PRETERM BIRTH OBSTETRICS II | MIDTERM (1st Sem)

Dr. Trician Villarosa

OUTLINE  Pose various complex, medical, social and ethical
I. DEFINITION OF TERMS considerations
A. Terminology and Diagnosis  ACOG 2012 – those born at 22 – 25 weeks
II. PRETERM NEWBORN MORBIDITY o Previable
A. WHO Key Facts
B. Clinical Management  Less than 24 weeks
III. CAUSES OF PRETERM BIRTH o Remote from term
A. Spontaneous Preterm Labor  24 to 32 weeks of gestation
B. Preterm Premature Rupture of Membranes
C. Multifetal Pregnancy o Near Term
IV. CONTRIBUTING FACTORS  33 to 36 weeks age of gestation
A. Pregnancy Factors
B. Lifestyle Factors
C. Genetic Factors  With respect to size:
D. Periodontal Disease o Small for Gestational Age (SGA)/ Fetal-Growth
E. Prior Preterm Birth
F. Infection
Restriction/ Intrauterine Growth Restriction (IUGR)
V. DIAGNOSIS  Newborns whose birthweight is <10th percentile
A. Symptoms for gestational age
B. Cervical Change
C. Ambulatory Uterine Monitoring
o Large for Gestational Age (LGA)
D. Fetal Fibronectin  Newborns whose birthweight is >90th percentile
E. Cervical Length Measurement for gestational age
VI. PRETERM BIRTH PREVENTION
A. Cervical Cerclage
o Appropriate for Gestational Age (AGA)
B. Prophylaxis with Progesterone Compounds  Newborns whose weight is between the 10th and
C. Prior Preterm Birth and Progesterone Compounds 90th percentiles
D. Progesterone Use without Prior Preterm Birth
VII. MANAGEMENT OF PRETERM PREMATURE RUPTURE OF MEMBRANES
A. Natural History  With respect to weight:
B. Hospitalization
C. Intentional Delivery
o Low Birth Weight
D. Considerations with Expectant Management  Neonates who are born too small weighing 1500 to
E. Clinical Chorioamnionitis 2500 g
F. Antimicrobial Therapy
G. Corticosteroids to Accelerate Fetal Lung Maturity
o Very Low Birth Weight
H. Membrane Repair  Between 1000 and 1500 g
VIII. MANAGEMENT OF PRETERM LABOR o Extremely Low Birth Weight
A. Amniocentesis to Detect Infection
B. Corticosteroids for Fetal Lung Maturation
 Between 500 and 1000 g
C. Magnesium Sulfate for Neuroprotection  Spontaneous Preterm Birth
D. Bed Rest o Unplanned or unintentional labor (preterm labor with intact
E. Emergency or Rescue Cerclage
F. Tocolysis to Treat Preterm Labor
membranes, PPROM, cervical insufficiency, uterine
G. Beta Adrenergic Receptor Agonist bleeding of unknown origin, multiple pregnancy,
H. Magnesium Sulfate intrauterine infection, utero-fundal abnormalities, fetal
I. Prostaglandin Inhibitors
J. Calcium- channel Blockers
anomalies)
K. Atosiban  Medical Preterm Birth
L. Labor o Intentional delivery of a fetus due to serious maternal or
M. Prevention of Intracranial Hemorrhage
N. Steroids
fetal medical condition( hypertension, autoimmune
diseases, infections)
I. DEFINITION OF TERMS
II. PRETERM NEWBORN MORBIDITY
 With respect to gestational age:
Newborns born before 37 weeks suffer various morbidities, largely due
o Preterm or premature birth
to organ system immaturity.
 Neonates who are born too early (less than 37
weeks, before 259 days or 245 days post
Table 1.0 Major Short- and Long- Term problem in Very Low
conception)
Birthweight Infants
 Neonate less than 37 completed weeks but more
than 20 weeks age of gestation.
 Early preterm: before 33 6/7 weeks
 Late preterm: born between 34 – 36 6/7 weeks
(>70% of all preterms)
o Early Term
 Born at 37 to 38 6/7 weeks age of gestation
o Term
 39 to 40 6/7 weeks age of gestation
o Threshold of viability
 Lies between 20 and 26 weeks age of gestation
 Lower limit of fetal maturation compatible with
extrauterine survival
 Neonates are described as fragile and vulnerable
because of immature organ systems

Brain injury from hypoxic-ischemic injury and sepsis  Brain

hemorrhage  White-matter injury  Periventricular leukomalacia 
poor brain growth  Neurodevelopmental impairment

 Associated morbidities
include intellectual
disability, cerebral palsy,
blindness, seizures, and
spastic quadriparesis

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A. WHO KEY FACTS
 15 M babies are born pre term annually Pre term birth  Four direct causes of preterm births:
complications are the leading cause of death among children
under 5 years of age (nearly 1M deaths in 2013)
 ¾ could have been saved with current cost effective
interventions
 Across 184 countries, rate of preterm birth is 5-18%
 350,000 preterm births in the Philippines annually
 Preterm birth is the world’s largest killer of babies in 2012
 Philippines ranks 8th out of 184 for the number of babies born
prematurely and, 17th for total number of deaths due to  Medical Preterm birth
complications from preterm birth
 48% of children who die under age 5years are newborns, and
39% of these die from preterm complications, making this the
leading cause of newborn mortality
 In 2011, 11,290 deaths due to preterm complications (31 deaths  Spontaneous Preterm birth
everyday)
B. CLINICAL MANAGEMENT
 The Obstetric Care Consensus document also addresses  Common associated findings:
management options based on the clinical characteristics of a
given pregnancy.
 Nonmodifiable factors
o Fetal gender
o Weight
o Plurality.
 Potentially modifiable antepartum and intrapartum factors
o Location of delivery
o Intent to intervene by cesarean delivery or labor
induction
o Administration of antenatal corticosteroids and
magnesium sulfate
 Despite their diversity, these processes culminate in a common
 Postnatal management addresses the initiation or withdrawal of
intensive care after birth.
 Areas of general guidance were then reviewed for each week of
gestation
Table 2.0 General Guidelines for Obstetrical Interventions for FOUR MAJOR CAUSES
Threatened and Imminent Periviable Delivery
OBSTETRICAL COMPLICATIONS ASSOCIATED WITH LATE-
PRETERM BIRTHS
Midterm (1st Sem) Preterm Birth
Dr. Trician Villarosa
OBSTETRICS II
III. CAUSES OF PRETERM BIRTH
1. Spontaneous unexplained preterm labor with intact
membranes (40-45%)
2. Idiopathic preterm premature rupture of membranes
(PPROM) (30-35%)
3. Delivery of maternal or fetal indications
4. Twins and higher-order multifetal births
A. SPONTANEOUS PRETERM LABOR
o Intentional delivery of a fetus due to serious maternal or
fetal medical condition (Hypertension, autoimmune
disease, infection)
o Pregnancies with spontaneous preterm labor must be
distinguished from those complicated by preterm
prematurely ruptured membranes
o Multifetal pregnancy
o Intrauterine infection
o Bleeding
o Placental infarction
o Premature cervical dilation
o Cervical Insufficiency
o Hydramnios
o Uterine fundal abnormalities
o Fetal anomalies
o Maternal illness from infections, autoimmune diseases,
and gestational hypertension
endpoint of premature cervical dilation and effacement and
premature activation of uterine contractions
1. Uterine Distention
o Multifetal distention, hydramnios
o Early uterine distention likely acts to initiate expression of
contraction-associated proteins (CAPs) in the
myometrium (related to gap-junction proteins i.e.
connexins, oxytocin receptors, prostaglandin synthase,
and gastrin – releasing peptides or GRPs that promote
myometrial contractility)
o Prematurely increased stretch and endocrine activity
may initiate events that shift the timing of uterine
activation, including premature cervical ripening
2. Maternal-fetal stress
o Maternal and fetal medical conditions which are severe
enough that put both mother and fetus into jeopardy
(nutrient restriction, diabetes, obesity, infection,
hypertension)
o Activation of the corticotrophin-releasing hormone (CRH)
that cause early loss of uterine quiescence
3. Cervical Dysfunction
o Premature cervical remodeling precedes premature labor
onset and in some instances, cervical dysfunction of
either the epithelia or stromal extracellular matrix is the
underlying cause
o Defect at the stroma or cervical epithelium, which allows
ascending infections that may lead to PPROM
4. Infection
o Intraamniotic infection as a primary cause of preterm
labor in pregnancies with intact membranes accounts for
25 to 40 percent of preterm births
o Transplacental transfer of maternal systemic infection
o Retrograde flow of infection into the peritoneal cavity
(fallopian tubes)
o Ascending infection with bacteria from the vagina and the
cervix

