Preterm Labor

2.

A 29-year-old G2P1001 with a twin gestation at 25 weeks presents to OB triage complaining of irregular uterine contractions and back pain. She also reports an increase in the amount of her vaginal discharge, but denies any "gush of fluid." She reports that in the morning she had some very light vaginal bleeding, but it has since resolved. She says that the babies have been active and moving as much as usual. She thinks that she may have overdone it with too much lifting as she has been rearranging the nursery to get it ready for the babies. She has no GI or urinary symptoms. She has had adequate PNC and denies any problems or complications with the pregnancy. On arrival to triage, she is placed on an external fetal monitor, which indicates uterine contractions every 2 to 4 min. She is afebrile and her vital signs are all normal. Her gravid uterus is nontender. The nurses call you to evaluate the patient. You decide to implement all of the following assessments EXCEPT which one?

Sterile digital exam
Intravenous hydration
Bedside ultrasound
Urinalysis and urine culture
Rectovaginal swab for Group B Strep

Correct Answer

A. Sterile digital exam

Explanation

Since this patient has multiple gestation along with bleeding, cramping, and increased vaginal discharge, PTL must be ruled out. Dehydration
can be a cause of premature contractions and uterine irritability, so IVF would be appropriate here A U/A with C & S would be appropriate because UTIs can cause uterine contractions. A GBS infection can also be associated with PTL, so you should obtain a culture for this as well.
An SVE should NOT be performed until placenta previa has been ruled out by an ultrasound, since the patient reported a history of vaginal bleeding.

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3.

A bedside ultrasound examination indicates that both fetuses are in the cephalic presentation and rules out the presence of a placenta previa. A sterile speculum exam is then performed, and a vaginal swab is obtained to perform a fern test on the vaginal discharge. The fern and nitrazine tests are negative. A subsequent digital exam indicates that the cervix is 50/2–3/−3. All of the following are appropriate next steps to manage this patient except

Prep the patient for an emergent cesarean
Administer tocolytics
Administer bethamethasone
Obtain a neonatal consultation

Correct Answer

A. Prep the patient for an emergent cesarean

Explanation

The patient is in preterm labor, because she has a dilated
and effaced cervix in the presence of regular uterine contractions. Therefore,
treatment is aimed at delaying delivery to allow continued fetal growth
and maturity. The administration of tocolytic therapy to treat the preterm
contractions is indicated. In addition, from 24 to 34 weeks, management
also includes the administration of steroids such as betamethasone to promote
fetal lung maturity. Respiratory distress syndrome (RDS) is a sequela
of preterm neonates and occurs less often in infants given betamethasone
in utero. If delivery seems likely, intravenous antibiotics are administered
to prevent possible neonatal sepsis. If the patient’s contractions subside and
there is no evidence of infection, then the antibiotics can be discontinued.
It is advantageous to obtain a neonatology consult on any patient who
appears to be in preterm labor so the parents know what to expect if they
give birth to preterm infants. There is no need to prepare for a cesarean section
in this patient. Attempts are made to stop the labor first. If the patient
continues to progress, then a vaginal delivery is preferred since the twins
do not have a malpresentation.

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4.

A 35-year-old G1P0 presents to her obstetrician’s office at 8 weeks gestation. She has a history of type I diabetes and is very concerned regarding the possible risks this illness may have on her fetus. As the patient’s physician, you tell her that all of the following are possible risks that can result from having diabetes in pregnancy except

Fetal malformations
First-trimester spontaneous abortions
Macrosomia
Preterm labor
Cesarean section

Correct Answer

A. Preterm labor

Explanation

Diabetes does not increase a patient's risk for preterm labor.

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4

5.

The strength of using fetal fibronectin as a screening test for preterm labor is in its:

Positive predictive value
Specificity
Negative predictive value
Sensitivity

Correct Answer

A. Negative predictive value

Explanation

fFN has a high negative predictive value, which means if it is negative, there is a very very small chance a patient will deliver in the next 7-10 days. However, if it is positive, it does not tell you that the patient will deliver prematurely. So use it to rule OUT PTL!

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Preterm Labor

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The strength of using fetal fibronectin as a screening test for preterm labor is in its: