Page 857 - TNFlipTest

Toronto Notes 2019 Obstetrical Complications
Management
A. Initial
• transfertoappropriatefacilityifstable
■ tocolysis and first dose of antenatal steroids prior to transfer
• hydration(NSat150mL/h)
• bedrestinleftlateraldecubituspositiontoreduceaortocavalcompressionandimprovecardiacoutput
• sedation(morphine)
• avoidrepeatedpelvicexams(increasedinfectionrisk)
• U/Sexaminationoffetus(GA,BPP,position,placentalocation,estimatedfetalweight)
• prophylacticantibiotics;(forGBS)importanttoconsiderifPPROM(e.g.erythromycincontroversial,
but may help to delay delivery)
B. Tocolysis (Suppression of Labour)
• doesnotinhibitpretermlabourcompletely,butmaydelaydelivery(usedfor<48h)toallowfor betamethasone valerate (Celestone®) and/or transfer to appropriate centre for care of the premature infant
• requirements(allmustbesatisfied)
■ pretermlabour
■ live, immature fetus, intact membranes, cervical dilatation of <4 cm ■ absence of maternal or fetal contraindications
• contraindications
■ maternal: bleeding (placenta previa or abruption), maternal disease (HTN, DM, heart disease),
preeclampsia or eclampsia, chorioamnionitis
■ fetal: erythroblastosis fetalis, severe congenital anomalies, fetal distress/demise, IUGR, multiple
gestation (relative)
• agents
■ calcium channel blockers: nifedipine
◆ 20 mg PO loading dose followed by 20 mg PO 90 min later
◆ 20mgcanbecontinuedq3-8hfor72hortoamaxof180mg
◆ 10 mg PO q20min x 4 doses
◆ relative contraindications: nifedipine allergy, hypotension, hepatic dysfunction, concurrent beta-
mimetics or magnesium sulfate use, transdermal nitrates, or other antihypertensive medications ◆ absolute contraindications: maternal congestive heart failure, aortic stenosis
■ prostaglandin synthesis inhibitors: indomethacin
◆ 1st line for early preterm labour (<30 wk GA) or polyhydramnios
◆ 50-100 mg PR loading dose followed by 50 mg q6h x 8 doses for 48 hours
C. Antenatal Corticosteroids
• betamethasonevalerate(Celestone®)12mgIMq24hx2dosesordexamethasone6mgIMq12hx4 doses
■ given between 24 - 36+6 wk GA
■ specific maternal contraindications: active TB
• enhancefetallungmaturity,reduceperinataldeath,reduceincidenceofsevereRDS,intraventricular
hemorrhage, necrotising enterocolitis, and neonatal sepsis
• someevidenceofmortalitybenefitinneonatesdeliveredbefore24wkGA,thusshouldbeofferedto
women at imminent risk of delivery before 24 wk who choose active neonatal management
Prognosis
• prematurityistheleadingcauseofperinatalmorbidityandmortality
• 24wk=50%survival(maybehigherintertiarycarecenterswithlevel3-4NICU)
• 30wkor1,500g(3.3lb)=90%survival
• 33wkor2,000g(4.4lb)=99%survival
• morbidityduetoasphyxia,hypoxia,sepsis,RDS,intraventricularcerebralhemorrhage,thermal
instability, retinopathy of prematurity, bronchopulmonary dysplasia, necrotizing enterocolitis
Premature Rupture of Membranes
Definitions
• PROM:premature(pre-labour)ruptureofmembranesatanyGA
• prolongedROM:>24helapsedbetweenruptureofmembranesandonsetoflabour
• pretermROM:ROMoccurringbefore37wkgestation
• PPROM:preterm(before37wk)ANDpremature(pre-labour)ruptureofmembranes
Risk Factors
• maternal:multiparity,cervicalincompetence,infection(cervicitis,vaginitis,STI,UTI),familyhistoryof PROM, low socioeconomic class/poor nutrition
• fetal: congenital anomaly, multiple gestation
• other risk factors associated with PTL
Clinical Features
• historyoffluidgushorcontinuedleakage
Obstetrics OB17
Tocolytics for Preterm Premature Rupture of Membranes
Cochrane DB Syst Rev 2014;2:CD007062 Purpose: To assess the potential benefits and harms of tocolysis in women with PPROM.
Selection Criteria: Pregnant women with singleton pregnancies and PPROM (23-36 wk and 6 d GA). Results: 8 studies with 408 women total. Prophylactic tocolysis with PPROM was associated with increased overall latency, without additional benefits for maternal/neonatal outcomes. For women with PPROM before 34 wk, there was a significantly increased risk of chorioamnionitis in women who received tocolysis. Neonatal outcomes were not significantly different.
Conclusion: Although there are limitations to the studies, there is currently insufficient evidence to support tocolytic therapy for women with PPROM, as there was an increase in maternal chorioamnionitis without significant benefits to the infant.
Membrane status determined by
• Pooling of fluid on speculum exam
• Increased pH of vaginal fluid (nitrazine test) • Ferning of fluid under light microscopy
• Decreased AFV on U/S