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o Inflammatory Responses
 Drive the pathogenesis of infection-induced
preterm labor
 LPS or other toxins elaborated by bacteria are
recognized by pattern-recognition receptors such
as toll-like receptors
 LPS-induced production of IL-1β in turn promotes
a series of responces
 In many tissues, including myometrium, decidua,
and amnion, IL-1β promotes prostaglandin
formation that induces cervical ripening and loss
of myometrial quiescence
 Proteases such as matrix metalloproteinases
(MMPs) are also induced by IL-1β and fuction to
break down extracellular matrix components such
as collagen or elastic fibers. This disrupts the
structural integrity of fetal membranes and the
cervix
o Origin of Cytokines
 It appears that cytokines produced in maternal
decidua and myometrium will have effects on that
side, whereas cytokines produced in the
membranes or in cells within the amniotic fluid will
not be transferred to maternal tissues
 In general, resident and invading leukocytes
produce the bulk of cytokines in cases of
inflammation resulting from infection.
 Invading leukocytes and certain parenchymal cells
produce cytokines and appear to be the primary
source of myometrial cytokines
 In the cervix, glandular and surface epithelial cells
appear to produce cytokines
 Amniotic cytokines are most likely secreted by
mononuclear phagocytes or neutrophils activated
and recruited into the amniotic fluid
o Vaginal Microbiota
 Genomic analysis has shown that the nonpregnant
vaginal tract hosts a complex microbial community.
These community state types can differ widely
among women who are all healthy. And, the vaginal
microbe changes during normal pregnancy
 Namely, the diversity and richness of microbe
populations are reduced during pregnancy and
become more stable
 Bacterial identification is interpreted as presumptive
evidence that specific microorganisms are more
commonly involved in the induction of preterm labor
B. PRETERM PREMATURE RUPTURE OF MEMBRANES
 Vaginal leakage of fluid (grossly examined through speculum
exam), pooling, or a decrease in the amount of amniotic fluid seen
in ultrasound, before the onset of 37 weeks gestation
 Risk factors:
o Low Socioeconomic income
o BMI <19.8
o Smoking
o History of STIs
o Previous Preterm Birth
o Uterine Overdistention
o Presence of vaginal bleeding
o History of cerclage/ amnio-infusion
 Presence of pooling at the posterior fornix, free flowing fluid (clear
or meconium stained) from the cervical canal
 pH determination (Vaginal pH=4.5 to 5.5) versus amniotic fluid
(7.0 to 7.5)
 Nitrazine test for presence of amniotic fluid changes the color of
the test paper
 Presence of arborization or ferning
 Detection of alpha-feto protein in the vaginal vault
 Identification of carmine indigo dye (injected into the amniotic sac
BACCAY | DAMMAY | CAUILAN | MARQUEZ
Midterm (1st Sem) Preterm Birth
Dr. Trician Villarosa
OBSTETRICS II
via abdominal amniocentesis)
 Molecular Changes
o Increased apoptosis or necroptosis of membrane cellular
components and greater levels of specific proteases in
membranes and amniotic fluid are related to PPROM
o There are proteins involved in the synthesis of mature
cross-linked collagen or matrix proteins that bind
collagen and thereby promote tensile strength. These
proteins are altered in membranes with premature
rupture
 Infection
o Several studies have investigated the incidence of
infection-induced PPROM
o The inflammatory response that leads to membrane
weakening and mediators of this process are currently
areas of research. One goal is to identify early risk
markers for PPROM
C. MULTIFETAL PREGNANCY
 Preterm delivery continues to be the major cause of the
excessive perinatal morbidity and mortality with multifetal
pregnancies
 Uterine distention or stretching
IV. CONTRIBUTING FACTORS
A. PREGNANCY FACTORS
 Several genetic and environmental factors affect the frequency
of preterm labor
 Vaginal Bleeding at 6 to 13 weeks’ gestation both light and
heavy were associated with subsequent preterm labor, placental
abruption, and pregnancy loss before 24 weeks
B. LIFESTYLE FACTORS
 Cigarette Smoking, inadequate maternal weight gain, and illicit
drug use affect the incidence and outcome of low-birthweight
neonates
 Other maternal factors implicated include young or advanced
maternal age, poverty, short stature, and Vitamin C deficiency
 Psychological factors such as depression, anxiety, and chronic
stress are also associated with preterm birth
 One metaanalysis of physical activity found that leisure-time
physical activity was associated with a reduced risk of preterm
birth
C. GENETIC FACTORS
 The recurrent, familial, and racial nature of preterm birth
suggests that genetics may play a casual role
D. PERIODONTAL DISEASE
 Gum inflammation is a chronic anaerobic inflammation that
affects as many as 50 percent of pregnant women in the United
States
 Studies have concluded that periodontal disease was
significantly associated with preterm birth
E. PRIOR PRETERM BIRTH
 The most important risk factor for preterm labor is prior preterm
delivery
 The recurrent preterm delivery risk for women with a preterm first
delivery was 3-fold greater than that of women whose first
neonate was born at term
 Thus, the influence of reproductive history has a profound
prognostic significance for risk of recurrence. Moreover, this may
also influence the supposed benefit attributed to various
interventions described later.
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F. INFECTION
 Antibiotic Prophylaxis
o Given to prevent preterm labor due to microbial invasion
 Bacterial Vaginosis
o Normal, hydrogen peroxide-producing, lactobacillus-
predominant vaginal flora is replaced with anaerobes
o Associated with spontaneous abortion, preterm labor,
PPROM, chorioamnionitis, and amnionic fluid
infection
o Mechanism similar to amnionic fluid infection
o Etiologic Agents: Gardnerella vaginalis, Mobiluncus
specie, Mycoplasma hominis
o Management: Metronidazole 500mg BID x 7days
o Screening and treatment have not prevented preterm
birth
V. DIAGNOSIS
A. SYMPTOMS
 Painful/painless uterine contractions
 Pelvic pressure
 Menstrual-like cramps
 Watery vaginal discharge
 Lower back pain
B. CERVICAL CHANGE
 Asymptomatic cervical dilatation after mid-pregnancy is
suspected to be a risk factor for preterm delivery
 Parity alone is not sufficient to explain cervical dilatation
discovered early in the third trimester
 2cm or 3cm dilatation, higher rates of delivery before 34weeks
 90% with 1cm dilatation delivered within 21 days of the initial
presentation
C. AMBULATORY UTERINE MONITORING
 An external tocodynamometer belted around the abdomen and
connected to an electronic waist recorder allows a woman to
ambulate while uterine activity is recorded
 Results are transmitted via telephone daily
 Women are educated concerning signs and symptoms of
preterm labor, and clinicians are kept apprised of their progress
 Use of this expensive and time-consuming system does not
reduce preterm birth rates and such monitoring is
discouraged
D. FETAL FIBRONECTIN
 Glycoprotein produced in 20 different molecular forms by various
cell types, including hepatocytes, fibroblasts, endothelial cells,
and fetal amnion cells
 Present in high concentrations in material blood and amniotic
fluid
 Functions in intercellular adhesion during implantation and in
maintenance of placental adherence to uterine decidua
 Detected in cervicovaginal secretions in women who have
normal pregnancies with intact membranes at term
