OBSTETRICS II

3D PRETERM LABOR AND BIRTH

OBII-15 Dr. Dela Cruz | September 17, 2019

DEFINITION OF TERMS o Philippines ranks 8th out of 184 for the number of
AS TO SIZE babies born prematurely and, 17th for total number
1) Small for Gestational Age (SGA)/ Fetal-Growth of deaths due to complications from preterm birth
Restriction/ Intrauterine Growth Restriction o 48% of children who die under age 5years are
(IUGR) newborns, and 39% of these die from preterm
 newborns whose birthweight is <10th percentile complications, making this the leading cause of
for gestational age newborn mortality
2) Large for Gestational Age (LGA) o In 2011, 11,290 deaths due to preterm complications
 newborns whose birthweight is >90th percentile (31 deaths everyday)
for gestational age
3) Appropriate for Gestational Age (AGA) Major Short- and Long-Term Problems in Very-Low-
 newborns whose weight is between the 10th Birth weight Infants
and 90th percentiles

AS TO WEIGHT
a. Low Birth Weight
- neonates who are born too small weighing
1500 to 2500 g
b. Very Low Birth Weight
- between 1000 and 1500 g
c. Extremely Low Birth Weight
- between 500 and 1000 g

AS TO AOG
A. PRETERM OR PREMATURE BIRTH
 neonates who are born too early
 delivery before 37 completed weeks
 Early Preterm: before 33 6/7 weeks
 Late Preterm: 34 – 36 6/7 weeks (>70% of all
preterms) THRESHOLD OF VIABILITY
B. TERM BIRTH  The lower limit of fetal maturation compatible with
 Early Term: 37 – 38 6/7 weeks extrauterine survival
 Late Term: 39 – 40 6/7 weeks  Currently lies between 20 and 26 weeks’ gestation
C. POST TERM BIRTH  Neonates are described as fragile and vulnerable
 >42 weeks because of immature organ systems
o brain injury from hypoxic-ischemic injury and
PREMATURITY sepsis brain hemorrhage white-matter
 Represents incomplete development of various injury periventricular leukomalacia poor
organ systems at birth brain growth neurodevelopmental
impairment
WHO KEY FACTS
 Associated morbidities include intellectual
o 15 M babies are born pre term annually
disability, cerebral palsy, blindness, seizures, and
o Pre term birth complications are the leading cause of spastic quadriparesis
death among children under 5 years of age (nearly  Pose various complex, medical, social and ethical
1M deaths in 2013)
considerations
o ¾ could have been saved with current cost effective
 ACOG 2012 – those born at 22 – 25 weeks
interventions
o Across 184 countries, rate of preterm birth is 5-18%
o 350,000 preterm births in the Philippines annually
o Preterm birth is the world’s largest killer of babies in
2012

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 OBII-15 PRETERM LABOR AND BIRTH
General Guidelines for Obstetrical Interventions for ADDITIONAL CAUSES:
Threatened and Imminent Periviable Delivery o Cervical Dysfunction - premature cervical
remodeling
o Infection
 Bacteria can gain access to intrauterine tissues
through:
(1) transplacental transfer of maternal systemic
infection
(2) retrograde flow of infection into the
peritoneal cavity via the fallopian tubes
(3) ascending infection with bacteria from the
vagina and cervix

