Preterm Labour and Premature Rupture of Membranes (PROM)

Regarding preterm labour: Broad spectrum IV antibiotics are used if there is evidence of infection. Cervical cerclage is contraindicated when membranes are ruptured, as it increases infection risk. IM dexamethasone (or betamethasone) is given to accelerate fetal lung maturation. Nifedipine can be used as a tocolytic to delay delivery. Erythromycin is given in the context of PPROM, not necessarily in preterm labour with intact membranes.

Management options for preterm labour include: Administration of IM dexamethasone (or betamethasone) to accelerate fetal lung maturity. Erythromycin is given in PPROM, not necessarily in preterm labour with intact membranes as is. Broad spectrum IV antibiotics are given if there is evidence of infection (chorioamnionitis) and can be used in PPROM to prolong latency. Emergency cerclage is not performed if membranes are ruptured, as it increases risk of infection; cerclage is a *preventative* measure.

At 36 weeks, with a normal SFH, the strongest indication for urgent delivery is a lack of variability in the CTG for 90 minutes. This suggests fetal compromise. Lack of fetal movements for 3 hours may warrant further investigation, but CTG changes are more concerning. Lack of maternal weight gain is not an indication for urgent delivery. Amniotic fluid index of 7 cm is within the normal range. Elevated uric acid suggests pre-eclampsia, which could warrant delivery, but CTG changes indicate *fetal* distress, which is the higher priority.

Preterm labour has several associations. Multiple pregnancy is a major risk factor. Oligohydramnios, surprisingly, is not typically a direct cause of *preterm labour* itself, although it may be associated with conditions that lead to it, or it may result from PPROM. Short cervical length at 20 weeks is a strong predictor of preterm birth.

A primigravida at 32 weeks with ruptured membranes requires a management plan that balances the risks of prematurity and infection. The most appropriate management is to give tocolytics and dexamethasone. Tocolytics (like nifedipine) may delay delivery to allow time for the dexamethasone to enhance fetal lung maturity. Maintaining a temperature chart is for monitoring, not primary management. Conservative management with sterile pads alone is insufficient and increases infection risk. Full blood count is a basic investigation but does not address the preterm labour. Oral antibiotics are indicated, but delaying delivery with tocolytics and giving steroids is a higher priority initially.

Management of preterm labour with intact membranes aims to delay delivery to allow for fetal lung maturation. Oral Nifedipine is used as a tocolytic to suppress uterine contractions. Dexamethasone injections are given to accelerate fetal lung maturation. C-reactive protein is a marker of inflammation, not a treatment. Hourly CTG is a monitoring tool. Oral Erythromycin is given in cases of PPROM, *not* with intact membranes.

A 32-year-old primigravida at 34 weeks with PPROM, fever, uterine tenderness, and tachycardia is showing signs of chorioamnionitis. The most appropriate action is to expedite delivery. Prolonged PROM with signs of infection requires prompt delivery to reduce maternal and fetal morbidity. Antibiotics are essential but are *secondary* to delivery. Dexamethasone is for fetal lung maturity but is less important when infection is present. A temperature chart is for monitoring, not a management action. CTG monitors fetal well-being, but the priority is to address the infection.

A primigravida at 30 weeks with abdominal pain and vaginal bleeding requires prompt assessment. USS for placental location is the most appropriate *initial* step to rule out placenta previa or abruption, which can cause both pain and bleeding, and significantly impact management. Dexamethasone is important in preterm labour, but first the cause of the pain and bleeding must be determined. Caesarean section is premature without knowing the cause. Pethidine is for pain relief, but not the initial diagnostic step. Vaginal examination is contraindicated in the presence of vaginal bleeding until placenta previa has been excluded by ultrasound.

The patient presents with signs of preterm labor (uterine contractions and cervical dilation). With a normal CTG, the initial management should focus on delaying delivery and promoting fetal lung maturity. IM Dexamethasone is crucial to enhance fetal lung maturation. Tocolysis (e.g., Nifedipine, not MgSO4 in this case) would also be considered to delay delivery. Await for spontaneous delivery is inappropriate with regular contractions and cervical change. EM-LSCS is not indicated in the absence of fetal distress. Syntocinon is used to *augment* labour, not to *stop* it in preterm labour.

