18 - biophysical profile

1. See Also
1. Fetal Assessment
2. Fetal Testing Indications
3. Fetal Heart Tracing
2. Cost: $275
3. Criteria (2 points for each)
1. Fetal Breathing
1. Thirty seconds sustained breathing in 30 minutes
2. Fetal Tone
1. Episode extremity extension and flexion
3. Body Movement
1. Three episodes body movement over 30 minutes
4. Amniotic Fluid Volume
1. More than 1 pocket amniotic fluid greater than 2 cm in depth
5. Non-Stress Test
1. Reactive
4. Scoring
1. Give 2 points for each positive above
5. Interpretation
1. Biophysical Profile: 8-10
1. Low risk or Normal result
2. Repeat Biophysical Profile weekly
3. Indications to repeat Biophysical Profile bi-weekly
1. Gestational Diabetes
2. Gestational age greater than 42 weeks
2. Biophysical Profile: 8
1. Delivery Indications: Oligohydramnios
3. Biophysical Profile: 6
1. Suspect asphyxia
2. Repeat Biophysical Profile in 24 hours
3. Delivery Indications
1. Repeat Biophysical Profile less than or equal to 6
4. Biophysical Profile: 4
1. Suspect asphyxia
2. Delivery Indications
1. Gestational age greater than 36 weeks
2. Lung Maturity Tests positive (L/S ratio greater than 2)
5. Biophysical Profile: 0-2
1. Likely asphyxia
2. Continue monitoring for 2 hours
3. Delivery Indications
1. Biophysical Profile less than 4

17 - fetal macrosomia ( large for gestational age )

1. Also See
1. Gestational Diabetes
2. Labor Dystocia
3. Shoulder Dystocia
2. Definition
1. Macrosomia
1. Fetal weight 4500 grams (ranges from 4000-5000 grams)
2. Large for Gestational Age
1. Birth weight above 90th percentile
3. Risk Factors for macrosomia
1. Maternal Diabetes Mellitus or Glucose Intolerance
2. Multiparity
3. Prior history of macrosomic infant
4. Post-Dates Gestation
5. Maternal Obesity or excessive weight gain
6. Male fetus
7. Parental stature
8. Labor Dystocia
1. Labor Augmentation needed
2. Prolonged second stage
4. Pathophysiology
1. Fetal Growth
1. Overgrowth
1. Hallmark of Diabetes Mellitus
2. No concurrent vascular disease present
2. Intrauterine Growth Retardation
1. Long standing Diabetes Mellitus
2. Vascular Disease with decreased placental perfusion
2. Control of Fetal Growth
1. First half of pregnancy: Genetics
2. Second half of pregnancy: Multifactorial
1. Nutrients
2. Oxygen
3. Insulin as growth factor
3. Selective Macrosomia
1. Insulin sensitive tissue
1. Heart
2. Liver and Spleen
3. Thymus
4. Adrenal
5. Subcutaneous fat
6. Shoulders
2. Insulin insensitive tissues
1. Water content
2. Brain mass (relative to rest of body)
5. Signs: Classic infant of Diabetic Mother
1. Gigantism
2. Visceromegaly
3. Plump, sleek liberally coated with vernix
4. Full faced and plethoric
6. Diagnosis
1. Clinician's fetal weight estimate (Leopold's Maneuvers)
1. Error in weight estimation: 300 grams
2. More accurate than Obstetric Ultrasound estimate
3. Estimate altered by physiologic characteristics
1. Amniotic fluid volume
2. Uterine Size and configuration
3. Mother's body habitus
2. Obstetric Ultrasound
1. Error in weight estimation: 300 to 550 grams
2. Estimated fetal weight and Abdominal circumference
3. Correlates 88% with diagnosis of macrosomia
7. Efficacy of fetal macrosomia prediction and prevention
1. Methods proven ineffective at complication prevention
1. Elective cesarean section
1. Analysis based on permanent Brachial Plexus Injury
2. C/S for EFW 4500g prevents 1 case/3700 treated
3. U.S. cost: $8.7 Million/case prevented
2. Early induction
1. Increases rate of cesarean section
2. Does not favorably alter perinatal outcomes
3. Sanchez-Ramos (2002) Obstet Gynecol 100:997
2. Specific population targeting is also ineffective
1. Vaginal Birth after Cesarean section
2. Maternal Diabetes Mellitus
1. Optimal Blood Glucose management is paramount
2. Other intervention strategies are unproven
3. Previous Shoulder Dystocia
8. Management
1. Tight glycemic control
1. Decreased fetal macrosomia
2. Decreased Neonatal Hypoglycemia
3. Decreased perinatal mortality
2. Elective Cesarean Section (no support in literature)
1. Indications per ACOG
1. Estimated fetal weight greater than 4500 grams
2. Possible Indications if Estimated fetal weight greater than 4000g
1. Pelvic architecture
2. Prior cesarean section
3. Prior Shoulder Dystocia
4. Evidence of Cephalopelvic Disproportion
5. History of poor progress of labor
9. Complications
1. Shoulder Dystocia
2. Perinatal asphyxia
3. Birth injury
4. Respiratory distress syndrome
5. Hypoglycemia
10. References
1. Combs (1993) Obstet Gynecol 81:492
2. Rouse (1996) JAMA 276:1480
3. Weeks (1995) Am J Obstet Gynecol 173:1215
4. Zamorski (2001) Am Fam Physician 63(2):302