 fFM appears to reflect stromal remodeling of the cervix before
labor
E. CERVICAL LENGTH MEASUREMENT
 Progressively shorter cervical canals assessed sonographically
are associated with increased rates of preterm birth
 At 24 weeks – Mean cervical length is 35mm
 Transvaginal cervical sonography
o Not affected by maternal obesity, cervix position, or
shadowing from fetal presenting part
o Performed after 16 weeks’ gestation
 Currently limited to singleton gestations but without a history of
preterm birth and not recommended for multifetal gestations
outside of research trials
BACCAY | DAMMAY | CAUILAN | MARQUEZ
Midterm (1st Sem) Preterm Birth
Dr. Trician Villarosa
OBSTETRICS II
VI. PRETERM BIRTH PREVENTION
A. CERVICAL CERCLAGE
 Prevention of preterm birth remains an elusive goal.
 Cerclage placement may be used to prevent preterm birth in at
least three circumstances.
1. The procedure may benefit women who have a history of
recurrent midtrimester losses and who are diagnosed
with cervical insufficiency.
2. Woman identified during sonographic examination to
have a short cervix.
3. The third indication is a ―rescue‖ cerclage, done
emergently when cervical incompetence is recognized in
women with threatened preterm labor.
 For women with a short cervix incidentally detected by
sonography, the benefit of cerclage placement appears directly
related to whether the woman has a history of prior preterm
birth. In those without a prior preterm birth, cerclage for a
sonographically detected short cervix alone offers no advantage.
 Short cervix is defined as length <25 mm.
 Cerclage significantly prevented preterm birth and improved
composite perinatal mortality and morbidity in women with prior
spontaneous preterm birth, singleton gestation, and cervical
length <25 mm.
 In women with a singleton pregnancy, prior spontaneous
preterm birth before 34 weeks, cervical length <25 mm, and
gestational age <24 weeks, cerclage placement may be
considered. (American College of Obstetricians and
Gynecologists (2016c)
B. PROPHYLAXIS WITH PROGESTOGEN COMPOUNDS
 During human parturition, maternal, fetal, and amnionic fluid
progesterone levels remain elevated. It has been proposed that
human parturition involves functional progesterone withdrawal
mediated by decreased activity of progesterone receptors.
 Administration of progesterone may block preterm labor.
 At present, the reported benefits of either of these progestogen
therapies (17-alpha hydroxyprogesterone caproate (17- OHP-C)
and vaginally administered progesterone) are limited to women
with singleton pregnancies.
 Progesterone prophylaxis specifically in multifetal gestations has
not lowered preterm birth rates
 Criteria for the use of progesterone therapy in singleton
pregnancies are a history of prior preterm birth or no prior
preterm birth but sonographically identified short cervix.
C. PRIOR PRETERM BIRTH AND PROGESTOGEN COMPOUNDS
 17-OHP-C
o A synthetic progestogen, and the first and only drug
approved by the FDA for prevention of recurrent
preterm birth.
METABOLISM
 Metabolism of 17-OHP-C was predominantly mediated by the
CYP3A enzymatic system.
 Other agents that induce or inhibit this enzymatic system as well
as hepatic impairment may alter drug levels.
 17-OHP-C is not converted after administration to the primary
progesterone metabolite, 17α-hydroxyprogesterone. The relative
binding affinity of 17-OHP-C to progesterone receptors
approximates only 30
percent of that by progesterone
 Because synthetic 17-OHP-C is not converted to a naturally
occurring progestogen and is not superior to progesterone in
eliciting a hormonal response via the classic steroid-receptor
mediated pathway, alternative pathways are now being
considered to explain its efficacy.
 17-OHP-C therapy half-life was relatively long (median 16.2
days).
 Pharmacokinetic parameters were affected by maternal body
habitus and varied widely between subjects.
 17-OHP-C crossed the placental barrier and was detectible in
cord plasma 44 days after the last maternal injection.
 Despite this, evidence to date suggests that 17-OHP-C is safe for
the fetus. No abnormalities, including abnormal genitalia, were
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found in a 48-month follow up study of infants exposed in the
2003 MFMU Network trial (Northen, 2007).
D. PROGESTERONE USE WITHOUT PRIOR PRETERM BIRTH
 Spontaneous delivery <34 weeks was significantly reduced by
progesterone therapy.
 Vaginal progesterone, but not 17-OHP-C, appears to benefit
women with a sonographically measured short cervix.
 17-OHP-C did not have local antiinflammatory effects at the
maternal-fetal interface or cervix and did not protect against
endotoxin-induced preterm birth.
 The American College of Obstetricians and Gynecologists
(2016c) concluded that universal cervical length screening in
women without a prior preterm birth is not mandatory. However,
this screening strategy could be considered in the context of
treatment with vaginal progesterone.
THE OPPTIMUM STUDY
 This study of 1228 high-risk women with singleton pregnancies is
the largest to date for vaginal progesterone prophylaxis (Norman,
2016).
 This randomized trial of vaginal progesterone, 200 mg daily from
22–24 weeks to 34 weeks of gestation, was termed the
OPPTIMUM study—dOes Progesterone Prophylaxis To
prevent preterm labor IMprove oUtcoMe?
 High-risk women were defined as those with a prior
spontaneous birth ≤34 weeks or with a cervical length ≤25 mm or
a positive fFN test result combined with other clinical risk factors
for preterm birth.
 The primary outcomes of OPPTIMUM were unique in that both
immediate obstetrical and childhood outcomes were examined.
These were fetal death or birth <34 weeks; a composite of death,
brain injury, or bronchopulmonary dysplasia; and a standardized
cognitive score at 2 years of age.
 Contrary to earlier reports, vaginal progesterone was not
associated with a lower risk of preterm birth or
composite neonatal adverse outcomes. In children at 2 years of
age, vaginal progesterone also had no long-term benefit or harm.
 Thus, evidence is conflicting as to the efficacy of progestogens
across the spectrum of the various specific indications.
 The results of recent studies should prompt a major review of
progesterone use for preterm birth prophylaxis, a search to
identify specific women who might specifically benefit, and a
redoubling of efforts to find alternative strategies to prevent
preterm birth in women at risk.
GEOGRAPHIC-BASED PUBLIC HEALTH-CARE PROGRAMS
 A well-organized prenatal system lowers the preterm birth rate in
high-risk indigent populations.
 Prenatal care is considered one component of a comprehensive
and orchestrated public health-care system that is community-
based.
BACCAY | DAMMAY | CAUILAN | MARQUEZ
Midterm (1st Sem) Preterm Birth
Dr. Trician Villarosa
OBSTETRICS II
VII. MANAGEMENT OF PRETERM PREMATURE RUPTURE OF
MEMBRANES
 A history of vaginal leakage of fluid, either as a continuous
stream or a gush, should prompt a speculum examination to
visualize gross vaginal pooling of amnionic fluid, clear fluid from
the cervical canal, or both.
 Confirmation of PPROM is usually accompanied by sonographic
examination to assess amnionic fluid volume, to identify the
presenting part, and if not p
 Previously determined, to estimate gestational age.
A. NATURAL HISTORY
 Cox and associates (1988) described pregnancy outcomes of
298 consecutive women who gave birth following spontaneously
ruptured membranes between 24 and 34 weeks’ gestation at
Parkland Hospital.
