II. Management: Initial
- Evaluation and Labs as described for Preterm Labor
- Treat genitourinary infections if present
- Bedrest
- Consider Intravenous Fluid for Dehydration
- Administer IV 1-2 liters of Lactated Ringers
- Treat underlying causes
-
Group B Streptococcus Prophylaxis
- Start Antibiotics if positive culture for GBS or status unknown this pregnancy
- If status unkown, obtain rectovaginal culture and may stop Antibiotics if negative
- Notify primary doctor regarding possible delivery
- Labor precautions
- Limit maternal Narcotics for pain control
- Anticipate malpresentations
- Complete cervical dilation may be less than 10 cm
- Elective ceserean <36 weeks offered in some settings
- Consider transport to tertiary center with NICU
- Strongly consider if <34 weeks gestation
- Contraindications
- Imminent delivery
- Fetal Distress or maternal status unstable
- No safe transport to referral center
III. Management: Corticosteroids
- Indications
- Intact membranes at 24-34 weeks
- PPROM without Chorioamnionitis at 24 to 32 weeks
- Consider in women 23 weeks gestation who are likely to delivery within subsequent week
- Mechanism
- Promotes Fetal Lung Maturity (decreased respiratory distress syndrome risk)
- Decreased risk of intraventricular Hemorrhage, Necrotizing Enterocolitis
- Preparations
- Betamethasone 12 mg IM every 24 hours for 2 doses
- Dexamethasone 6mg IM every 12 hours for 4 doses
- Course
- Delay delivery at least 24-48 hours after steroids
- See Tocolytics below
- Repeated Corticosteroid Injection if >7 weeks from last dose
- From 2016 ACOG Practice bulletin, consider repeat dose if still <34 weeks and risk for preterm delivery
- Prior studies from 2004 recommended only one dose in first week of presentation
- Delay delivery at least 24-48 hours after steroids
IV. Management: Tocolytic agents
- See Tocolytic
- Contraindications
- Intrauterine Fetal Demise or lethal fetal anomaly
- Nonreassuring Fetal Status
- Severe Preeclampsia or Eclampsia
- Maternal bleeding with hemodynamic instability
- Chorioamnionitis
- Preferred Tocolytics
- Magnesium Sulfate (also used for neuroprotective benefit, in addition to Tocolysis)
- Load: 6 grams bolus IV over 20 min (Very high dose!)
- Maintenance: 2 grams/hour IV infusion
- Must follow protocols for patient safety
- Tocolytic and neuroprotective (with decreased risk of Cerebral Palsy in deliveries before 32 weeks)
- Indomethacin
- Load: 50-100 mg orally or rectally
- Maintenance: 25-50 mg orally every 4-6 hours
- Avoid use >48 hours (risk of oligohydramnios, premature closure ductus arteriosus)
- Nifedipine
- Load: 30 mg orally
- Maintenance: 10-20 mg every 4-6 hours (max: 180 mg/day)
- Higher risk of maternal adverse effects when combined with Magnesium Sulfate
- Magnesium Sulfate (also used for neuroprotective benefit, in addition to Tocolysis)
- Other Tocolytics
- Terbutaline
- Load: 0.25 mg SQ every 20-30 min for up to 4 doses
- Maintenance: 0.25 mg every 3-4 hours until Uterus quiet for 24 hours
- Terbutaline
- References
V. Management: Ambulatory Protocol
- Weekly cervical exam between 20 and 37 weeks
- Home self monitoring for contractions
- Evaluation for over 4 to 6 contractions per hour
- Pelvic rest
- Bedrest
- Patient Education regarding Preterm Labor
- Oral Tocolytics are not effective
- Avoid oral Terbutaline and Nifedipine
- Also avoid Indomethacin due to adverse effects
VI. References
- Iams in Gabbe (2002) Obstetrics p.755
- (2016) Obstet Gynecol 128(4):e155-64 [PubMed]
- Huddleston (2003) Clin Perinatol 30:803-24 [PubMed]
- Rundell (2017) Am Fam Physician 95(6): 366-72 [PubMed]