16 - intrauterine growth retardation ( IUGR )

1. Definitions
1. Intrauterine Growth Retardation (IUGR)
1. Estimated fetal weight less than 10% per gestational age
2. Some suggest cutoff of 5% to reduce false positives
2. Small for Gestational Age (SGA)
1. Normal small infants without adverse risks
2. Evaluation
1. Indicators of IUGR
1. Poor Maternal Weight gain
1. Most sensitive indicator for IUGR
2. Fundal Height less than expected for gestational age
2. Consider environmental and comorbid factors
1. Tobacco abuse (most significant individual risk)
2. Poor Nutrition
3. Illicit Drug Use
4. Alcohol Abuse
5. Minimal to no prenatal care
6. Traumatic stress
3. Fetal Assessment
1. Follow Fetal Movement Counts (kick) counts
2. Follow Non-Stress Test
3. Serial Obstetric Ultrasounds for growth
4. Biophysical Profile
3. Diagnosis
1. Detection rate in-utero: 70%
2. Indications for Obstetric Ultrasound
1. Low risk fetus smaller than expected size
2. High risk monitoring
3. Ultrasound interpretation
1. Head Circumference to Abdominal Circumference ratio
1. Most useful in assessing Asymmetric IUGR
4. Management
1. Address risk factors
1. Tobacco Cessation
2. Eliminate other negative habits
3. Ensure adequate maternal weight gain
4. Maximize prenatal care
5. Reduce environmental stressors
2. Perinatology Consultation Indications
1. Poor Nonstress Test
2. Decreasing Biparietal diameter
3. Oligohydramnios
4. Abdominal circumference 4 weeks less than BPD
3. Early Delivery Indications
1. Doppler diastolic flow 0 mmHg in umbilical artery
5. Peripartum Risks of IUGR
1. Meconium aspiration
2. Intrauterine Asphyxia
3. Polycythemia
4. Hypoglycemia
6. Causes of IUGR
1. Symmetric IUGR (Head and body growth retarded)
2. Asymmetric IUGR (head growth spared)
7. References
1. Gabbe (1996) Obstetrics, Churchill, p. 863-886
2. Ahluwalia (2001) Obstet Gynecol 97:649

15 - uterine size in pregnancy

1. Indications
1. Pregnancy Dating
2. Pre-procedure (e.g. D&C)
2. Changes that decrease accuracy of measurement
1. Obesity
2. Uterine Fibroids or other tumor
3. Retroverted uterus
3. Estimating uterine size in pregnancy
1. Week 6: Plum or golf ball size
2. Week 8: Tennis ball size
3. Week 10: Large orange or softball size
4. Week 12: Grapefruit size (palpable at suprapubic area)
5. Week 14: Cantaloupe size