 By the time they presented, 76 percent of the women were
already in labor, and 5 percent were delivered for other
complications. Thus, only 19 percent initially were permitted
expectant management.
 Ultimately, delivery was delayed 48 hours or more after
membrane rupture in only 7 percent of the total study cohort.
There was benefit noted from delayed delivery, however, as
none of the neonates died in this group.
 This contrasted with a neonatal death rate of 80 per 1000 in
preterm newborns delivered within 48 hours of membrane
rupture.
 The time from PPROM to delivery is inversely proportional to the
gestational age when rupture occurs (Carroll, 1995).
B. HOSPITALIZATION
 Most clinicians hospitalize women with ruptured membranes.
 Carlan and coworkers (1993) randomly assigned 67 women with
ruptured membranes to home or hospital management. No
benefits were found for hospitalization, and maternal hospital
stays were reduced by 50 percent in those sent home—14 versus
7 days.
 Investigators emphasized that this study was too small to
conclude that home management was safe in regard to umbilical
cord prolapse.
C. INTENTIONAL DELIVERY
 Before the mid-1970s, labor was usually induced in women with
preterm ruptured membranes because of fear of sepsis.
 Maternal infection risk and fetal prematurity risk vary according to
the gestational age at membrane rupture, and management
decisions hinge on this balance.
 Prolonged latency after membrane rupture was not associated
with a greater incidence of fetal neurological damage. An
important correlate is that infection—specifically
chorioamnionitis—is recognized as a risk factor for development
of neonatal neurological injury (Gaudet, 2001; Wu, 2000).
 Women with rupture of membranes before 37 weeks’ gestation
without contraindications to continuing the pregnancy, a policy of
expectant management with careful monitoring was associated
with better outcomes for both the mother and newborn.
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 Clearly, gestational age is an important consideration. At 24 0/7 to
33 6/7 weeks, expectant management in the absence of
nonreassuring fetal status, clinical chorioamnionitis, or placental
abruption is recommended.
 At 34 0/7 weeks of gestation or greater, delivery is still
recommended by the College for all women with ruptured
membranes.
D. CONSIDERATIONS WITH EXPECTANT MANAGEMENT
 Performance of digital cervical examination
o They compared those who had one or two digital cervical
examinations with women who were not examined. Those
who were examined had a rupture-to-delivery interval of 3
days compared with 5 days in those not examined. This
difference did not worsen maternal or neonatal outcomes.
 Rupture of membranes following second-trimester amniocentesis
is uncommon.
o Pregnancies complicated by PPROM after genetic
amniocentesis resulted in significantly better perinatal
outcomes.
o After counseling, affected women are typically managed
expectantly as outpatients with serial surveillance of
amnionic fluid.
o The mean time to documentation of a normal amnionic fluid
volume after amniocentesis approximated 2 weeks.
 Tocolysis has been used in few studies.
o In women with ruptured membranes and lack of labor,
prophylactic tocolysis does not improve neonatal outcomes
but is associated with greater rates of chorioamnionitis.
o Therapeutic tocolysis—for those with ruptured membranes
and labor—has also not provided significant perinatal
benefit.
 There is uncertainty regarding PPROM in the woman who has
undergone cervical cerclage.
o Cerclage retention for more than 24 hours after preterm
rupture of membranes may be associated with pregnancy
prolongation, however, there is risk of intrauterine infection
and its consequences.
 With PPROM in general, the volume of amnionic fluid remaining
after rupture appears to have prognostic importance in
pregnancies before 26 weeks.
 Virtually all women with oligohydramnios delivered before 25
weeks, whereas 85 percent with adequate amnionic fluid volume
were delivered in the third trimester.
 Carroll and coworkers (1995) observed no cases of pulmonary
hypoplasia in fetuses born after membrane rupture at 24 weeks or
beyond. This suggests that 23 weeks or less is the threshold
 When contemplating early expectant management, consideration
is also given to oligohydramnios and resultant limb compression
deformities.
 In neonates born to women with active herpetic lesions who were
expectantly managed, the infectious morbidity risk appeared to be
outweighed by risks associated with preterm delivery
 Expectant management of women with PPROM and noncephalic
presentation was associated with a higher rate of umbilical cord
prolapse, especially before 26 weeks.
E. CLINICAL CHORIOAMNIONITIS
 Infection is a major concern with membrane rupture.
 If chorioamnionitis is diagnosed, prompt efforts to effect
delivery, preferably vaginally, are initiated.
 Fever is the only reliable indicator for the diagnosis of
Chorioamnionitis. A temperature ≥38°C (100.4°F) accompanying
ruptured membranes has implied infection.
 The diagnosis of suspected intraamniotic infection is made when
the maternal temperature is ≥39.0°C or when the maternal
temperature is 38.0 to 38.9°C and one additional clinical risk
factor is present. Suggested factors include:
o Low parity
o Multiple digital examinations
o Use of internal uterine and fetal monitors
o Meconium-stained amnionic fluid,
o Presence of certain genital tract pathogens (Examples
are group B streptococcus and sexually transmitted
agents.)
BACCAY | DAMMAY | CAUILAN | MARQUEZ
Midterm (1st Sem) Preterm Birth
Dr. Trician Villarosa
OBSTETRICS II
 Isolated maternal fever is defined as any maternal temperature
between 38.0°C and 38.9°C with no additional risk factors
present, and with or without persistent temperature elevation.
 With chorioamnionitis, fetal and neonatal morbidity are
substantively increased.
 Intraamnionic infection in preterm neonates was related to
increased rates of cerebral palsy.(Yoon and colleagues (2000).
F. ANTIMICROBIAL THERAPY
 The proposed microbial pathogenesis for spontaneous preterm
labor or ruptured membranes has prompted investigators to give
various antimicrobials to forestall delivery.
 MFMU Network designed a trial to study expectant management
combined with placebo or with a 7-day antibiotic regimen.
o Treatment included intravenous ampicillin plus
erythromycin every 6 hours for 48 hours, which was
followed by oral amoxicillin plus erythromycin, every 8
hours for 5 days. The women had membrane rupture
between 24 and 32 weeks’ gestation. Neither tocolytics
nor corticosteroids were given.
o Antimicrobial-treated women had significantly fewer
newborns with RDS, necrotizing enterocolitis, and
composite adverse outcomes.
 Other studies have examined the efficacy of shorter treatment
lengths and different antimicrobial combinations. Three-day
treatments compared with 7-day regimens using either ampicillin
or ampicillin-sulbactam appear equally effective in regard to
perinatal outcomes.
 Erythromycin compared with placebo offered a range of
significant neonatal benefits.
 The amoxicillin-clavulanate regimen was not recommended
because of its association with an increased incidence of neonatal
necrotizing enterocolitis.
G. CORTICOSTEROIDS TO ACCELERATE FETAL LUNG
MATURITY
 A single course of corticosteroids is now recommended for
pregnant women with ruptured membranes between 24 0/7 and
34 0/7 weeks’ gestation.
 As with periviability, a single course of corticosteroids as early as
