TEALE FENNING

drhatta · Joined: 20 Feb 2007 Posts: 32 Location: Malaysia

saw a case in clinic today... any takers?

30 year old currently in her 3rd pregnancy, has history of preterm labour at 30th and 34th weeks gestation. Her first baby died a day after delivery.
Identify her risk for this pregnancy (3 marks)
How would you counsel her regarding this pregnancy? (7 marks)
How would you investigate and manage her this time (10 marks)
Nick, may be you can 'word' it better??
P.S. has such Q appeared in previous exams?

Nick Raine-Fenning · Posted: Thu Mar 15, 2007 1:37 pm Post subject:

Good effort but how about this ...

You are asked to see a 30-year old woman for pre-pregnancy counselling. She has had two previous spontaneous preterm deliveries at 26 weeks and 30 weeks gestation. Her first baby died a day after delivery.

What would you want to know from her history (6 marks)

How would you assess her risk? (5 marks)

How would you manage any subsequent pregnancy? (9 marks)
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Xerxes I · Posted: Tue Jul 29, 2008 1:47 pm Post subject:

You are asked to see a 30-year old woman for pre-pregnancy counselling. She has had two previous spontaneous preterm deliveries at 26 weeks and 30 weeks gestation. Her first baby died a day after delivery.

What would you want to know from her history (6 marks)
preterm birth is the single most important cause of neonatal death and is notoriously dificult to predict. events preceding labour should be explored. Preterm rupture of membranes has been associaated with infective processes, especially in earlier gestations. A history of abnormal vaginal discharge or urinary symptoms suggests infective predisposing factors. A "silent" and painless early labour suggests cervical incompetence. Concurrent medial conditions may have a role, for xample, diabetes mellitus and thyroid dysfunction are associated with preterm birth, so is inflammatory bowel diseases.
It is also important to ask about history of early ans recurrent miscarriages and history of venous thromboembolism as these point towards antiphospholipid syndrome.
Social history in particular smoking, socioeconomic status and history of recreational drug use should be taken tactfully without suggesting any causal relationship.
History of surgery on cervix (ie LLETZ)

How would you assess her risk? (5 marks)
The number of previous spontaneous preterm labours is the most important predictor. The risk also depends on other causes of previous PTL if any found. For example, Cervical incompetence has a very high risk of recurrence wheras infective cause, if treated adequately prepregnancy, should not cause any recurrence, swabs from genital tract should therefore be taken. Diabetes melllitus and gestational diabetes also have a high recurrence rate. A random glucose therefore is justified.

don't know, dow do I assess her risk?

How would you manage any subsequent pregnancy? (9 marks)
In case of suspected cervical incompetence, elective cervical cerclage can be considered, however, it is not proven to improve outcome and is associated with significant risks, ie ROM and infection.
If Antiphospholipid syndrome is diagnosed, combination of Heparin and Aspirin has been shown to be effective treatment. Urine sample in early pregnancy and in subsequent trimesters should be sent for culture and sensitivity and any urinary tract infecton or asymptomatic bacteriuria should be treated with appropriate antibiotics. A high vaginal swab may be justified to dignose and treat bacterial vaginosis. Random glucose should also be taken to rule out GDM.

Pregnancy should be monitored closely by serial growth scans in the third trimester. Steroids may be considered to be given electively early in tirds trimester. The disadvantage of this practice is that steroids are thought to have their maximum effect if given within 7 days of delivery and the safety of repeat steroid courses is not clear.

Another policy could be to perform serial cervical length measurements. If funnelling or shorteing of the cervix is noted, then steroid for lung maturation commenced.

Tocolysis is only justified if the delay gained is used for steroid administration or inutero transfer.

Blood pressure and urine dipstick should be monitored by midwife regularly to detect early signs of pre-eclampsia.

What else?

shama · Joined: 17 May 2007 Posts: 44 Location: Malaysia

I would like to add a word about cervical fibronectin.

Encirclage does help in those with suggestive history.So, I think appropriate for this patient if short duration of previous labours with minimal discomfort.

Antiphospholipid Syndrome doesn't cause spontaneous preterm labour.I don't think , it is needed here.

Connective tissue disorders do cause cervical insuffiency.So, probably need a mention.
Diabetes and thyroid if uncontrolled will cause infertility and 1st trimester miscarriages. are they important here too?

Xerxes I · Posted: Fri Aug 15, 2008 8:29 am Post subject:

Thanks Shama,

connective tissue disorders is a good point, not sure though if it would get a point as very rare.

APS has a well established association with preterm labour, usually secondary to placental insufficiency or PET. In fact in the diagnostic criteria for it, one of the three conditions you can have to prove adverse pregnancy outcome is preterm delivery.
>=3 Miscarriages <10/40
>=1 morphologically normal fetal death >10/40
>=1 PT birth < 34/40 due to severe PET, eclampsia or placental insufficiency

again, thyroid dysfunction has a well established association with preterm labour, I know it for sure for hyper, need to check if hypo is also assocaited. I am not so sure about diabetes though. It makes sense that secondary to polyhydramnios and macrosomia, they would have preterm babies.