14 - bishop score

1. Scoring
1. Cervical Dilation
1. Cervix dilated less than 1 cm: 0
2. Cervix dilated 1-2 cm: 1
3. Cervix dilated 2-4 cm: 2
4. Cervix dilated greater than 4 cm: 3
2. Cervical Length (Effacement)
1. Cervical Length greater than 4 cm (0% effaced): 0
2. Cervical Length 2-4 cm (0 to 50% effaced): 1
3. Cervical Length 1-2 cm (50 to 75% effaced): 2
4. Cervical Length less than 1 cm (greater than 75% effaced): 3
3. Cervical Consistency
1. Firm cervical consistency: 0
2. Average cervical consistency: 1
3. Soft cervical consistency: 2
4. Cervical Position
1. Posterior cervical position: 0
2. Middle or anterior cervical position: 1
5. Zero Station Notation (presenting part level)
1. Presenting part at ischial spines -3 cm: 0
2. Presenting part at ischial spines -1 cm: 1
3. Presenting part at ischial spines +1 cm: 2
4. Presenting part at ischial spines +2 cm: 3
2. Modifiers
1. Add 1 point to score for:
1. Preeclampsia
2. Each prior vaginal delivery
2. Subtract 1 point from score for:
1. Postdates Pregnancy
2. Nulliparity
3. Premature or prolonged Rupture of Membranes
3. Interpretation
1. Indications for Cervical Ripening with prostaglandins
1. Bishop Score less than 5
2. Membranes intact
3. No regular contractions
2. Indications for Labor Induction with Pitocin
1. Bishop Score greater than or equal to 5
2. Rupture of Membranes

13 - leopold's maneuvers

1. See Also
1. Fetal Malpresentation
2. Leopold's Maneuvers
1. First Maneuver (Upper pole)
1. Examiner faces woman's head
2. Palpate uterine fundus
3. Determine what fetal part is at uterine fundus
2. Second Maneuver (Sides of maternal abdomen)
1. Examiner faces woman's head
2. Palpate with one hand on each side of abdomen
3. Palpate fetus between two hands
4. Assess which side is spine and which extremities
3. Third Maneuver (Lower pole)
1. Examiner faces woman's feet
2. Palpate just above symphysis pubis
3. Palpate fetal presenting part between two hands
4. Assess for Fetal Descent
4. Fourth Maneuver (Presenting part evaluation)
1. Examiner faces woman's head
2. Apply downward pressure on uterine fundus
3. Hold presenting part between index finger and thumb
4. Assess for cephalic versus Breech Presentation
3. Focus areas for abdominal palpation
1. Assess Fundal Height
1. Fundal height (cm) approximates weeks of gestation
2. Assess Fetal Lie
1. Longitudinal (Normal)
2. Transverse
3. Oblique
3. Assess Fetal Presentation
1. Breech Presentation
2. Cephalic Presentation
1. Vertex Presentation (Normal attitude: Full flexion)
2. Face Presentation (Abnormal attitude: Head extends)
4. Assess Fetal Vertex Position
1. Left Occiput Lateral (LOL) 40%
2. Left Occiput Anterior (LOA) 12%
3. Left Occiput Posterior (LOP) 3%
4. Right Occiput Lateral (ROL) 25%
5. Right Occiput Anterior (ROA) 10%
6. Right Occiput Posterior (ROP) 10%
5. Assess Fetal Descent
1. Is Vertex engaged?
4. Other methods of determining fetal orientation
1. Obstetric Ultrasound
2. Digital cervical exam