ANTECEDENTS AND CONTRIBUTING FACTORS

 Cesarean delivery at the threshold of viability I. PREGNANCY FACTORS (Threatened Abortion)
o Controversial  Vaginal bleeding in early pregnancy is
o Was not protective against poor outcomes associated with increased adverse outcomes
(neonatal death, intraventricular hemorrhage,  Associated with subsequent preterm labor,
seizures, respiratory distress and subdural placental abruption and pregnancy loss prior to
hemorrhage) 24weeks
II. LIFESTYLE FACTORS
 Cigarette smoking
Obstetrical Complications Associated With Late-  Inadequate maternal weight gain
Preterm Births  Illicit drug use
 Extremes of maternal weight (underweight and
obese mothers)
 Young or advanced maternal age
 Poverty
 Short stature
 Vitamin C deficiency
 Psychological factors: depression, anxiety, and
chronic stress
 Occupational factors: working long hours and
hard physical labor (prolonged walking/ standing,
strenuous working conditions)
 Aerobic exercise in normal-weight women with
uncomplicated singleton pregnancies is safe and not
CAUSES OF PRETERM BIRTH associated with preterm birth
Four direct causes for preterm births: III. GENETIC FACTORS
(1) Spontaneous unexplained preterm labor with intact  Immunoregulatory genes in potentiating
membranes (40 – 45%) chorioamnionitis
(2) Idiopathic preterm premature rupture of membranes  Birth Defects
(PPROM) (30 – 35%) IV. INTERVAL BETWEEN PREGNANCIES
(3) Delivery for maternal or fetal indications  Intervals <18 months and >59 months linked
 Maternal–Fetal Stress which can be caused by with SGA and preterm birth
premature activation of the placental–adrenal V. PRIOR PRETERM BIRTH
endocrine axis  Most important risk factor for preterm labor
 Stressors - nutrient restriction, obesity, infection,  Recurrent preterm delivery risk: 3fold increase
diabetes and psychological duress like racial  70% of the recurrent births occurred within 2
discrimination, childhood stress, depression or weeks of the gestational age of the prior preterm
PTSD delivery
(4) Twins and higher-order multifetal births (early uterine  Risk of recurrent preterm birth is influenced by
distention causes contraction-associated protein (CAP) three factors
gene expression) o frequency of prior preterm deliveries
o severity as measured by gestational age
o order in which the prior preterm delivery
occurred
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 OBII-15 PRETERM LABOR AND BIRTH
VI. INFECTION TRICHOMONIASIS AND CANDIDA VAGINITIS
 Periodontal disease – gum inflammation  Etiologic Agent: Trichomonas vaginalis
 Intrauterine infections (25-40%) – triggers  Diagnostic Features:
preterm labor by activation of the innate o Demonstration of Trichomonads by wet mount
immune system of vaginal secretions (most accurately by
 Antibiotic Prophylaxis culture using Diamond Medium, Direct
o Given to prevent preterm labor due to Immunofluorescent; Monoclonal Ab staining is
microbial invasion sensitive and specific)
 Management:
o Routine screening and treatment is not
recommended (individualized)
o Metronidazole 25mg TID x 7days (DOC for
Trichomoniasis)
o Miconazole, Clotrimazole and Nystatin for
vaginal candidiasis
LOWER GENITAL TRACT INFECTION
 Etiologic Agent: Chlamydia Trachomatis
 Diagnostic Features:
o Genitourinary Chlamydial infection at 24weeks
but not at 28weeks detected via ligase chain
reaction was associated with a 2-fold increase
in spontaneous preterm labor
 Management: Erythromycin 500mg PO QID for
7days
PERIODONTITIS
 Etiologic Agent: Fusobacterium nucleatum and
Capnocytophage species
 Management:
o Teeth cleaning and polishing
o Deep root scaling and planning plus
INFECTIONS RELATED TO PRETERM LABOR Metronidazole
BACTERIAL VAGINOSIS
 Normal, hydrogen peroxide-producing,
lactobacillus-predominant vaginal flora is replaced IDENTIFICATION OF WOMEN AT RISK FOR
with anaerobes SPONTANEOUS PRETERM LABOR
 Associated with spontaneous abortion, preterm 1. SIGNS AND SYMPTOMS
labor, PPROM, chorioamnionitis, and amnionic  Painful/ Painless uterine contractions
fluid infection  Pelvic pressure
 Mechanism similar to amnionic fluid infection  Menstrual-like cramps
 Etiologic Agents: Gardnerella vaginalis, Mobiluncus  Watery vaginal discharge
specie, Mycoplasma hominis  Lower back pain
 Diagnostic Features: 2. CERVICAL DILATATION
o Vaginal pH >4.5  Asymptomatic cervical dilation after
o Homogenous vaginal discharge midpregnancy is a risk factor
o Amine odor when vaginal secretions are mixed  Normal anatomical variant for some (Parous
with KOH women)
o Vaginal epithelial cells heavily coated with  Parity alone is not sufficient to explain cervical
bacilli “clue cells” dilatation early in 3rd trimester
o Gram staining of vaginal secretions show few  1cm or 2cm dilatation, higher rates of delivery
white cells along with mixed flora as compared before 34weeks
with the normal predominance of lactobacilli  90% with 1-cm dilatation delivered within 21
 Management: Metronidazole 500mg BID x 7days days of the initial presentation
 Screening and treatment have not prevented
preterm birth

