CASE SUMMARY:

The patient was a 29 year old, primi gravida at 28 weeks and 4 days of gestation who presented
on 18th September with one episode of painless bleeding per vaginally from 5pm, at 27 weeks
and 4 days of gestation. Her panty liner was fully soaked and the blood was dark red, without
any clots or mucous. She had regular contractions (2 contractions per 10 minutes). But there was
no leaking of liquor. Her BMI was 20 before pregnancy, which increased to 22.8 by 27 weeks.
Her family history, social history, past medical history, gynaecological history and surgical
history was insignificant. Speculum examination revealed an ectropion on the cervix and the
cervical os was open. Bloody show was also noted, but there was no pooling of liquor and cough
impulse was negative. Vaginal examination showed that the cervix was dilated to 2cm, but the
membrane was intact. The length of the cervix was 1cm. The provisional diagnosis was pre-
term labour secondary to cervical insufficiency. The differential diagnosis can be antepartum
haemorrhage secondary to cervical ectropion, but this is ruled out by the presence of
contractions.
She was transferred to the labour room and was started on IM Dexamethasone 12mg stat and 12
hours later, IM Pethidine 50mg stat, Tab. Nifedipine 20mg stat and then 10mg TDS for one week
and IV Magnesium Sulphate. Her contractions stopped 12 hours later and she was transferred
back to the ward.
A Transvaginal ultrasound performed later revealed the cervical length to be 2.38cm, confirming
the cause of the pre-term labour as cervical insufficiency and an Arabin Pessary measuring 70cm
x 17cm x 35cm was inserted for her.
At the time of clerking (2th September 2018), she did not have any labour symptoms. She was
being observed till 34 weeks and her next scan was planned for 2nd October, when she would be
at 29 weeks and 5 days of gestation.
Her Symphysio-fundal height was 26cm. The rest of the physical examination was
unremarkable.

LEARNING ISSUES:
1. Discuss the suitable and safe management options for your patient.

1. Accurate diagnosis by ruling out the differentials and finding the causes and risk factors
for pre-term labour and the management:
Differential diagnoses for antepartum haemorrhage include (1,2)
- Placenta abruption
- Placenta Previa
- Cervical Ectropion
- “Show”
- Trauma
Causes of and risk factors for pre-term labour and their management: (3,4)
● Previous preterm labor or premature birth, particularly in the most recent pregnancy or in
more than one previous pregnancy (N/A)
● Pregnancy with twins, triplets or other multiples (N/A)
● Problems with the uterus, cervix or placenta (Cervical insufficiency) : This was
managed by the insertion of the Arabin Pessary
● Smoking cigarettes or using illicit drugs (N/A)
● Certain infections, particularly of the amniotic fluid and lower genital tract (N/A)
● Some chronic conditions, such as high blood pressure and diabetes (N/A)
● Stressful life events, such as the death of a loved one (N/A)
● Polyhydramnios (N/A)
● Vaginal bleeding during pregnancy (1 episode of Painless PV bleeding) : Stopped
spontaneously
● Presence of a fetal birth defect (N/A)
● An interval of less than six months between pregnancies (N/A)

2. Fetal complications of pre-term delivery and how to prevent them (3,4,5)

○ Increased risk of Autism, Intellectual Disabilities, Cerebral Palsy, Vision and
Hearing loss
○ Low Birth Weight
○ Underdeveloped organs
○ Temperature instability
○ Respiratory Problems (Hyaline membrane disease/respiratory distress
syndrome, Chronic lung disease, Incomplete lung development and Apnea) : Give
IM Dexamethasone for prevention
○ Cardiovascular
■ Patent ductus arteriosus (PDA)
■ Hypotension or Hypertension
■ Bradycardia
○ Blood and metabolic
■ Anemia (may require blood transfusion)
■ Jaundice (due to immaturity of liver and gastrointestinal function)
■ Hypoglycemia or Hyperglycemia
■ Immature kidney function
○ Gastrointestinal
 ■ Difficulty feeding (many are unable to coordinate suck and swallow
before 35 weeks gestation)
■ Poor digestion
■ Necrotizing enterocolitis (NEC)- (Prevented by IM Dexamethasone)
○ Neurologic
■ Intraventricular hemorrhage (Prevented by IM Dexamethasone)
■ Periventricular leukomalacia--softening of tissues of the brain around the
ventricles
■ Poor muscle tone
■ Seizures (may be due to IVH)
■ Retinopathy of prematurityeye
■ Poor cerebral perfusion (Give IV Magnesium Sulphate to prevent it)
○ Infections

3. Tocolytics:
IV Magnesium Sulphate infusion over 24 hours
T. Nifedipine 20mg stat and then 10mg TDS for 1 week

4. Fetal Surveillance:
Fetal Kick Chart and Doppler every 4 hours
Ultrasound scan 2 weeks later

2. Write your reflection on your involvement in the care of your patient.

The patient did not know much about the complications of pre-term labour, so she asked me why
she could not deliver the baby when she was in labour. I explained the risks for the baby if born
prematurely. Then she was concerned about the development of her baby, so I also explained the
purpose of the Pessary ring and tocolytics as well as the Magnesium Sulphate and
Dexamethasone and how they will help the baby to develop enough to be delivered with as low a
risk as possible. I tried my best to reassure her.
I did follow up with the patient everyday, but I was not actively involved in her care other than to
reassure her. She mentioned she was bored of staying in the hospital and wanted to leave at her
own risk. I felt like I was not qualified enough to advise her on the best course of action,
although I emphasised the importance of proper monitoring for her and the importance of being
admitted in the hospital so that even if she starts going in to labour again, she would be in the
hospital where proper care can be given to her baby quickly. Retrospectively, I could have done
so much for her and advised her on a lot of other issues.
References:
1) Antepartum Haemorrhage [Internet]. Rcog.org.uk. 2018 [cited 24 September 2018].
Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_63.pdf
2) Rosalba Giordano M. Antepartum Haemorrhage [Internet]. PubMed Central (PMC). 2018
[cited 24 September 2018]. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263934/
3) Preterm labor - Symptoms and causes [Internet]. Mayo Clinic. 2018 [cited 24 September
2018]. Available from: https://www.mayoclinic.org/diseases-conditions/preterm-
labor/symptoms-causes/syc-20376842
4) Premature Labor [Internet]. WebMD. 2018 [cited 24 September 2018]. Available from:
https://www.webmd.com/baby/guide/premature-labor#1
5) Stanford Children's Health [Internet]. Stanfordchildrens.org. 2018 [cited 24 September
2018]. Available from: https://www.stanfordchildrens.org/en/topic/default?id=preterm-
labor-90-P02497