11 - pregnancy signs and symptoms

1. See Also
1. Pregnancy Dating
2. Week 4
1. Symptoms
1. Amenorrhea
2. Nausea (See Morning Sickness)
3. Fatigue
2. Labs
1. Quantitative bhCG: 250
3. Week 5 (8 to 9 days after missed menstrual period)
1. Labs
1. Urine Pregnancy Test is positive
2. Quantitative bhCG: 1000
2. Transvaginal Ultrasound
1. Gestational Sac visible
4. Week 6-8
1. Symptoms
1. Urinary frequency onset at 6 weeks
2. Signs
1. Areola darkens by 6-8 weeks
2. Breasts engorge by 6-8 weeks
3. Transvaginal Ultrasound
1. Fetus visible at 6-7 weeks
2. Fetal heart activity by 8 weeks
5. Week 10 to 12
1. Symptoms
1. Irregular contractions start
2. Signs
1. Uterus is size of Orange by 10 weeks
2. Uterus is size of Grapefruit by 12 weeks
3. Fetal Heart Tones auscultated by Doppler
6. Week 15 to 20
1. Symptoms
1. Quickening in multiparous patients by 15 to 17 weeks
2. Quickening in nulliparous patients by 18 to 20 weeks
2. Signs
1. Fetal Heart Tones by Fetoscope by 16 to 20 weeks
2. Irregular Contractions palpable by 20 weeks
7. Other signs of pregnancy
1. Chadwick's Sign
1. Darkened vulva and vagina
2. Chloasma (Mask of pregnancy)
1. Dark under eyes, bridge nose
3. Linea Nigra
1. Dark midline low abdomen
4. Hegar's Sign
1. Softened low uterine segment on bimanual exam

9 - hegar's sign

1. Indication
1. Diagnosis of early pregnancy
2. Physiology
1. Occurs during first trimester of pregnancy
2. Softening of uterus at junction with cervix (isthmus)
3. Signs
1. Softened lower uterine segment on bimanual exam
1. Cervix may seem to separate from fundus
2. Contrast with firmness of uterine fundus

8 - fetal foot measurement

1. Indications
1. Intrauterine Fetal Demise dating
2. Subarachnoid Hemorrhage demise dating
3. Most accurate method for dating gestational age
2. Fetal Foot Measurements
1. Week 8.5: Foot Length: 3 mm
2. Week 9.0: Foot Length: 4 mm
3. Week 9.5: Foot Length: 5 mm
4. Week 10.0: Foot Length: 6 mm
5. Week 11.0: Foot Length: 7-8 mm
6. Week 12.0: Foot Length: 9 mm
7. Week 13.0: Foot Length: 11 mm
8. Week 14.0: Foot Length: 14 mm
9. Week 15.0: Foot Length: 18 mm
10. Week 16.0: Foot Length: 20 mm
11. Week 17.0: Foot Length: 23 mm
12. Week 18.0: Foot Length: 26 mm
13. Week 19.0: Foot Length: 29 mm
14. Week 20.0: Foot Length: 33 mm
15. Week 21.0: Foot Length: 36 mm
16. Week 22.0: Foot Length: 39 mm
17. Week 23.0: Foot Length: 42 mm
18. Week 24.0: Foot Length: 45 mm

7 - stillborn

1. Labs: Maternal
1. Hemoglobin A1C
2. Kleihauer-Betke
3. Syphilis Serology (RPR, VDRL)
4. Antinuclear Antibody (ANA)
5. Partial Thromboplastin Time (PTT)
6. Anticardiolipin Antibodies
7. Urine Tox Screen
2. Exam: Fetus
1. Placental pathology
2. Autopsy of fetus
3. Fetal Foot Measurement
1. Most accurate method for dating gestational age
4. Fetal Chromosomal analysis
5. Evaluate for fetal dysmorphology
6. Obtain cord blood or cardiac puncture
1. Use Green top tube (Heparinized)
7. Obtain skin biopsy
1. Store in normal saline
3. Radiology
1. Fetal Ultrasound
1. Two examiners should independently confirm IUFD
4. Management
1. Induction for delivery of fetus
2. Grief counseling for family

6 - Premature rupture of membranes (PROM)