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 OBII-15 PRETERM LABOR AND BIRTH
3. CERVICAL CHANGE IN LENGTH
o At 24weeks – Mean cervical length is 35mm
o Progressively shorter cervical canals (<25mm),
higher rates of preterm birth
o 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
o Transvaginal cervical sonography
 Not affected by maternal obesity, cervix
position, or shadowing from the fetal
presenting part
 Performed after 16 weeks’ gestation
4. INCOMPETENT CERVIX
 Recurrent, painless cervical dilatation and
spontaneous mid trimester birth in the absence
of spontaneous membrane rupture, bleeding or
infection
5. AMBULATORY UTERINE MONITORING
o An external tocodynamometer belted around Recommended Management of Preterm Membrane
the abdomen and connected to an electronic Rupture at Parkland Hospital and University of
waist recorder allows a woman to ambulate Alabama at Birmingham
while uterine activity is recorded After confirmation of ruptured membranes, the
o Results are transmitted via telephone daily following steps are taken:
o Women are educated concerning signs and 1. Cervical dilatation and effacement are estimated
symptoms of preterm labor, and clinicians are visually during a sterile speculum examination
kept apprised of their progress 2. If <34weeks, if there are no maternal or fetal
o *Use of this expensive and time-consuming system indications for delivery, the woman and her fetus
does not reduce preterm birth rates are initially observed in the labor unit. Broad-
6. FETAL FIBRONECTIN spectrum parenteral antimicrobials are begun to
 Glycoprotein produced in 20 different molecular prevent chorioamniotis. Fetal heart rate and uterine
forms by various cell types, including activity are monitored for cord compression, fetal
hepatocytes, fibroblasts, endothelial cells, and compromise and early labor.
fetal amnion cells 3. If <34weeks, Betamethasone (two 12mg-dose IM
 Present in high concentrations in maternal blood 24hours apart) or Dexamethasone (four 6mg-dose
and amnionic fluid IM 12hours apart) is given.
 Functions in intercellular adhesion during 4. If the fetal status is reassuring and if labor does not
implantation and in maintenance of placental ensue, the woman is usually transferred to an
adherence to uterine decidua antepartum unit and observed for labor, infection or
 Detected in cervicovaginal secretions in women fetal jeopardy.
who have normal pregnancies with intact 5. For pregnancies 34weeks or beyond, if labor does
membranes at term not begin spontaneously, then it is induced with IV
 fFN appears to reflect stromal remodeling of the oxytocin unless contraindicated. CS is performed for
cervix before labor usual indications (eg. Failed induction of labor)
6. During labor or induction, a parenteral antimicrobial
MANAGEMENT OF PRETERM RUPTURE OF is given for prevention of group B streptococcal
MEMBRANES (PPROM) infection.
o A history of vaginal leakage of fluid, either as a
continuous stream or a gush, should prompt a
speculum examination to visualize gross vaginal CLINICAL CHORIOAMNIONITIS
pooling of amnionic fluid, clear fluid from the o Prolonged PROM is associated with increased fetal
cervical canal, or both and maternal sepsis
o Confirmation is usually accompanied by o If chorioamnionitis is diagnosed, prompt efforts to
sonographic examination to assess amnionic fluid effect delivery preferably vaginally are initiated
volume, to identify the presenting part, and to o Fever (38°C/ 100.4°F) is the only reliable indicator
estimate gestational age (if not previously determined) for this diagnosis accompanied by ROM