23 0/7 weeks in those who are at risk for preterm delivery within 7
days may be considered.
H. MEMBRANE REPAIR
 Tissue sealants are used for various purposes in medicine,
including achieving surgical hemostasis but data are currently
insufficient to evaluate sealing procedures for ruptured
membranes.
VII. MANAGEMENT OF PRETERM LABOR
 Women with signs and symptoms of preterm labor with intact
membranes are managed similarly to those with PPROM.
 If possible, delivery before 34 weeks’ gestation is delayed.
A. AMNIOCENTESIS TO DETECT INFECTION
 Intraamnionic infection can be confirmed with a positive result.
There is little utility for routine amniocentesis.
B. CORTICOSTEROIDS FOR FETAL LUNG MATURATION
 Glucocorticosteroids accelerate lung maturation in preterm sleep
fetuses.
 Corticosteroid therapy was effective in lowering the incidence of
RDS and neonatal mortality rates if birth was delayed for at least
24 hours after initiation of betamethasone.
 Treatment was associated with lower rates of perinatal death,
neonatal death, RDS, intraventricular hemorrhage, necrotizing
enterocolitis, need for mechanical ventilation and systemic
infection in the first 48 hours of life.
 A single course corticosteroids is currently recommended for
women between 24 and 34 weeks who are at risk for delivery
within 7 days.
 Betamethasone and dexamethasone appear to be equivalent for
fetal lung maturation.
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 For betamethasone, 12 mg doses and each dose is given
intramuscularly 24 hours apart. With dexamethasone, 6 mg doses
are given IM every 12 hours for four doses.
 A single course of betamethasone is recommended for women
between 34 weeks and 36 6/7 weeks gestation at risk of preterm
birth within 7 days, and who have not received a previous course
of antenatal corticosteroids.
 A single repeat course of antenatal corticosteroids should be
considered in women who are <34 weeks gestation who are at
risk of preterm delivery within 7 days, whose prior antenatal
corticosteroid was previously administered more than 14 days.
C. MAGNESIUM SULFATE FOR NEUROPROTECTION
 Very low birthweight neonates whose mothers were treated with
magnesium sulfate for preterm labor or preeclampsia were found
to have a reduced incidence of cerebral palsy at 3 years.
 Magnesium Sulfate is a calcium antagonist and decrease
myometrial repolarization and contractility.
 MgSO4 4-6 g/SIVP over 20 mins, then 2 g/IV/hour infusion,
increase by 1g/hr until patient has <1 contraction in 10 mins; max
dose of 4g/hr
 Contraindications: myasthenia gravis, hypoglycemia
D. BED REST
 Bed rest for 3 days or more increased thromboembolic
complications to 16 per 1000 women compared with only 1 per
1000 with normal ambulation.
E. EMERGENCY OR RESCUE CERCLAGE
 For women facing a poor pregnancy prognosis due to cervical
dilation at midgestation, it is reasonable to offer emergency or
rescue cerclage with appropriate counseling.
F. TOCOLYSIS TO TREAT PRETERM LABOR
 Tocolytic agents do not markedly prolonged gestation but may
delay delivery in some women for up to 48 hours. This may allow
transport to an obstetrical center with higher-level neonatal care
and permit time for a course of corticosteroid therapy but this
treatment do not improve perinatal outcome rates.
 Beta-adrenergic agonists, magnesium sulfate, calcium channel
blockers, or indomethacin are the recommended tocolytic agents
for this short-term use.
 Most do not recommend use of tocolytics after 33 weeks’
gestation and as maintenance after acute therapy.
 In many women, tocolytics stop contractions temporarily but
rarely prevent preterm birth.
G. BETA-ADRENERGIC RECEPTOR AGONIST
 Ritodrine
o Neonates whose mothers were treated with ritodrine
for threatened preterm labor had lower rates of
preterm birth and its complications.
 Beta-agonist drug infusion has resulted in serious and even
fatal maternal side effects.
 Beta-agonists agents cause retention of sodium and water, and
with time—usually 24 to 48 hours—these can cause volume
overload. The drugs have been implicated in increased
capillary permeability, cardiac rhythm disturbances, and
myocardial ischemia.
 Terbutaline:
o Is a betamimetics (increase camp causing smooth
muscle relaxation)
o 0.25mg SC every 30 minutes up to 1 mg in 4 hours
o 2.5 mcg/min IV up to 30 mcg/min
o Contraindications: maternal tachycardia, thyroid
disease
o Maternal Effects: arrythmia, pulmonary edema, MI,
hypotension, tachycardia, hyperglycemia,
hyperinsulinemia, antidiuresis, hyper/hypokalemia,
nervousness,
BACCAY | DAMMAY | CAUILAN | MARQUEZ
Midterm (1st Sem) Preterm Birth
Dr. Trician Villarosa
OBSTETRICS II
nausea/vomiting.
o Recommended only for short term inpatient use as a
tocolytic or as acute therapy of uterine tachysystole.
H. MAGNESIUM SULFATE
 Calcium antagonist and decrease myometrial repolarization
and contractility
 MgSO4 4-6g/SIVP over 20 min, then 2 g/IV/hour infusion,
increase by 1g/hr until patient has <1 contraction in 10 min;
max dose of 4g/hr
 Contraindication: myasthenia gravis, hypocalcemia, heart
block, renal failure
 Maternal effects: flushing, N/V, headache, ileus,
hypocalcemia, pulmonary edema, cardiac arrest (TOXICITY
SIGNS: somnolence, muscle paralysis, loss of patellar
reflexes, respiratory depression)
 Fetal effects: lethargy, hypotonia, respiratory depression,
demineralization with prolonged use, death
 Prolonged use of magnesium sulfate to arrest preterm labor
can cause bone thinning and fractures in fetuses exposed for
more than 5 to 7 days.
I. PROSTAGLANDIN INHIBITORS
 Indomethacin:
o A nonselective cyclooxygenase inhibitor that halts
contractions and delay preterm birth. Indomethacin use
should be limited to 24 to 48 hours because of
concerns for oligohydramnios, which can develop with
therapeutic doses.
o 50mg rectal or 50-100 mg po loading dose, then 25-
50mg po q6hours for 48 hours
o Causes renal or hepatic damage, pud, rectal bleeding
J. CALCIUM-CHANNEL BLOCKERS
 Prevents extracellular Ca influx into the myometrium
 Nifedipine:
o 30 mg/tab loading dose then 10-20mg every 4-6 hours
o Contraindicated (cardiac disease, use with caution in renal
disorders, hypotension, transient tachycardia, palpitation,
cardiac toxicity)
o Maternal side effects (flushing, headache, dizziness,
nausea, transient hypotension, transient bradycardia,
palpitation cardiac toxicity)
o Fetal effects (fetal distress, sudden fetal death)
o safer and more effective tocolytic agent than beta agonist
drugs. This drug in combination with magnesium for
tocolysis is potentially dangerous because nifedipine
enhances the neuromuscular blocking effects of
magnesium, which can interfere with pulmonary and
cardiac function.
 Betamimetics (increases cAMP causing smooth muscle
relaxation)
o Terbutaline
K. ATOSIBAN
 Is an oxytocin-receptor antagonist and was linked with neonatal
morbidity
 6.75 mg bolus over 1 minute then 18mg/hr infusion for 3 hours
and then 6mg/hr for up to 45 hours
L. LABOR
 Whether preterm labor is induced or spontaneous, abnormalities
of fetal heart rate and uterine contractions are sought.
 Fetal tachycardia, especially with ruptured membranes, is
suggestive of sepsis.
 Metabolic acidemia raised the risks related to prematurity in
neonates delivered prior to 34 weeks’ gestation.
 Intrapartum acidosis, umbilical artery blood pH <7.0--- had an
important role in neonatal complications.
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 Group B streptococcal infections are common and dangerous in
the preterm neonate, and antimicrobial prophylaxis should be
provided.