Preterm labour is multifactorial. Asymptomatic bacteriuria is a recognized risk factor. Hypertension (both chronic and gestational) increases the risk. Teenage pregnancy is a risk factor. Low socioeconomic background is associated with an increased risk. Obesity can contribute to the risk, but the relationship is complex and not always a direct cause.

In PPROM, even with normal maternal and fetal parameters, the administration of steroids (dexamethasone or betamethasone) is crucial to promote fetal lung maturity. According to RCOG Green-top Guideline No. 73 (2010, updated 2023), steroids should be given to women between 24 and 37 weeks of gestation who are at risk of preterm delivery. Antibiotics (like co-amoxiclav) are also indicated in PPROM to prolong latency and reduce the risk of infection, but steroids are more important for the immediate benefit of the fetus’s lungs. Caesarean section is not indicated without fetal distress or other complications. Induction of labour is typically considered if labour does not start spontaneously, and steroids have been given. Ultrasound is important for assessing fetal growth, but steroids are the priority.

When a woman presents with signs of preterm labour, even with a normal CTG, the most important intervention to benefit the fetus is the administration of dexamethasone (or betamethasone) to promote fetal lung maturity. Nifedipine may be used tocolysis, but the primary benefit for the fetus is from steroids. LSCS is not indicated in the absence of fetal distress or a non-reassuring CTG. Cervical cerclage is a preventive measure. Erythromycin is used for PPROM, not for preterm labour with intact membranes.

In preterm labour, the most beneficial intervention to improve neonatal outcome is the administration of dexamethasone (or betamethasone) to the mother. This accelerates fetal lung maturation. Tocolysis with Nifedipine is used to delay delivery, but the primary benefit to the baby comes from steroids. Micronized progesterone is for *prevention* of preterm birth, not active preterm labour. MgSO4 is for fetal neuroprotection but is given *when delivery is anticipated*, not as the primary intervention in early preterm labour. Continuous electronic fetal heart rate monitoring is essential but is a *monitoring* tool, not a therapeutic intervention to benefit the baby’s lungs.

Several factors increase the risk of preterm labour. An interval from the last pregnancy less than one year increases risk, suggesting inadequate time for maternal recovery. Low BMI is associated with increased risk. Teenage pregnancy is a risk factor. Polyhydramnios and chorioamnionitis both significantly increase the risk. Maternal exercise in a normal pregnancy does *not* increase the risk.

Management of preterm labour with intact membranes at 32 weeks aims to delay delivery to allow for fetal lung maturity. Dexamethasone (or betamethasone) is given to the mother to accelerate fetal lung maturation. Nifedipine is a tocolytic used to suppress uterine contractions. Erythromycin is given for prolonged latency with PPROM, *not* with intact membranes. Progestogen is used for *prevention* of preterm birth in women with a short cervix, not for active preterm labour. MgSO4 is used for fetal neuroprotection prior to preterm birth, as delivery is anticipated, and not strictly a tocolytic.

In a patient presenting with PPROM, a sterile speculum examination is essential to confirm the diagnosis and assess the cervical status. According to RCOG Green-top Guideline No. 73 (2010, updated 2023). A CTG is important for monitoring fetal well-being, but the speculum examination should precede it to confirm PROM. CRP and FBC are useful if infection is suspected. Measuring cervical length is more relevant in the *prediction* of preterm birth, not the initial assessment of PROM. USS can assess amniotic fluid volume, but speculum examination is the primary diagnostic tool.

Maternal risk factors for preterm birth are complex and multifactorial. Small inter-pregnancy interval (<6-12 months between deliveries) is a known risk factor. Teenage pregnancy is associated with increased risk. Pregnancy following assisted reproduction technologies (ART), especially multiple gestations, increases risk. Obesity is associated with an increased risk of preterm birth, although the relationship is complex. Exercise in a normal pregnancy *does not* increase the risk of preterm birth; in fact, it is generally beneficial.