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 OBII-15 PRETERM LABOR AND BIRTH
PRETERM LABOR WITH INTACT FETAL INHIBITION OF PRETERM LABOR
MEMBRANES 1. Bed rest
Diagnosis 2. Hydration and sedation
 Criteria to document preterm labor: 3. Beta adrenergic receptor agonist
o Four contractions in 20minutes or eight in - Ritodrine
60minutes plus progressive change in the cervix - Terbutaline
o Cervical dilatation greater than 1cm - Isoxuprine
o Cervical effacement of 80% or greater Beta adrenergic drugs
- Parenteral beta agonists prevent preterm birth
Management for at least 48hours facilitating maternal
 Same management with those preterm ruptured transport and giving of steroids
membranes 4. Magnesium sulfate
 The cornerstone of treatment is to avoid delivery - Ionic magnesium in a sufficiently high
prior to 34weeks, if possible concentration can alter myometrial contractility
1. Amniocentesis to detect infection (not usually - Role is that of a calcium antagonist
indicated) - Clinical observations are that magnesium in
2. Steroid therapy to enhance fetal lung maturation pharmacological doses may inhibit labor
3. Thyrotropin-releasing hormone for fetal lung - Intravenously administered Magnesium sulfate
maturation – 4g loading dose followed by a continuous
4. Antenatal phenobarbital and vitamin K – infusion of 2g/hr – usually arrests labor
combination is not recommended for the prevention 5. Prostaglandin inhibitors (eg. Indomethacin)
of neonatal intraventricular hemorrhage 6. Calcium Channel Blockers (eg. Nifedipine)
7. Atosiban (Oxytocin antagonist)
INTERVENTIONS TO DELAY PRETERM BIRTH 8. Nitric oxide donors (Nitroglycerin) – not effective
A. ANTIMICROBIALS – not recommended for the
sole purpose of preventing delivery RECOMMENDED MANAGEMENT OF PRETERM
B. EMERGENCY CERCLAGE LABOR
o PROPHYLACTIC CERCLAGE – used in women a. Confirmation of preterm labor
who have a history of recurrent midtrimester b. For pregnancies <34weeks in women with no
losses and who are diagnosed with cervical maternal or fetal indications for delivery
insufficiency; used for women identified during - close observation with monitoring of uterine
sonographic examination to have a short cervix contractions and fetal heart rate is appropriate
o RESCUE CERCLAGE – done emergently when - serial examinations are done to assess cervical
cervical incompetence is recognized in women changes
with threatened preterm labor - glucocorti
C. TREATMENT FOR BACTERIAL VAGINOSIS c. For pregnancies <34weeks in women with maternal
or fetal indications for delivery
PROPHYLAXIS WITH PROGESTIN COMPOUNDS - Glucocorticoids are given for lung maturation
Progesterone Withdrawal d. For pregnancies <34weeks in women who are not in
 Considered to be a parturition-triggering even advanced labor
 Progesterone levels in most mammals fall rapidly - Glucocorticoid therapy and Group B
before the onset of labor streptococcal prophylaxis are given
e. For pregnancies at 34weeks and beyond in women
 It follows conceptually that the administration of with preterm labor
progesterone to maintain uterine quiescence may - Labor progression and fetal well being are
block preterm labor. monitored
 At the center of the controversy is whether or not f. For women in active labor
progestins prevent preterm birth in women with a - Antimicrobial is given for prevention of
singleton pregnancy but without prior preterm neonatal Group B streptococcal infection
birth, especially nulliparous women.
 The FDA rejected progesterone gel for use in the US INTRAPARTUM MANAGEMENT
because the results did not meet the level of 1. Labor
statistical significance required to show efficacy in  Continuous electronic monitoring is preferred
the subjects recruited in the country  Fetal tachycardia, especially with ROM, is
 17-hydroxyprogesterone caproate (17-OHPC) was suggestive of sepsis
ineffective

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 OBII-15 PRETERM LABOR AND BIRTH
 Intrapartum academia may intensify some of the 42–2. The neonatal mortality rate is expected to be
neonatal complications usually attributed to lowest for newborns born at which of the following
preterm delivery gestational ages?
2. Prevention of Neonatal Group B streptococcal a. 36 weeks 6 days
infections b. 37 weeks 4 days
 ACOG recommends either Penicillin G or c. 39 weeks 6 days
Ampicillin IV every 6hours until delivery for d. 41 weeks 2 days
women in preterm labor 42–3. Late-preterm births, defined as those between 34
3. Delivery and 36 weeks’ gestation, compose what percentage of all
 Staff proficient in resuscitative techniques preterm births?
commensurate with gestational age of the a. 35% b. 50%
newborn and fully oriented to any specific c. 70% d. 85%
problems should be present 42–4. Which of the following etiologies is largely
4. Prevention of Neonatal Intracranial Hemorrhage responsible for the increase in preterm birth rates in the
 Preterm newborns have germinal matrix United States during the past 20 years?
bleeding that can extend to more serious a. Triplet pregnancies
intraventricular hemorrhage b. Spontaneous preterm labor
 It was hypothesized that CS to obviate trauma c. Preterm rupture of fetal membranes
from labor and vaginal delivery might prevent d. Indicated (iatrogenic) preterm birth
these complications 42–5. After achieving a birth weight of at least 1000
 This has not been validated by most subsequent grams, neonatal survival rates reach 95 percent at
studies approximately what gestational age with regard to
 Hemorrhages related to whether or not the fetus newborn sex?
had been subjected to the active phase of labor, a. 28 weeks for both males and females
defined as the interval before 5cm cervical b. 30 weeks for both males and females
dilatation c. 28 weeks for females and 30 weeks or males
 Avoidance of active phase labor is impossible in d. 30 weeks for females and 28 weeks or males
most preterm births because the route of 42–6. Cesarean delivery for neonates born at the
delivery cannot be decided until the active threshold of viability has been demonstrated to protect
phase labor is firmly established against which of the following adverse newborn
outcomes?
EXPECTANT MANAGEMENT a. Seizures
o Despite extensive literature concerning expectant b. Intraventricular hemorrhage
management of PPROM: c. Respiratory distress syndrome
 Tocolysis has been used in few studies d. None of the above
 Active interventions did not improve perinatal 42–7. Compared with neonates born at term, the risks to
outcomes those born between 34 and 36 weeks’ gestation include
o Use of digital cervical examinations and cerclage are which of the following?
considered a. Increased serious morbidity and mortality rates
o Maternal and fetal risks vary with gestational age at b. Equivalent serious morbidity and mortality rates
membrane rupture c. Increased serious morbidity but decreased
o Volume of amnionic fluid remaining after rupture mortality rates
appears to have prognostic importance in d. Increased serious morbidity but equivalent
pregnancies <26weeks mortality rates
o Women with preterm ROM and non-cephalic 42–8. Maternal stress may potentiate preterm labor by
presentation was associated with an increased rate which of the following mechanisms involving
of umbilical cord prolapse <26weeks corticotropin-releasing hormone (CRH)?
a. Increased production of maternal-derived CRH
b. Decreased production of maternal-derived CRH
WILLIAMS 24TH EDITION STUDY GUIDE c. Increased production of placental-derived CRH
42–1. The term small-for-gestational age is generally d. Decreased production of placental-derived CRH
used to designate newborns whose birth weight is less
than what percentile?
a. 3% b. 5%
c. 10% d. 15%

