hopdoc
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32 yo G3P3 30 weeks gestation presents with new onset of regular and painful uterine contractions 5 hours ago. Preterm labor at 28 weeks gestation in her second pregnancy. Current preg uneventful so far. She denies any leakage of fluid or bleeding from vagina, dysuria, urgency or vaginal discharge. Vitals: Temp- 37C, BP - 125/70, PR- 80/min, RR-17/min. Pelvic exam shows a soft partially effaced posterior cervix, 2cm dilated and a negative nitrazine test. Non-stress test reveals a reassuring fetal pattern and uterine contractions occuring every 7 mins. What is the most appropriate next step in management?
A) Tocolysis with magnesium sulphate
B) Hydration and bed rest
C) Reassurance and discharge home
D) Hasten delivery
E) Perform cerclage
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| msyamp
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B hydration and bed rest
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| hopdoc
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Yes that is correct msyamp. This qs is from USMLE world. I am not sure I understand why though. My ans was A because uterine contractions have started and the cervix is dilated 2 cm. Any comments?
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| msyamp
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a 2cm dialated cx is normal in third trimester. a bit of effacement is also seen here. encircle is done in 4 to 5 months. we dont send her back as she prematurely delivered previously. most of the contractions decreased with rest and hydration. so we dont continue to tocolytics yet.even the baby is ok here so...
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| hopdoc
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Thank you I understand now. 
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| kingsofke
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a 2cm dialated cx is normal in third trimester. a bit of effacement is also seen here.
I am not easy with this one, I think dilatation is a key criteria for true labor in difference to false labor which actually is common in third trimester.
Rest just might be the awnser but i have yet to read any supporting comment about it in any book, i still would go with Mg in exam as kaplan is very clear about it. Any comments from blueprints series anyone ?
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| an
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kaplan says a contraindication for tocolysis is cervical dilation >/= 2 cm...
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| mesh
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well tocolysis is CI in advanced cervical dilatation as kaplan says.....
and more over to diagnose preterm labour the criteria of cervical dilatation tells that it should be >/=2..and we have to give tocolysis if maternal or fetal jeopardy is not there....
we can start with hydration and bed rest..if that doesnt work then go for tocolysis with Mg..
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| SilatK
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Well I think the 2 cm dilation would be some what normal in this patient since she's P3. I would go for B but if after 30mins if the contractions do not decrease then I would start with tocolysis.
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| achilles
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well cervical dilation is a contraindication but it has to be advanced cervical dilation (6cms or more) and is that really a contraindication (particularly in absense of rupture of membranes) or the tocolysis is not actually as effective after that ...
the answer is A - tocolysis with mg sulfate and this provides a window of time for administration of beclomethasone i.m. and transportation of mother and fetus inutero to a facility with neonatal intensive care unit.
and tocolysis has to be parental. oral tocolysis is not more effective than a placebo..
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| stepkiller
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Please tell the answer
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| achilles
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well kaplan very clearly says to give tocolysis and they do not mention the importance of bed rest and hydration...i tried and looked up other text too but could not find much on bed rest. i am confused...i dread to think that UW can get it wrong. and if they are right then kaplan hasnt mentioned it ... someone pls clear this.
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| DrS
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This is indeed a very controversial issue!
This is what blueprints has to say about tocolytics in preterm labour
"The goal of a tocolytic is to decrease or halt the cervical change resulting from contractions. In the case of preterm contractions without cervical change, hydration can often decrease the number and strength of the contractions. "
"........Thus, hydration, which decreases the level of ADH, may also decrease the number of contractions. For patients who do not respond to hydration whose cervixes are actively changing, a variety of tocolytics may be used"
So basically blueprints seems to say: preterm labour + cervical change = tocolytics; preterm labour without cervical changes = hdyration
I guess going from the above it would have to be mentioned that in this patient there certainly are "cervical changes". and the answer would have to be A
A few more details from emedicine.com (http://www.emedicine.com/med/topic3245.htm)
"Criteria that indicate consideration of tocolytic therapy include more than 6 contractions per hour plus documented evidence of cervical change (preferably by the same observer). Cervical change is defined as a cervix that is less than 2.5 cm in length based on ultrasound measurement, greater than 80% effaced based on digital examination findings, or cervical dilation greater than 1 cm. If contractions are present without cervical change, management options include continued observation for cervical change for a total of 23 hours or therapeutic sleep (morphine sulphate 15 mg SQ). If the results of the fetal fibronectin analysis are negative, the patient may be sent home, with appropriate follow-up evaluation. "
This also certainly suggests that this patient should recieve tocolytics, but I'm not sure as to how accurate this information is............
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| achilles
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good work DrS...great!!
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| ujaala
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when i read the question, my immediate answer was A. tocolysis with magnesium sulfate
but after reading all the views and checking kaplan , this is what i have to say...
it is true tht if the cervix is dilating then we have to give tocolysis and betamethasone and then arrange to take the baby in utero to a hospital where neonatal ICU is present...
but kaplan manages in this sequence :
1. confirm labor
2. rule out contraindications to tocolysis
3. give i/v hydration
4. give tocolysis
5. do cervical/urine culture and give i/v penicillin G if reqd
6. give i/m betamethasone
so may b USMLE marked i/v hydration and bed rest as the next step in management b/c we have to do but after the hydration?????
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| bioguy
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bump
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| nightflight1945
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ujaala wrote:
when i read the question, my immediate answer was A. tocolysis with magnesium sulfate
but after reading all the views and checking kaplan , this is what i have to say...
it is true tht if the cervix is dilating then we have to give tocolysis and betamethasone and then arrange to take the baby in utero to a hospital where neonatal ICU is present...
but kaplan manages in this sequence :
1. confirm labor
2. rule out contraindications to tocolysis
3. give i/v hydration
4. give tocolysis
5. do cervical/urine culture and give i/v penicillin G if reqd
6. give i/m betamethasone
so may b USMLE marked i/v hydration and bed rest as the next step in management b/c we have to do but after the hydration?????
It is not only Kaplan's approach to preterm labor , but also a universal approach .
For sure this patient is in preterm labor , but as mentioned above first step is IV -hydration and bed rest
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