A 29-year-old woman, gravida 1 para 0, comes to the emergency department at 33 weeks gestation with contractions. The patient was seen in the emergency department 5 days ago for preterm contractions. At that time the tocometer showed contractions every 5 minutes. Her cervix was found to be closed, long, and posterior. Nucleic acid amplification testing of the cervix for Neisseria gonorrhea and Chlamydia trachomatis, rectovaginal culture for Group B Streptococcus, and a urine culture were all negative. After several hours the contractions subsided. A reexamination of the cervix showed no change and the patient was discharged. Today, the patient has had contractions of increasing intensity every 3 minutes but no vaginal bleeding or rupture of membranes. She has no medical problems or previous surgery. The patient has no drug allergies and takes a prenatal vitamin daily. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 88/min. Fetal heart rate monitoring shows no abnormalities. Tocometer shows contractions every 3 minutes. A pelvic examination shows the cervix to be 5 cm dilated. A bedside ultrasound confirms a vertex presentation. Which of the following is the best next step in management of this patient?

Question

A 29-year-old woman, gravida 1 para 0, comes to the emergency department at 33 weeks gestation with contractions.  The patient was seen in the emergency department 5 days ago for preterm contractions.  At that time the tocometer showed contractions every 5 minutes.  Her cervix was found to be closed, long, and posterior.  Nucleic acid amplification testing of the cervix for Neisseria gonorrhea and Chlamydia trachomatis, rectovaginal culture for Group B Streptococcus, and a urine culture were all negative.  After several hours the contractions subsided.  A reexamination of the cervix showed no change and the patient was discharged. Today, the patient has had contractions of increasing intensity every 3 minutes but no vaginal bleeding or rupture of membranes.  She has no medical problems or previous surgery.  The patient has no drug allergies and takes a prenatal vitamin daily.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 88/min.  Fetal heart rate monitoring shows no abnormalities.  Tocometer shows contractions every 3 minutes.  A pelvic examination shows the cervix to be 5 cm dilated.  A bedside ultrasound confirms a vertex presentation.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c03f_a651_8f63_3b202e9e9d6b_MD0005_00 This patient presents with preterm labor, defined as regular uterine contractions resulting in cervical change (eg, dilation) at <37 weeks gestation. The majority of cases of preterm labor are spontaneous; however, associated risk factors include a history of prior preterm labor, extremes of maternal age, uterine malformations (eg, leiomyoma), and multifetal gestation. The management of preterm labor involves inhibition of uterine contractions (eg, tocolysis) for prolongation of the pregnancy to maximize fetal protection and development. Variations in management are dependent on gestational age; an earlier gestational age is associated with increased morbidity and mortality, thereby requiring more extensive intervention. Between 32 and 34 weeks gestation, management includes corticosteroids, tocolytics, and penicillin. Intramuscular betamethasone, a corticosteroid, is indicated at <37 weeks gestation as it decreases the risk of respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, and neonatal mortality. Tocolysis between 32 and 34 weeks gestation is with nifedipine, a calcium channel blocker. Penicillin is indicated in patients with either a positive or unknown Group B Streptococcus (GBS) rectovaginal culture to prevent neonatal infection. This patient has a recent negative GBS rectovaginal culture and does not require GBS prophylaxis with penicillin (Choice C). (Choice B) Intravenous magnesium sulfate is used for fetal neuroprotection at <32 weeks gestation as it has been shown to decrease the incidence of cerebral palsy. Magnesium sulfate is no longer indicated for tocolysis. (Choice D) Indomethacin, a cyclooxygenase inhibitor, is indicated for tocolysis at <32 weeks gestation. Indomethacin is contraindicated at >32 weeks gestation due to risk of oligohydramnios and premature closure of the fetal ductus arteriosus. (Choice E) Vaginal progesterone is indicated to prevent preterm delivery in patients with an incidental short cervix (<2 cm) found on second trimester ultrasound (18-24 weeks gestation). It does not inhibit active, acute labor.Educational objective: Preterm labor is defined as regular uterine contractions resulting in cervical change at <37 weeks gestation. Intramuscular corticosteroids (eg, betamethasone) are indicated at <37 weeks gestation to decrease the risk of neonatal respiratory distress, necrotizing enterocolitis, and intraventricular hemorrhage associated with prematurity. References: Practice bulletin no. 159: management of preterm labor. (http://www.ncbi.nlm.nih.gov/pubmed/26695585)

A 29-Year-Old Woman, Gravida 1 Para 0, Comes to the Emergency