preterm labor scenario

[MacGyver]

32 week pregnant mother wakes in bed in a pool of blood from vaginal discharge. No cramps, nausea, pain or other symptoms. Heads straight for the ER. No previous complications during pregnancy.

At the OB unit, she is examined:

Fetal heart rate: 155 bpm
Cervix: 1.5 cm dilated, no active bleeding, no thinning
BP: 130/80
Urinalysis: negative for proteinuria or hematuria
U/S: negative for placenta previa or placental hemorrhage; placenta appears intact.

Ob docs give SubQ injections of Terbutaline q3h (total of 3).

Contractions monitored and stay steady at about 6-7 per hour. Contractions are very mild and mother has no pain.

Ob docs decide terbutaline isnt working, so they start IV Mag Sulfate. After 24 hours on MgSO4, contractions are reduced to approx 3 per hour. Patient is discharged with orders on bed rest and constant monitoring of contractions. Standing order of oral terbutaline is given in case of contractions > 6 per hour.

Questions/Comments:

1) Are these Braxton Hicks contractions?

2) Source of bleeding was determined to be from the cervix. Will mild contractions (< 4 per hour) at home cause further bleeding?

3) Any other drugs besides terbutaline and MgSO4 used to prevent contractions? MGSO4 is the worst drug known to man. Nausea, vomiting, extreme heat/flushing, shakiness, short term memory loss, delirium, irritability, cognitive decline, blurred vision are just a few of the side effects.

4) What effect if any does MGSO4 have on the fetus? I'm assuming decreased muscular tone, but anything else?

5) If the 32 week baby was to be delivered, whats the prognosis? When does the surfactant protein in the lung begin to be produced? Would this require just an incubator or also 24/7 ventilation?

6) How do you estimate the size (lbs) of the baby? U/S? Measurement of abdominal girth? Fetal head size?

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[starayamoskva]

32 week pregnant mother wakes in bed in a pool of blood from vaginal discharge. No cramps, nausea, pain or other symptoms. Heads straight for the ER. No previous complications during pregnancy.

At the OB unit, she is examined:

Fetal heart rate: 155 bpm
Cervix: 1.5 cm dilated, no active bleeding, no thinning
BP: 130/80
Urinalysis: negative for proteinuria or hematuria
U/S: negative for placenta previa or placental hemorrhage; placenta appears intact.

Ob docs give SubQ injections of Terbutaline q3h (total of 3).

Contractions monitored and stay steady at about 6-7 per hour. Contractions are very mild and mother has no pain.

Ob docs decide terbutaline isnt working, so they start IV Mag Sulfate. After 24 hours on MgSO4, contractions are reduced to approx 3 per hour. Patient is discharged with orders on bed rest and constant monitoring of contractions. Standing order of oral terbutaline is given in case of contractions > 6 per hour.

Questions/Comments:

1) Are these Braxton Hicks contractions?

Braxton Hicks contractions by definition do not cause cervical change. If her cervix is dilated to 1.5 cm, then probably not.

[/QUOTE]2) Source of bleeding was determined to be from the cervix. Will mild contractions (< 4 per hour) at home cause further bleeding? [/QUOTE]
Anything is possible

[/QUOTE]3) Any other drugs besides terbutaline and MgSO4 used to prevent contractions? MGSO4 is the worst drug known to man. Nausea, vomiting, extreme heat/flushing, shakiness, short term memory loss, delirium, irritability, cognitive decline, blurred vision are just a few of the side effects. [/QUOTE]

Yes, but in most instances MGSO4 is first line. Terb isn't used routinely for PTL in our facility. We use nifedipine and occasionally calcium channel blockers for PTL. I understand that there is evidence to support use of Vistaril but haven't seen the papers on it.
Regardless of method chosen it us fairly rare to postpone true PTL for more than a few days

The shakiness was more than likely from the terb as Mag is a muscle relaxant.
Side effects of MGSO4: Side effects of Terbutaline
Diaphoresis tremor
Facial flushing nervousness
Hypotension dizzyness
Depressed reflexes drowsiness
Hypothermia weakness
Reduced heart rate headache
Circulatory collapse nausea
Respiratory depression flushing/sweating

[/QUOTE] 4) What effect if any does MGSO4 have on the fetus? I'm assuming decreased muscular tone, but anything else? [/QUOTE]

Yes, decreased muscle tone and if levels are high enough you can have some respiratory depression.

[/QUOTE] 5) If the 32 week baby was to be delivered, whats the prognosis? When does the surfactant protein in the lung begin to be produced? Would this require just an incubator or also 24/7 ventilation? [/QUOTE]
I am not qualified to answer this question but would think it would depend on multiple factors. Did she receive any steroids to promote lung maturity?

[/QUOTE] 6) How do you estimate the size (lbs) of the baby? U/S? Measurement of abdominal girth? Fetal head size?[/QUOTE]

You use mulitple measurements from the US to determine an estimated fetal weight... just remember it is estimated and can be off by quite a bit.

Hope that helps