1. See Also
1. Preterm Labor
2. Preterm Labor Management
2. Definitions
1. Premature Rupture of Membranes (PROM)
1. Rupture of membranes >1 prior to labor onset
2. Preterm Premature Rupture of Membranes (PPROM)
1. PROM that occurs prior to 37 weeks gestation
3. Epidemiology
1. Incidence
1. Premature Rupture of Membranes (PROM): 8%
2. Preterm Premature Rupture of Membranes (PPROM): 2%
4. Symptoms
1. Gushing of fluid from vagina
2. Fluid leakage increases with movement change
5. Signs
1. See evaluation below
6. Differential diagnosis
1. Urinary Incontinence
2. Vaginal Discharge
3. Water from recent bathing
7. Complications
1. Premature Birth (PPROM)
2. Chorioamnionitis
3. Cord compression
4. Respiratory distress syndrome
5. Abruptio Placentae
6. Malpresentation
8. Course prior to delivery
1. Term: Labor starts within 24 hours in 95% of cases
2. Weeks 28 to 34
1. Labor starts within 24 hours in 50% of cases
2. Labor starts within 1 week in 80% of cases
3. Weeks 24 to 26
1. Labor starts within 1 week in >50%
2. Labor delayed 4 weeks in 22%
4. References
1. Schucker (1996) Semin Perinatol 20:389
9. Risk Factors
1. History of PROM in prior pregnancy
2. Prior cervical cone biopsy
3. Amniocentesis or Cerclage
4. Uterine distention
1. Polyhydramnios
2. Multiple Gestation pregnancy
5. Tobacco abuse
6. Cervical or vaginal infections
1. Group B Streptococcus
2. Bacterial Vaginosis
3. Mycoplasma
4. Ureaplasma
5. Neisseria Gonorrhea
6. Chlamydia
7. Intercourse (unproven)
10. Evaluation
1. Methods to confirm rupture of membranes
1. Vaginal Pooling
2. Vaginal Fluid Ferning
3. Vaginal Fluid pH (Nitrazine)
2. Other bedside evaluation
1. Visualize cervix with speculum to estimate dilation
2. DNA probe for Chlamydia and Gonorrhea
3. Group B Streptococcus culture from vagina and rectum
4. Fetal monitoring for well-being
3. Advanced diagnostics to consider
1. Consider ultrasound
1. May help confirm diagnosis (oligohydramnios)
2. Determines Fetal Position and placental location
3. Estimates fetal weight
2. Amniocentesis
1. Evaluate Fetal Lung Maturity
2. Method to confirm ROM in uncertain cases
1. Uses Indigo carmine dye 1 ml in 9 ml sterile NS
2. Instilled into uterus via amniocentesis
3. Vaginal tampon turns blue within 30 min in ROM
11. Precautions: Avoid digital cervical exam in PPROM
1. Digital exam raises infection risk, other morbidities
1. Alexander (2000) Am J Obstet Gynecol 183:1003
2. Digital exam reduces time to labor by 9 days
1. Lewis (1992) Obstet Gynecol 80:630
3. Speculum visualization offers similar dilation estimate