M. PREVENTION OF INTRACRANIAL HEMORRHAGE

 Preterm newborns frequently have intracranial germinal matrix

bleeding that can extend to more serious intraventricular
hemorrhage and it was hypothesized that CS delivery to obviate
trauma from labor and vaginal delivery might prevent these
complications.

STEROIDS
 Single dose of steroids is recommended for women between 24
weeks and 33 6/7 weeks gestation at risk of preterm delivery
within days (including ROM and multiple gestation)

References
 Cunningham, F. G. (2018). Williams Obstetrics 25th Edition.
New York: McGraw-Hill Education. Williams Obstetrics (25th
Edition), Cunningham, Gary., Leveno, Kenneth J. and
Gilstrap, Larry C., 2018. Blacklick, USA: McGraw-Hill
Professional Publishing.
 Dr. Trician Villarosa's lecture

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th
WILLIAM’S GUIDE 24 EDITION
42–1. The term small-for-gestational age is generally used to
designate newborns whose birth weight is less than what percentile?
a. 3% b. 5% c. 10% d. 15%
42–2. The neonatal mortality rate is expected to be lowest for
newborns born at which of the following gestational ages?
a. 36 weeks 6 days c. 39 weeks 6 days
b. 37 weeks 4 days d. 41 weeks 2 days
42–3. Late-preterm births, defined as those between 34 and 36
weeks’ gestation, compose what percentage of all preterm births?
a. 35% b. 50% c. 70% d. 85%
42–4. Which of the following etiologies is largely responsible for the
increase in preterm birth rates in the United States during the past 20
years?
a. Triplet pregnancies
b. Spontaneous preterm labor
c. Preterm rupture of fetal membranes
d. Indicated (iatrogenic) preterm birth
42–5. After achieving a birth weight of at least 1000 grams, neonatal
survival rates reach 95 percent at approximately what gestational
age with regard to newborn sex?
a. 28 weeks for both males and females
b. 30 weeks for both males and females
c. 28 weeks for females and 30 weeks or males
d. 30 weeks for females and 28 weeks or males
42–6. Cesarean delivery for neonates born at the threshold of
viability has been demonstrated to protect against which of the
following adverse newborn outcomes?
a. Seizures
b. Intraventricular hemorrhage
c. Respiratory distress syndrome
d. None of the above
42–7. Compared with neonates born at term, the risks to those born
between 34 and 36 weeks’ gestation include which of the following?
a. Increased serious morbidity and mortality rates
b. Equivalent serious morbidity and mortality rates
c. Increased serious morbidity but decreased mortality rates
d. Increased serious morbidity but equivalent mortality rates
42–8. Maternal stress may potentiate preterm labor by which of the
following mechanisms involving corticotropin-releasing hormone
(CRH)?
a. Increased production of maternal-derived CRH
b. Decreased production of maternal-derived CRH
c. Increased production of placental-derived CRH
d. Decreased production of placental-derived CRH
42–9. A 26-year-old G2P1 presents at 29 weeks’ gestation
complaining of leaking clear fluid from her vagina. A speculum
examination reveals scant pooling of fluid in the posterior vagina,
and the microscopic analysis of the fluid reveals a pattern. You
diagnose premature rupture of the fetal membranes (PROM). Of the
known risk factors for this condition, which is most commonly
identified in such patients?
a. Smoking
b. Low socioeconomic status
c. Prior pregnancy complicated by PROM
d. None of the above
42–10. All EXCEPT which of the following lifestyle factors has been
identified as an antecedent for preterm labor?
a. Frequent coitus
b. Illicit drug use
c. Young maternal age
d. Inadequate maternal weight gain
42–11. A 24-year-old G2P1 at 6 weeks’ gestation presents for
prenatal care and complains of bleeding, painful gums. Her obstetric
history is significant for two prior preterm births. You counsel her
that periodontal disease treatment in pregnancy has been proven to
have which of the following favorable outcomes?
a. Improved periodontal health
b. Decreased rates of preterm birth
c. Decreased rates of low birth weight
d. All of the above
BACCAY | DAMMAY | CAUILAN | MARQUEZ
Midterm (1st Sem) Preterm Birth
Dr. Trician Villarosa
Obstetric II
42–12. Intervals shorter than how many months between
pregnancies have been associated with an increased risk for preterm
birth?
a. 18 b. 24 c. 36 d. 48
42–13. A 33-year-old G2P2 is contemplating pregnancy but is
hesitant since her two prior deliveries occurred at 28 and 29 weeks’
gestation, respectively. You inform her that her risk for a recurrent
preterm birth less than 34 weeks’ gestation approximates what
value?
a. 15% b. 25% c. 40% d. 70%
42–14. A 22-year-old G2P1 at 14 weeks’ gestation complains of a
malodorous vaginal discharge. You recommend antimicrobial
treatment for this condition for what principal reason?
a. Resolution of symptoms
b. Prevention of preterm birth
c. Avoidance of spontaneous abortion
d. Treatment of intraamnionic infection
42–15. Characteristics of Braxton Hicks contractions can include all
EXCEPT which of the following?
a. Painful c. Irregular pattern
b. Non rhythmical d. Associated with cervical change
42–16. Performance of routine cervical examinations at each prenatal
care visit has been demonstrated to effect what outcome?
a. Decreased preterm birth rate
b. Increased interventions for preterm labor
c. Increased rate of premature rupture of fetal membranes
d. None of the above
42–17. Which of the following is true regarding sonographic
evaluation of the cervix as a part of the assessment for preterm birth
risk?
a. Transabdominal approach is preferred to avoid cervical manipulation.
b. In research populations, women with progressively shorter cervices had
increased preterm labor rates.
c. Women with prior preterm birth and with cervical lengths equal to 35
mm will benefit from cerclage placement.
d. All of the above
42–18. Potential indications to perform the cerclage include which of
the following?
a. Recurrent mid trimester losses
b. Short cervix identified sonographically
c. Threatened preterm labor with cervical dilatation
d. All of the above
42–19. 17-Hydroxyprogesterone caproate has been demonstrated in
a randomized, controlled trial to decrease the preterm birth rate in
women with which of the following characteristics?
a. Nulliparous b. Carrying twins
c. Prior preterm birth d. None of the above
42–20. Based on the known natural history of preterm premature
ruptured membranes, approximately what percentage of women will
be delivered within 48 hours of membrane rupture when this
complication occurs between 24 and 34 weeks’ gestation?
a. 20% b. 40% c. 70% d. 90%
42–21. A 20-year-old primigravida at 18 weeks’ gestation
presents after she noticed a gush of fluid from her vagina. You
confirm the diagnosis of preterm rupture of the fetal membranes.
Sonographic evaluation confirms anhydramnios. In the unlikely
event that she remains undelivered at a viable gestational age,
perinatal survival would be unlikely because of underdevelopment of
what organ system?
a. Brain b. Lungs c. Heart d. Kidneys
42–22. What is the only reliable indicator of clinical chorioamnionitis
in women with preterm rupture of the fetal membranes?
a. Fever c. Fetal tachycardia
b. Leukocytosis d. Positive cervical or vaginal cultures
42–23. Several antibiotic regimens have been used to prolong the
latency period in women with preterm rupture of the fetal membranes
who are attempting expectant management. Which antibiotic should
be avoided in this setting because it has been associated with an
increased risk of necrotizing enterocolitis in the newborn?
a. Ampicillin b. Amoxicillin c. Erythromycin d. Amoxicillin-clavulanate
42–24. A 25-year-old primigravida at 34 weeks and 5 days’ gestation
by certain dating criteria is found to have preterm rupture of the fetal
membranes. What is the most appropriate management strategy?