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42–9. A 26-year-old G2P1 presents at 29 weeks’ gestation 42–16. Performance of routine cervical examinations at
complaining of leaking clear fluid from her vagina. each prenatal care visit has been demonstrated to effect
A speculum examination reveals scant pooling of fluid what outcome?
in the posterior vagina, and the microscopic analysis of a. Decreased preterm birth rate
the fluid reveals a pattern. You diagnose premature b. Increased interventions for preterm labor
rupture of the fetal membranes (PROM). Of the known c. Increased rate of premature rupture of fetal
risk factors for this condition, which is most commonly membranes
identified in such patients? d. None of the above
a. Smoking 42–17. Which of the following is true regarding
b. Low socioeconomic status sonographic evaluation of the cervix as a part of the
c. Prior pregnancy complicated by PROM assessment for preterm birth risk?
d. None of the above a. Transabdominal approach is preferred to avoid
42–10. All EXCEPT which of the following lifestyle cervical manipulation.
factors has been identified as an antecedent for preterm b. In research populations, women with
labor? progressively shorter cervices had increased preterm
a. Frequent coitus labor rates.
b. Illicit drug use c. Women with prior preterm birth and with cervical
c. Young maternal age lengths equal to 35 mm will benefit from cerclage
d. Inadequate maternal weight gain placement.
42–11. A 24-year-old G2P1 at 6 weeks’ gestation presents d. All of the above
for prenatal care and complains of bleeding, painful 42–18. Potential indications to perform the cerclage
gums. Her obstetric history is significant for two prior include which of the following?
preterm births. You counsel her that periodontal disease a. Recurrent mid trimester losses
treatment in pregnancy has been proven to have which b. Short cervix identified sonographically
of the following favorable outcomes? c. Threatened preterm labor with cervical dilatation
a. Improved periodontal health d. All of the above
b. Decreased rates of preterm birth 42–19. 17-Hydroxyprogesterone caproate has been
c. Decreased rates of low birth weight demonstrated in a randomized, controlled trial to
d. All of the above decrease the preterm birth rate in women with which of
42–12. Intervals shorter than how many months between the following characteristics?
pregnancies have been associated with an increased risk a. Nulliparous b. Carrying twins
for preterm birth? c. Prior preterm birth d. None of the above
a. 18 b. 24 42–20. Based on the known natural history of preterm
c. 36 d. 48 premature ruptured membranes, approximately what
42–13. A 33-year-old G2P2 is contemplating pregnancy percentage of women will be delivered within 48 hours
but is hesitant since her two prior deliveries occurred at of membrane rupture when this complication occurs
28 and 29 weeks’ gestation, respectively. You inform her between 24 and 34 weeks’ gestation?
that her risk for a recurrent preterm birth less than 34 a. 20% b. 40%
weeks’ gestation approximates what value? c. 70% d. 90%
a. 15% b. 25% 42–21. A 20-year-old primigravida at 18 weeks’ gestation
c. 40% d. 70% presents after she noticed a gush of fluid from her
42–14. A 22-year-old G2P1 at 14 weeks’ gestation vagina. You confirm the diagnosis of preterm rupture of
complains of a malodorous vaginal discharge. You the fetal membranes. Sonographic evaluation confirms
recommend antimicrobial treatment for this condition anhydramnios. In the unlikely event that she remains
for what principal reason? undelivered at a viable gestational age, perinatal
a. Resolution of symptoms survival would be unlikely because of
b. Prevention of preterm birth underdevelopment of what organ system?
c. Avoidance of spontaneous abortion a. Brain b. Lungs
d. Treatment of intraamnionic infection c. Heart d. Kidneys
42–15. Characteristics of Braxton Hicks contractions can 42–22. What is the only reliable indicator of clinical
include all EXCEPT which of the following? chorioamnionitis in women with preterm rupture of the
a. Painful fetal membranes?
b. Non rhythmical a. Fever
c. Irregular pattern b. Leukocytosis
d. Associated with cervical change c. Fetal tachycardia
d. Positive cervical or vaginal cultures