1. Munson (1985) Am J Obstet Gynecol 153:562
12. Management: Term Premature Rupture of Membranes (PROM)
1. Indications
1. Fetus 36 weeks gestation or
2. Weight >2500 grams or
3. Fetal Lung Maturity adequate by amniocentesis
2. Protocol
1. Expectant management
2. Consider Oxytocin induction of labor
1. Spontaneous labor onset within 48 hours in 90%
2. Oxytocin decreases PROM infection rates
3. Oxytocin does not increase ceserean rates in PROM
3. Consider Cervical Ripening if unfavorable cervix
1. Decreases risk of Chorioamnionitis in PROM
2. Does not increase ceserean rate in PROM
4. Indications for GBS Prophylaxis
1. Prolonged ruptured membranes anticipated >18 hours
2. Fever >38 degrees Celsius
13. Management: Preterm Premature Rupture Membranes (PPROM)
1. Indications
1. Fetus <32-34>
2. Weight <2500>
3. Indequate Fetal Lung Maturity
2. Protocol: General
1. See Preterm Labor Management
2. Tocolysis
1. Delay labor unless overt infection, Fetal Distress
3. Maternal Corticosteroids for 2 days (single course)
1. Betamethasone 12 mg IM 2 doses 24 hours apart or
2. Dexamethasone 6 mg IM 4 doses 12 hours apart
4. Maternal antibiotic prophylaxis
1. See GBS Prophylaxis
2. Antibiotic protocol improves neonatal outcomes
1. Initial 48 hours start with IV agents
1. Ampicillin 2 grams IV q6 hours and
2. Erythromycin 250 mg IV q6 hours
2. After 48 hours, switch to oral agents for 5 days
1. Amoxicillin 250 mg PO q8 hours and
2. Erythromycin base 333 mg PO q8 hours
3. Reference
1. Mercer (1997) JAMA 278:989
5. Consider transfer to tertiary care center
6. Avoid digital cervical exam
7. Observation
1. Signs of Chorioamnionitis
2. Fetal well-being
3. Protocol: Gestational age specific
1. Gestational age 34 weeks or older
1. Consider transport to facility with NICU
2. Antibiotics (see regimen above)
3. Labor Induction
2. Gastational age 32-33 weeks
1. Transport to facility with NICU
2. Antibiotics (see regimen above)
3. Amniocentesis for Fetal Lung Maturity
1. Fetal lungs mature: Labor Induction
2. Fetal lungs not mature
1. Maternal Corticosteroids as above
2. Delay delivery 48 hours (preferably >34 weeks)
3. Gestational age 24-31 weeks
1. Transport to facility with NICU
2. Antibiotics (see regimen above)
3. Daily or continuous fetal monitoring
1. Higher risk of cord compression
4. Gestational age <24>
1. Consultation with neonatology
14. References
1. Morrison (2000) ALSO, p. 1-7
2. Ehrenberg (2001) Clin Perinatol 28(4):807
3. Lee (2001) Clin Perinatol 28(4):721
4. Medina (2006) Am Fam Physician 73(4):659