a. Expedited delivery
b. Expectant management
c. Administer a course of corticosteroids followed by delivery
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d. Expectant management unless fetal lung maturity is confirmed 42–7. A 25-year-old G2P1 presents at 23 weeks and 3 days’ gestation
42–25. Corticosteroids administered to women at risk for preterm with painful contractions. Her cervix is dilated to 3 cm. Which
birth have been demonstrated to decrease rates of respiratory interventions should be considered based on her presentation?
distress if the birth is delayed for at least what amount of time after a. Magnesium sulfate c. Cesarean delivery for fetal indications
the initiation of therapy? b. Corticosteroid therapy d. All of the above
a. 12 hours b. 24 hours c. 36 hours d. 48 hours 42–8. Approximately what percentage of all preterm births in the
42–26. When antimicrobials have been administered to forestall United States occurs after 34 weeks’ gestation?
preterm birth in women with preterm labor, rates of which of the a. 30% b. 50% c. 70% d. 90%
following untoward perinatal outcomes have been consistently 42–9. Of the responses listed below, which complication is least
reduced? commonly associated with preterm delivery?
a. Neonatal death c. Chronic lung disease a. Hypertension c. Placental abruption
b. Cerebral palsy d. None of the above b. Fetal complications d. None of the above
42–27. Although bed rest is commonly prescribed for women 42–11. Which of the following placental hormones may play a role in
deemed to be at increased risk for preterm birth, limited data exist to preterm birth caused by maternal–fetal
support a benefit of this recommendation. Which of the following stress?
negative outcomes have been reported in pregnant women placed on a. Estrogen c. Insulin-like growth hormone
bed rest compared with those without this restriction? b. Human placental lactogen d. Corticotropin-releasing hormone
a. Greater bone loss c. Greater maternal weight gain 42–12. Which of the following bacteria may enhance the risk for
b. Impaired fetal growth d. Higher rates of preeclampsia preterm birth by secretion of hyaluronidase?
42–28. A 21-year-old primigravida presents at 28 weeks’ gestation in a. Escherichia coli c. Bacterial vaginosis
active preterm labor, and intravenous terbutaline is administered for b. Peptostreptococcus d. Group B streptococcus
tocolysis. Approximately 2 hours after therapy initiation, she begins 42–13. Which of the following enzymes is not involved in the
to cough, and her peripheral oxygen saturation is noted to be 80 inflammatory cascade by which infection induces preterm labor?
percent. In which of the following clinical settings is the risk for this a. IL-4 b. IL-8 c. Tumor-necrosis factor alpha d. All of the above
complication increased? 42–14. Which of the following bacteria is frequently detected
a. Twin pregnancy c. Concurrent administration o corticosteroids in the amnionic fluid of women with preterm labor?
b. Maternal sepsis d. All of the above a. Mycoplasma hominis c. Ureaplasma urealyticum
42–29. What reversible complication can be seen when indomethacin b. Gardnerella vaginalis d. All of the above
is used for tocolysis longer than 24 to 48 hours? 42–15. Which of the following lifestyle factors is not associated with
a. Oligohydramnios c. Neonatal necrotizing enterocolitis preterm birth?
b. Placental abruption d. Neonatal intraventricular hemorrhage a. Poverty c. Vitamin D deficiency
42–30. The combination of nifedipine with what other tocolytic agent b. Short stature d. Advanced maternal age
can potentially cause dangerous neuromuscular blockade? 42–16. A 32-year-old G2P1 presents at 16 weeks’ gestation for
a. Atosiban b. Terbutaline c. Indomethacin d. Magnesium sulfate prenatal care. She describes a history of preterm premature rupture
42–31. A 28-year-old primigravida at 27 weeks’ gestation presents of membranes in her last pregnancy with delivery at 31 weeks’
with regular painful uterine contractions, and her cervix is 8 cm gestation. How significantly increased is her preterm birth risk in her
dilated. The fetus has a vertex presentation. The fetal heart rate current pregnancy based on this history?
tracing is reassuring. Which of the following procedures will help a. 2-fold increase c. 4-fold increase
decrease the risk for intraventricular hemorrhage in her neonate? b. 3-fold increase d. Her recurrent preterm birth risk is not increased
a. Episiotomy c. Forceps-assisted vaginal delivery 42–18. You perform a routine cervical exam on a 39-year-old G3P2 at
b. Cesarean delivery d. None of the above 30 weeks’ gestation. You find her cervix to be 2 to 3 cm dilated. She
42–32. Although the efficacy is somewhat controversial, intrapartum denies having any contractions, discharge, pelvic pain or pressure.
administration of magnesium sulfate to women who deliver preterm What is her chance of a preterm delivery before 34 weeks’ gestation?
has been demonstrated to reduce rates of which of the following a. 5% b. 15% c. 25% d. 35%
neonatal outcomes? 42–19. Which of the following is true regarding transvaginal
a. Cerebral palsy c. Neonatal seizure activity sonographic evaluation of the cervix as a part of the assessment for
b. Necrotizing enterocolitis d. Bronchopulmonary preterm labor?
a. It can be performed any time after 14 weeks’ gestation.
WILLIAM’S GUIDE 25th EDITION b. It is not affected by maternal obesity, cervix position, or shadowing.
42–1. What is the definition of very low birthweight? c. The American College of Obstetricians and Gynecologists recommends
a. <500 grams c. 1000 to 1500 grams it for all women with a history of a spontaneous preterm birth.
b. 500 to 1000 grams d. 1500 to 2500 grams d. All of the above
42–2. What is the approximate preterm birth rate in the United States 42–21. The Food and Drug Administration approved 17-
based on the most recently available data (2015)? hydroxyprogesterone caproate for the prevention of recurrent
a. 9.5% b. 10.0% c. 10.5% d. 11.0% preterm birth based on a 2003 Maternal- Fetal Medicine Units (MFMU)
42–3. You deliver a 17-year-old G1 at 28 weeks’ gestation following Network study performed by Meis et al. What was one of the major
preterm labor. She gives birth to a female infant weighing 1090 criticisms of this study?
grams who is immediately taken to the neonatal intensive care unit a. It was underpowered
for evaluation. What would you tell her is the approximate survival b. Injections were not initiated until 16 weeks’ gestation
rate for her infant? c. There was an unexpectedly high preterm delivery rate in the placebo
a. 85% b. 90% c. 95% d. 99% arm
42–4. An infant born at 25 weeks’ gestation is at risk for all except d. All of the above
which of the following complications? 42–22. A recent study by Nelson et al showed that which of the
a. Asthma c. Blood cancers following complications might be increased in pregnant women
b. Blindness d. Pulmonary hypertension using 17-hydroxyprogesterone caproate to prevent recurrent preterm
42–5. What percentage of infants born at 22 weeks’ gestation is birth?
expected to survive without neurodevelopmental impairment? a. Depression c. Gestational diabetes
a. 0.5% b. 1.0% c. 1.5% d. 2.0% b. Hypertension d. Urinary tract infections
42–6. At what gestational age does the Obstetric Care Consensus 42–23. A 23-year-old G1 is incidentally noted to have a cervical
document recommend consideration of neonatal resuscitation? length of 18 mm at 21 weeks’ gestation. According to available
a. 21 weeks’ gestation c. 23 weeks’ gestation research, which of the following therapies could be offered to
b. 22 weeks’ gestation d. 24 weeks’ gestation potentially decrease her chance of preterm birth?
a. Cerclage c. 17-hydroxyprogesterone caproate
b. Vaginal progesterone d. None of the above