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42–23. Several antibiotic regimens have been used to 42–29. What reversible complication can be seen when
prolong the latency period in women with preterm indomethacin is used for tocolysis longer than 24 to
rupture of the fetal membranes who are attempting 48 hours?
expectant management. Which antibiotic should be a. Oligohydramnios
avoided in this setting because it has been associated b. Placental abruption
with an increased risk of necrotizing enterocolitis in the c. Neonatal necrotizing enterocolitis
newborn? d. Neonatal intraventricular hemorrhage
a. Ampicillin b. Amoxicillin 42–30. The combination of nifedipine with what other
c. Erythromycin d. Amoxicillin-clavulanate tocolytic agent can potentially cause dangerous
42–24. A 25-year-old primigravida at 34 weeks and 5 neuromuscular blockade?
days’ gestation by certain dating criteria is found to have a. Atosiban
preterm rupture of the fetal membranes. What is the b. Terbutaline
most appropriate management strategy? c. Indomethacin
a. Expedited delivery d. Magnesium sulfate
b. Expectant management 42–31. A 28-year-old primigravida at 27 weeks’ gestation
c. Administer a course of corticosteroids followed by presents with regular painful uterine contractions, and
delivery her cervix is 8 cm dilated. The fetus has a vertex
d. Expectant management unless fetal lung maturity presentation. The fetal heart rate tracing is reassuring.
is confirmed Which of the following procedures will help decrease
42–25. Corticosteroids administered to women at risk for the risk for intraventricular hemorrhage in her neonate?
preterm birth have been demonstrated to decrease rates a. Episiotomy
of respiratory distress if the birth is delayed for at least b. Cesarean delivery
what amount of time after the initiation of therapy? c. Forceps-assisted vaginal delivery
a. 12 hours b. 24 hours d. None of the above
c. 36 hours d. 48 hours 42–32. Although the efficacy is somewhat controversial,
42–26. When antimicrobials have been administered to intrapartum administration of magnesium sulfate to
forestall preterm birth in women with preterm labor, women who deliver preterm has been demonstrated to
rates of which of the following untoward perinatal reduce rates of which of the following neonatal
outcomes have been consistently reduced? outcomes?
a. Neonatal death a. Cerebral palsy
b. Cerebral palsy b. Necrotizing enterocolitis
c. Chronic lung disease c. Neonatal seizure activity
d. None of the above d. Bronchopulmonary dysplasia
42–27. Although bed rest is commonly prescribed for
women deemed to be at increased risk for preterm birth,
limited data exist to support a benefit of this
recommendation. Which of the following negative
outcomes have been reported in pregnant women placed
on bed rest compared with those without this
restriction?
a. Greater bone loss
b. Impaired fetal growth
c. Greater maternal weight gain
d. Higher rates of preeclampsia
42–28. A 21-year-old primigravida presents at 28 weeks’
gestation in active preterm labor, and intravenous
terbutaline is administered for tocolysis. Approximately
2 hours after therapy initiation, she begins to cough, and
her peripheral oxygen saturation is noted to be 80
percent. In which of the following clinical settings is the
risk for this complication increased?
a. Twin pregnancy
b. Maternal sepsis
c. Concurrent administration o corticosteroids
d. All of the above

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