Preterm Labor

Explanation
In patients with a prior history of preterm labor, cervical length can be monitored by transvaginal ultrasound screening. This patient's ultrasound examination demonstrates a shortened cervix (< 20 mm) and funneling of the membranes. Given these ultrasound findings, in addition to her prior history of pre-term labor, the patient should be offered a cerclage. There is no significant difference in treatment outcomes between vaginal and IM progesterone supplementation. Reduction amniocentesis is an invasive procedure and may introduce unnecessary risk to the patient; further, there is no evidence that her amniotic fluid level is elevated. Uterine evacuation might be considered in the setting of preterm PROM at 18 weeks, but it would not be appropriate management in this patient. Contraindications to cerclage include intrauterine infection, active bleeding, active labor, premature rupture of membranes, and a fetal anomaly incompatible with life.

What is the ONLY condition in pregnancy that a patient should be placed on bedrest for?
PREECLAMPSIA!

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.

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.

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

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!