Sterile speculum examination is the primary and most accurate method for diagnosing PROM. It allows direct visualization of amniotic fluid pooling in the vaginal vault. Fetal fibronectin is used to assess the risk of preterm delivery in women with threatened preterm labor, not for diagnosing PROM. Nitrazine test is less specific and can be positive with other alkaline fluids. Ultrasound assesses amniotic fluid volume but does not confirm membrane rupture. Digital vaginal examination is contraindicated in suspected PROM.

Sterile speculum examination is the first-line investigation for suspected rupture of membranes, to visualize pooling of amniotic fluid in the posterior fornix. If this is inconclusive, further tests are needed. According to RCOG Green-top Guideline No. 73 (2010, updated 2023), the Nitrazine test is less specific and can give false positives. Fetal fibronectin is used to assess the risk of *impending* preterm delivery, not for confirming rupture of membranes. Ultrasound scan assesses amniotic fluid volume but does not confirm membrane rupture. Sterile pad observation is not a reliable diagnostic test.

When sterile speculum examination is inconclusive for rupture of membranes, further testing is required. According to RCOG Green-top Guideline No. 73 (2010, updated 2023), Transvaginal ultrasound (TV USS) can be used to assess amniotic fluid volume, but is not the definitive test for rupture of membranes. Amniotic fluid specific markers such as placental alpha-microglobulin-1 (PAMG-1) (Amnisure) or fetal fibronectin (fFN) are more accurate. As the speculum exam was inconclusive, the next best step is TV USS *or* a test like Amnisure/fFN. Commencement of antibiotics is premature without confirming PROM. Digital vaginal examination is contraindicated in suspected PROM due to increased risk of infection. Measuring inflammatory markers is useful if infection is suspected, but not for confirming PROM. Sterile pad examination is not a reliable diagnostic test.

In preterm premature rupture of membranes (PPROM), the primary goal is to balance the risks of prematurity with the risks of infection. Since the steroids have been given and completed 5 days ago, and the patient is planned for delivery, the most important action to improve neonatal outcome is to give IV MgSO4. Magnesium sulfate is neuroprotective for the fetus in preterm deliveries (RCOG Green-top Guideline No. 44, 2022). CTG is for fetal monitoring. Referral to a neonatologist is essential but should have already been done. Repeat dexamethasone is not indicated as the course has been completed. Nifedipine is a tocolytic and not indicated when delivery is planned.

Women with a history of preterm birth and a short cervix are at high risk of recurrent preterm birth. NICE guidelines (NG25, 2015, updated 2019) recommend offering cervical cerclage to women with a singleton pregnancy, a previous preterm birth before 34 weeks, and a cervical length of 25 mm or less at or before 24 weeks of gestation. Low-dose aspirin is for pre-eclampsia prophylaxis. Serial cervical length assessment is important for monitoring, but does not prevent preterm birth. Vaginal progesterone is used for women with a short cervix *without* a prior preterm birth history. Vaginal clindamycin is used to treat bacterial vaginosis.

Prolonged rupture of membranes (PROM) at term (37 weeks) increases the risk of chorioamnionitis. According to RCOG Green-top Guideline No. 73 (2010, updated 2023), if PROM occurs at term, and labour does not start spontaneously, induction of labour is recommended to reduce the risk of infection. Oxytocin infusion is the standard method for induction of labour at term. Antibiotics (like erythromycin) are used for prolonged PROM *before* term to prolong latency and reduce neonatal morbidity. Emergency C-section is not indicated in the absence of fetal distress or other obstetric complications. Foley catheter induction is a cervical ripening method, typically used *before* oxytocin, and less common at term. Observation for 48 hours increases the risk of infection.

A short cervical length (<25mm) at or before 24 weeks' gestation in a woman with a history of previous preterm birth is a strong predictor of increased risk of preterm birth. According to NICE guidelines (NG25, 2015, updated 2019), for women with a singleton pregnancy, a previous preterm birth before 34 weeks, and a cervical length of 25 mm or less at or before 24 weeks of gestation, offer cervical cerclage. High vaginal swab is used to exclude infection, but is not the primary management here. Progesterone may be used in women with a short cervix without a history of preterm birth. Repeat cervical length assessment is part of serial monitoring, but not the immediate next step. Low-dose aspirin is used for pre-eclampsia prophylaxis.