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42–24. In women who experience preterm premature rupture of

membranes between 24 and 34 weeks’ gestation, what percentage
might be expected to still be pregnant 48 hours after rupture?
a. 5–10% c. 15–20%
b. 10–15% d. 20–25%
42–25. A pregnant woman presents at 32 weeks and 5 days’
gestation complaining of mild contractions and heavy discharge.
You perform a speculum exam, which demonstrates pooling in the
posterior fornix. Which of the following interventions would not be
considered based on the clinical presentation?
a. Antimicrobials c. Magnesium sulfate
b. Corticosteroids d. Expectant management
42–26. What appears to be the gestational age threshold for lung
hypoplasia in women with early membrane rupture?
a. 19 weeks’ gestation c. 23 weeks’ gestation
b. 21 weeks’ gestation d. 25 weeks’ gestation
42–27. Which of the following neonatal outcomes was potentially
improved following antimicrobial therapy for pregnant woman with
premature rupture of membranes before 35 weeks’ gestation?
a. Improved survival
b. Decreased risk for sepsis
c. Decreased risk for intracranial hemorrhage
d. Decreased risk for respiratory distress syndrome
42–28. Which of the following drugs would not be recommended
either alone or in combination for treatment of preterm premature
rupture of membranes?
a. Amoxicillin
b. Erythromycin
c. Ampicillin-sulbactam
d. None of the above
42–29. A pregnant patient is transferred to your facility because of
concerns for preterm labor at 35 weeks’ gestation. She received a
single course of corticosteroids prior to transfer. What neonatal
complication is her infant potentially at greater risk for?
a. Sepsis
b. Hypothermia
c. Hypoglycemia
d. Transient tachypnea of the newborn
42–30. Treatment with magnesium sulfate is often used for
neuroprotection for women at risk for delivery prior to 32 weeks’
gestation. Approximately how many women need to be treated with
magnesium to prevent one case of cerebral palsy?
a. 65
b. 70
c. 75
d. 80
42–31. Which of the following is a potential consequence of bed rest
for suspected preterm labor?
a. Bone loss
b. Venous thromboembolism
c. Increased risk for preterm delivery
d. All of the above
42–34. Which of the following is true regarding indomethacin use in
pregnancy?
a. It can only be administered orally
b. It can lead to reversible oligohydramnios
c. It lowers the risk for necrotizing enterocolitis
d. All of the above
42–35. Cesarean delivery would be expected to decrease the risk for
intracranial hemorrhage in which of the following scenarios?
a. Estimated fetal weight <1000 grams
b. Estimated fetal weight <1500 grams
c. Estimated fetal weight <2000 grams
d. None of the above

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