Obstetrics Book

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Preterm Labor Management

Aka: Preterm Labor Management
  1. See Also
    1. Preterm Labor
  2. Management: Initial
    1. Evaluation and Labs as described for Preterm Labor
    2. Treat genitourinary infections if present
    3. Bedrest
    4. Consider Intravenous Fluid for dehydration
      1. Administer IV 1-2 liters of Lactated Ringers
    5. Treat underlying causes
      1. Urinary Tract Infection
    6. Group B Streptococcus Prophylaxis
      1. Start antibiotics if positive culture for GBS or status unknown this pregnancy
      2. If status unkown, obtain rectovaginal culture and may stop antibiotics if negative
    7. Notify primary doctor regarding possible delivery
    8. Labor precautions
      1. Limit maternal Narcotics for pain control
      2. Anticipate malpresentations
      3. Complete cervical dilation may be less than 10 cm
      4. Elective ceserean <36 weeks offered in some settings
    9. Consider transport to tertiary center with NICU
      1. Strongly consider if <34 weeks gestation
      2. Contraindications
        1. Imminent delivery
        2. Fetal Distress or maternal status unstable
        3. No safe transport to referral center
  3. Management: Corticosteroids
    1. Indications
      1. Intact membranes at 24-34 weeks
      2. PPROM without Chorioamnionitis at 24 to 32 weeks
      3. Consider in women 23 weeks gestation who are likely to delivery within subsequent week
    2. Mechanism
      1. Promotes Fetal Lung Maturity (decreased respiratory distress syndrome risk)
      2. Decreased risk of intraventricular Hemorrhage, Necrotizing Enterocolitis
    3. Preparations
      1. Betamethasone 12 mg IM every 24 hours for 2 doses
      2. Dexamethasone 6mg IM every 12 hours for 4 doses
    4. Course
      1. Delay delivery at least 24-48 hours after steroids
        1. See Tocolytics below
      2. Repeated Corticosteroid Injection if >7 weeks from last dose
        1. From 2016 ACOG Practice bulletin, consider repeat dose if still <34 weeks and risk for preterm delivery
        2. Prior studies from 2004 recommended only one dose in first week of presentation
          1. Lee (2004) Obstet Gynecol 103:274-81 [PubMed]
  4. Management: Tocolytic agents
    1. See Tocolytic
    2. Contraindications
      1. Intrauterine Fetal Demise or lethal fetal anomaly
      2. Nonreassuring Fetal Status
      3. Severe Preeclampsia or Eclampsia
      4. Maternal bleeding with hemodynamic instability
      5. Chorioamnionitis
    3. Preferred Tocolytics
      1. Magnesium Sulfate (also used for neuroprotective benefit, in addition to Tocolysis)
        1. Load: 6 grams bolus IV over 20 min (Very high dose!)
        2. Maintenance: 2 grams/hour IV infusion
        3. Must follow protocols for patient safety
        4. Tocolytic and neuroprotective (with decreased risk of Cerebral Palsy in deliveries before 32 weeks)
          1. Doyle (2009) Obstet Gynecol 113(6): 1327-33 [PubMed]
      2. Indomethacin
        1. Load: 50-100 mg orally or rectally
        2. Maintenance: 25-50 mg orally every 4-6 hours
        3. Avoid use >48 hours (risk of oligohydramnios, premature closure ductus arteriosus)
      3. Nifedipine
        1. Load: 30 mg orally
        2. Maintenance: 10-20 mg every 4-6 hours (max: 180 mg/day)
        3. Higher risk of maternal adverse effects when combined with Magnesium Sulfate
    4. Other Tocolytics
      1. Terbutaline
        1. Load: 0.25 mg SQ every 20-30 min for up to 4 doses
        2. Maintenance: 0.25 mg every 3-4 hours until Uterus quiet for 24 hours
    5. References
      1. (2016) Obstet Gynecol 128(4):e155-64 [PubMed]
      2. Haas (2009) Obstet Gynecol 113(3): 585-94 [PubMed]
  5. Management: Ambulatory Protocol
    1. Weekly cervical exam between 20 and 37 weeks
    2. Home self monitoring for contractions
      1. Evaluation for over 4 to 6 contractions per hour
    3. Pelvic rest
    4. Bedrest
    5. Patient Education regarding Preterm Labor
    6. Oral Tocolytics are not effective
      1. Avoid oral Terbutaline and Nifedipine
      2. Also avoid Indomethacin due to adverse effects
  6. References
    1. Iams in Gabbe (2002) Obstetrics p.755
    2. (2016) Obstet Gynecol 128(4):e155-64 [PubMed]
    3. Huddleston (2003) Clin Perinatol 30:803-24 [PubMed]
    4. Rundell (2017) Am Fam Physician 95(6): 366-72 [PubMed]

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