Controversial preterm case

[Mercedes86]

A patient came in today (not mine) that became the topic of a small debate. Wondering how you would handle it, I'll tell you what the doctor did later.

History:
The patient came into the ER once before at 28 weeks complaining of contractions every 5 mins, but was sent home on Nifedipine with a closed cervix, no thinning (still contracting). No other complications.

Today:
Patient now is 30 weeks, returning as instructed as contractions have become more frequent and very painful (patient indicates a 7). Patient was monitored for 8 hours, contractions were steady and did not respond to hydration, Nifedipine, Indocin, Terbutaline, or Magnesium. Corticosteroids given.

Contractions: every 1-2 minutes
Fetal heart rate: 145 bpm (temporary drop to 90 once in 8 hours)
Cervix: 1.5 cm dilated, 80% effaced
BP: 130/75
Fetal Fibronectin: negative

4 Questions:
After 8 hours and no further cervical change, are these braxton hicks?
Would you send her home?
If you do, what advice would you give her about when to return?
If you don't, what treatment options would you pursue next?

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[FutureDoctor719]

Is she a primip or a multip? Either way, I think I'd have a problem sending her home with cxns that painful, regardless of the negative FFN. Since she was dilated, in my opinion, she should be kept for further evaluation, though I wouldn't do anything to induce since she wasn't ruptured. I would observe for 24 hours, and if no progress was made and the cxns had slowed down, then send her home.

(I'm by no means a professional, just a pre-med who loves OB)

 

[kirurgilaakari]

Yeah, pts hx is pretty important in this scenario. Nobody wants to be put in that position as a mother. Sucks.

Anyways, 8hrs seems to be a long time to evaluate cervical change. False labor can present the exact same way as true labor, and the only thing that can differentiate them is cervical change/effacement. Generally, if a preterm primip/multip comes in for triage c/o contractions that seem regular, if no cervical change is seen after at least an hour (especially if the pts hx supports contractions for hours, which if were true labor would create cervical change) and the baby's strips look reassuring, and depending on her previous OB hx, it would seem prudent to send her home from ER to follow up very very soon with her OB, and to possibly schedule a formal US and check for cervical length. She really should have had a formal US ordered in the ED, showing cervical length. If her cervical length is >3cm, there would have been no need to perform a fFN. If preterm labor doesnt seem eminent, especially after US indicating a reassuring HR and a good BPP and AFI, then mom would probably be ok going home with close follow up with her OB.

I would also check for gonorrhea/chlamydia and other cervicitis infx's via spec exam, as it could be cervical/uterine irritation mimicking the contractions.

If she were continuously contracting every 1-2 min with EFM in triage, I would probably advocate keeping her overnight for continuous EFM, labs; (IV hydration hasn't been proven efficacious in diagnosing PTL). She would likely be put on a tocolytic, and may go home on it as well after IUP shown to be reassuring after all.

She has a negative fFN, which generally has a real good negative predictive value (somewheres in the 65-92% range) indicating that if its negative, there is a good chance she won't deliver in the next 1-2 weeks or so. If the test was positive, it wouldnt necessarily indicate PTL. Positive predictive value for fFN is about 20% or less and thus not very helpful.

Hope this helps

 

[Mercedes86]

Patient had a previous spontaneous abortion at 9 weeks and a late preterm live birth at 36 weeks in 2009.

Doctor kept her for observation longer because she was consistently contracting every 1-2 minutes and indicating they were painful. But, let her go when her cervix was not showing change 8 hours later, even though she was still contracting and in pain.

Anyway: THANKS!! Sounds like "consensus" is to keep her, which I and some others agreed with also. But, I haven't seen anyone contracting like that and not go into labor before, yet. Regardless of the fFN.

 

[kirurgilaakari]

Patient had a previous spontaneous abortion at 9 weeks and a late preterm live birth at 36 weeks in 2009.

Doctor kept her for observation longer because she was consistently contracting every 1-2 minutes and indicating they were painful. But, let her go when her cervix was not showing change 8 hours later, even though she was still contracting and in pain.

Anyway: THANKS!! Sounds like "consensus" is to keep her, which I and some others agreed with also. But, I haven't seen anyone contracting like that and not go into labor before, yet. Regardless of the fFN.

My wife just delivered 5 weeks ago. She was contracting very regularly at 31-32 wks-ish. No preterm labor indicators, no bad previous hx. They were painful. Made me worry a bit, not gonna lie. She delivered @38 5/7. Kinda strange how she contracted for so long, very regularly, without it going into true labor, etc.

This really isnt a rare occurrence. It does happen.

 

[FutureDoctor719]

I guess I'm just overly cautious. But someone coming in with painful cxns at 31 weeks is serious, and you never really know if it's for real or not. I've seen plenty of cases in L&D where it was false labor, but I'd rather observe and closely monitor all of them just in case one does end up being in true labor. Thanks for posting this, Mercedes...very interesting!

 

[jvarga]

Although a lot of what has been posted is controversial and up for academic debate, it seems pretty straight forward that most would not argue with extended monitoring. Unlike most of our colleagues who are fixated on the "is this preterm labor or not" aspect, I think attention should be paid to the underlying cause of the contractions (remember that preterm contractions are a symptom/sign of an underlying problem). In particular, are you dealing with subclinical chorioamnionitis or abruption? Fortunately there are very simple and straightforward tests at your disposal that will aid you along the way. If an etiology for the contractions is found, the decision on how to manage the patient will become evident. If no etiology could be confirmed, then close follow-up is warranted. Let us know how this turns out.

 

[THP]

We see this scenario almost every other night in our OB triage. If we give a patient Betamethasone we almost always keep them overnight. We try different tocolytics and sometimes sedate them for comfort so they can get some sleep.

Agree with jvarga - you need to reasonably make sure there is not an abruption or chorio before giving any kind of tocolytic. We don't often add a second tocolytic without an amnio to r/o infection.

kirurg - my wife is the same way. Contracts from 28 weeks until delivery.

 

[Diane L. Evans]

While the FFN has a good Negative predicitive value there are some false positives. My DDX is chorio, abruption, PPROM, drug abuse, UTI, cervicitis, gastoenteritis, dehydration, then preterm contractions

In this particular case I would of as formentioned rule out a subclinical chorioamnionitis with amniocentesis but first do a detailed US I would specifically look for an occult PPROM, perhaps if amniotic fluid was low ask my MFM to perform a amnio dye test . Collect serial CBC and fibrinogen to look for occult abruption as an US rarely can diagnose this (15-20% sensitivity).

However, in the absence of cervical change and reasurring FHT and absence of fever it simply may be preterm contractions

This is why the lawyers have a field day with OB/GYN because the diagnosis could be anything.... Until we validate more testing such as IL-6 for Chorio etc its going to be a long arduous process of deciding how to individualize and best treat each patient without legal recourse

In essence if CBC, vitals, reassuring FHT. lack ROM was documented this would be a reasonable step for discharge. With a claimer necessitating followup in a few days or return if any PPROm, fever, bleeding etc.