5 - preterm labour ( preterm delivery )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
2. Consider Ampicillin for Group B Streptococcus
6. Notify primary doctor regarding possible delivery
7. 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>
8. Consider transport to tertiary center with NICU
1. Strongly consider if <34>
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
2. Mechanism
1. Promotes Fetal Lung Maturity
3. Preparations
1. Betamethasone 12 mg IM q24 hours for 2 doses
2. Dexamethasone 6mg IM q12 hours for 4 doses
4. Course
1. Delay delivery at least 24-48 hours after steroids
1. See Tocolytics below
2. No longer recommended to repeat weekly
1. Administer only first week
2. Lee (2004) Obstet Gynecol 103:274
4. Management: Tocolytic agents
1. See Tocolytic
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, Ritodrine and Nifedipine
2. Also avoid Indomethacin due to adverse effects
6. References
1. Iams in Gabbe (2002) Obstetrics p.755
2. Huddleston (2003) Clin Perinatol 30:803

4 - preterm delivery

1. Definition of Preterm labor
1. Gestational age 20-37 weeks
2. Contractions with cervical change
2. Epidemiology
1. Incidence 7-8% of deliveries
3. Differential Diagnosis
1. Gastrointestinal
1. Appendicitis
2. Constipation
2. Uterus
1. Uterine Fibroids
2. Placental Abruption
3. Urinary
1. Acute Cystitis
2. Pyelonephritis
3. Nephrolithiasis
4. Musculoskeletal
1. Abdominal wall strain
4. Risk Factors predisposing to Preterm Labor
1. No associated risk factor in 50% of preterm labor
2. Tobacco abuse over 1/2 pack per day Cigarettes
3. Prior cervical cone biopsy
4. Pyelonephritis
5. Advanced cervical dilatation
6. Increased Uterine Size
1. Twin Gestation
2. Polyhydramnios
7. Low pre-pregnant weight (Body Mass Index <19.8)
8. Low socioeconomic status or poor nourishment
9. Prior preterm delivery
10. History spontaneous second trimester abortion
11. African American race
12. Uterine anomaly
1. Unicornuate uterus or bicornuate uterus
2. Uterine Fibroids
3. Diethylstilbestrol (DES) exposure in utero
13. Genitourinary Infection (40% of preterm births)
1. Urinary Tract Infection
1. Pyelonephritis
2. Asymptomatic Bacteriuria in Pregnancy
2. Vaginal infections
1. Group B Streptococcus (PPROM)
2. Bacterial Vaginosis
1. N Engl J Med (1995) 333:1732
3. Sexually Transmitted Disease
1. Neisseria gonorrhoeae
2. Chlamydia trachomatis
3. Trichomonas vaginalis
4. Syphilis
4. Infections with possible risk
1. Ureaplasma urealyticum
2. Mycoplasma hominis
5. Symptoms
1. Keep a high index of suspicion
1. Contraction frequency does not predict risk
2. Symptoms do not predict risk
2. Pelvic pressure
3. Vaginal pain
4. Menstrual-like cramps
5. Backache
6. Vaginal Discharge or fluid leakage (see PPROM)
7. Vaginal Bleeding
6. Signs
1. Examine Cervix as soon as possible
1. Avoid cervical exam until labor if PPROM confirmed
2. Examine Uterus
1. Assess for Abruptio Placentae
2. Check for firm, tender uterus with minimal relaxation
7. Evaluation: Four key concerns
1. Determine if patient is in labor
1. Evaluate abdominal or Pelvic Pain
2. Distinguish preterm labor from preterm contractions
2. Determine if membranes are ruptured
1. See Labs below
3. Establish clear gestational age
1. Review Last Menstrual Period
2. Review Estimated Due Date
3. Review prior ultrasound dating
4. Does fundal height correlate with gestational age
4. Evaluate maternal and fetal health
1. Consider underlying injury or infection
1. Recent trauma
2. Vaginal infection
3. Urinary Tract Infection in pregnancy
2. Consider comorbidity
1. Gestational Diabetes
2. Pregnancy Induced Hypertension
3. Intrauterine Growth restriction
4. Oligohydramnios or Polyhydramnios
3. Evaluate fetal activity and fetal health
1. External fetal monitoring
8. Labs
1. Evaluate for Rupture of Membranes
1. Nitrazine Testing
2. Ferning
2. Microscopy to evaluate Vaginitis
1. Saline wet preparation
2. KOH Preparation
3. Culture
1. Gonorrhea Culture
2. Chlamydia culture
3. Group B Streptococcus Culture (Todd Hewitt media)
1. Periurethral or outer-third of vaginal swab
2. Rectal swab
4. Urine Culture
5. Consider non-genitourinary sources of infection
4. Other Testing
1. Fetal Fibronectin
1. Reassuring if negative
2. Poor Positive Predictive Value
2. Urine testing
1. Urinalysis and Urine Culture
2. Urine drug Screening
5. Fetal Lung Maturity Assessment
1. Indicated for 34 week gestation or greater
9. Radiology: Obstetric Ultrasound
1. Fetal evaluation
1. Biophysical Profile
2. Amniotic fluid index
2. Placental location
3. Fetal Presentation
4. Estimated Fetal Weight (EFW)
5. Ultrasound Exam of Cervical Length
10. Efficacy of evaluation criteria
1. Evaluation criteria do not predict preterm delivery
1. Fetal Fibronectin
2. Uterine contraction frequency
3. Cervical Length assessment
2. These criteria however have Negative Predictive Value
1. No Cervical Length change and negative fibronectin
2. Suggests less than10% chance of preterm delivery
3. References
1. Iams (2002) N Engl J Med 346:250
11. Management
1. See Preterm Labor Management
12. References
1. Iams in Gabbe (2002) Obstetrics p.755