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
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
Plan
For Gram stain and Wet smear of cervicovaginal discharge
For Urinalysis
For 75 g OGTT
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
Gram Stain of Cervicovaginal Discharge Nugents Score of 4 with 50 pus cells per hpf
Wet Smear
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
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
Placenta previa
Unexplained bleeding
Diabetes
Renal disease
Rupture of membranes before labor and prior to 37 weeks Can result from a wide array of pathological mechanisms, including intra-amnionic infection.
3. Decidual activation
Diagnosis
PATIENT SYMPTOMS Braxton Hicks Contractions
- irregular, non rhythmical, painful or painless contractions
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
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
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
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
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