        Cerclage in place, keep baby fine,
        Starts at 16, ends at 29!
    - - Use
        
        Hx recurrent spontaneous preterm birth
        
        Hx late miscarriage
  - - - CS
        
        Consider for breech between 26+0 and 36+6
        
        Highlight difficulties associated wit CS + preterm birth
        
        Often indicated
      - Vaginal preferred
    - - Delayed - 60s before clamping if not c/i by maternal condition
    - - Vacuum C/I - foetus is already high risk
- - - - Presentation
      - Uterine tone
      - SFH
    - - Sterile speculum
      - Assess ROM
      - Visualise cerivcal os
      - Swab microbiology
      - Quantative Fetal Fibronect test (fFN) / partosure
      - Exclude placental praviae / ROM
      - Examine cervical dialtion
  - - - Predictive of preterm labour
    - - PTL unlikely
      - Discharge if all other causes excluded
    - - Bleeding / ROM
      - <23 or > 34 weeks (limited predictive value)
      - Cervix more than 3cm dilated
      - Sexual intercourse / vaginal exam in last 24hrs
      - Recent tx of vaginal candidiasis
      - Presence of soaps, gels, lubricants, disinfectatns
    - - Before 23, it’s too soon to see,
        After 34, it tells no more!
  - - - FBC
      - CRP
      - G&H
    - - Abdo USS confirm gestation
      - TV USS assess cervical lenght if
        → > 15mm unlikely to be PTL
    - - Calculates risk of PTB in next 7 days
      - Factors:
        
        Previous PTB
        
        Foetal fibronectin
        
        Cervical length measurement
- - - - 24+0 to 36+6 GA
    - - Rupture before onset of labour
    - - Spontaneous rupture of foetal membranes
  - - - Local cytokines
      - Imbalance fo interaction between metalloprotinases + Tissue inhibitors of metalloproteinases
      - Increased collagenase and protease activity
  - - - Previous PPROM / Preterm delivery
      - Previous abortion
    - - Short cervical length
      - 2nd/3rd trimester vaginal bleeding
      - Reproductive tract infx
      - Uterine overdistension
    - - Nutritional deficiencies - copper, ascorbic acid
      - Low BMI
      - Low socioeconomic status
      - Smoking
      - Illicit drugs
    - - Gestational DM
      - Gestational HTN
      - Connective tissue disorders
  - - - Sepsis
      - Chorioamnionitis
    - - Abruption
    - - Prematurity
      - Pulmonary hypoplasia
      - Cord prolapse
      - Malpresentation
      - Limb contracture
  - - - Rupture of membranes AFTER 37 weeks
    - - Rupture of membranes BEFORE 37 weeks
  - - - Short latency followed by labour & delivery
- - - - Accuracy of EDD
      - Anatomy scan
      - Any complications to date
    - - Time / onset of fluid leakage
      - Amount
      - Colour and odour
      - Bleeding
      - Contractions
      - Foetal movement
      - Recent trauma
      - Recent sexual encounters
  - - - Uterine tone
      - Tenderness
      - Presentation
      - Amniotic fluid
    - - Pooling of liqour
      - Cervical changes - dialtion / effacement
      - Cord prolapse
      - Bleeding
  - - - Speculum High vaginal swab
      - Amnisure
      - Urine dipstick
    - - FBC
      - CRP
    - - USS
        
        Foetal assesment
        
        Presentation
        
        Placenta
        
        AFI
      - CTG
        
        Foetal monitoring
  - - - Amniotic fluid Microscopy
        
        Ferning pattern
      - pH
        
        Amniotic fluid normally 7.1 - 7.3
        not always reliable
      - Amnisure
        
        Highly sensitive 1st line screening
        
        MOA
        
        Detects placental alpha-microglobulin1 (Protein in amniotic flui)
        
        Benefits
        
        Rapid
        
        Non-invasive
        
        Can be used at all gestations
        
        99% accurate in detecting PPROM
        
        Highly specific - not affected by semen, blood, urine, infx
  - - - Abx
        
        Azithromycin
        
        Use
        
        Reduced chorioamnionitis
        Prolongs latency
        Improved neontal outcomes
      - Corticosteroids
        
        Offer 24+0-34+6
        
        Use
        
        Reduces incidence of IVH and need for mechanical ventilation -
      - MgSO4
        
        PPROM in established labour or planned preterm birth within 24hrs
        23+5 - 32 weeks (From 23+5 brain's alive, At 32 Mg is through)
        
        Use
        
        Neuroprotection
        Reduction in Cerebral palsy
      - Not recommended
        
        Tocolysis
    - - Inform neonatologists
      - Offer women + partner additional emotional support during / postnatal
    - - Individual basis
      - If delivery imminent - in patient indicated
    - - After 24+0 and no c/i to continuing pregnancy
        
        Expectant managment until 37+0
      - Consider pt preference / ongoing clinical assessment
    - - CAred for by obstetrician
- - - - Only way to cure chorioamniotis
      - Plan for delivery regardless of gestation
      - IOL and trial of labour unless c/i
    - - Broad spectrum abx : Co-amoxiclav and Gentamicin
    - - Coricosteroids 24 - 34+6
      - MgSO4 23+5 - 32