See also: [[Neonatal life support|neoresus]] > [!references]- Resources & References > - [Dunn premature labour](x-devonthink-item://0FC4F533-D798-4D4E-9C23-5D108536D91C) > - [RWH - PPROM](x-devonthink-item://D9FF35F8-DD26-4EE8-8F9E-B8E740DE38D7) > - [RWH - preterm labour](x-devonthink-item://F53A2FEE-E7D9-49F9-A48C-16749DD17ACF) > > ***Extreme Prematurity Links*** > - [Extreme prematurity guideline - SaferCare Victoria](https://www.safercare.vic.gov.au/sites/default/files/2020-12/20201222%20Extreme%20Prematurity%20Guideline_FINAL.pdf) - [devonthink link](x-devonthink-item://3C4D8700-358B-4A7A-9794-E33179297B1F?page=2) > - [Extreme Prematurity](https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/neonatal/extreme-prematurity) → links and flowcharts at the bottom > - [Active management of the extremely preterm newborn 22+0 to 24+6 weeks gestation](x-devonthink-item://9C0B090A-88B8-497B-91CC-C391848A30B5) > - [22 weeks parent info sheet](https://www.safercare.vic.gov.au/sites/default/files/2021-02/Information%20sheet_Babies%20born%20extremely%20preterm%20at%2022%20weeks%20of%20pregnancy.pdf) > - [23 weeks parent info sheet](https://www.safercare.vic.gov.au/sites/default/files/2021-02/Information%20sheet_Babies%20born%20extremely%20preterm%20at%2023%20weeks%20of%20pregnancy.pdf) > - [24 weeks parent info sheet](https://www.safercare.vic.gov.au/sites/default/files/2021-02/Information%20sheet_Babies%20born%20extremely%20preterm%20at%2024%20weeks%20of%20pregnancy.pdf) > [!key points] > - <37 weeks should have **betamethasone** 11.4mg IM Q24 h x2 to prevent resp distress syndrome (usually would be no later than 36 weeks) > - <30 weeks [[Magnesium]] 20mmol (2 vials, which is 5g) for neuroprotection > - <34 weeks **nifedipine** tocolysis (with CAUTION! usually just if hail mary to transfer elsewhere) > - Preterm premature rupture of membranes (PPROM) - the rupture of the membranes prior to 37 completed weeks gestation AND prior to the onset of labour. > - **abx** to cover GBS or choriamnionitis as described in [[#PPROM]] abx section \>20 **weeks** can result from direct uterine impact or from disturbance in maternal physiology, such as maternal bleeding or hypoxia. outcome largely dependent on gestational age ; overall responsible for 75% of perinatal deaths # survival rates | gestational age | survival rate at 2 years | | --------------- | ------------------------ | | >32 | >99% | | 30 | 95 | | 28 | 90 | | 26 | 60 | | 24 | 40 | | 22 | 7% | # complications - lung disease - immature lungs, inadequate surfactant - feeding difficulties -- immature sucking and swallowing reflex - temp control issues - aponea - immature resp centre - bradycardia -- usually caused by aponea - jaundice - liver unable to process bilirrubin properly - other disabilities - very low birth weight bubs have an IQ 10-15 pts below term babies - ADHD - autism # PPROM - preterm <37 weeks and premature (i.e. not during labour) rupture of membranes - if gestation is >36 weeks, then induction of labour with obstetrics if no contraindications to vaginal delivery - if <34 weeks, give betamethasone - tocolysis if <34 weeks for steroids to work - PPROM may occur as a consequence of infection and is also a/w increased risk of premature labour due to ascending infection. therefore, ==antibiotics== should be used for pregnancies where pregnancy prolongation is likely to result in a reduction of newborn morbidities. - for PPROM with suspected or confirmed **choriamnionitis** (i.e. fever with other clinical manifestations such as uterine tenderness and purulent amniotic fluid), treat for choriamnionitis: - Amoxycillin 2g 6-hourly IV, and - Gentamicin - Metronidazole 500mg IV, 12-hourly. - cont IV abx until afebrile for 48 hours - for PPROM without suspected chorioamnionitis AND <36 weeks gesation, give PPROM prophylaxis - *erythromycin* 250mg oral Q6H 7 days + *amoxicillin* 2g IV Q6H for 48 hours - followed by amoxicillin 250mg TDS for 5 days - if imminent delivery or >46 weeks gestation, PPROM ppx not required. # Extreme prematurity **Further links on this topic in the “resources” at the top of this page** > The **zone of parental discretion** ([ZPD](x-devonthink-item://3C4D8700-358B-4A7A-9794-E33179297B1F?page=6)) refers to scenarios where it is ethically legitimate for parents to make decisions for the care of their child. This includes decisions that are not in line with the preferences of the treating team, as long as those decisions will not – on balance – cause significant harm to the child. - At the lower limits (22+0 to 22+6) and upper limits (23+0 to 23+6) of the ZPD, you may give strong recommendations or directive communication that incorporates the family’s values and beliefs. - Infants <22 weeks or >=24+0 weeks’ gestation will usually have a prognosis that puts them outside the ZPD. Consequently, decisions about providing or withholding resuscitation will usually not be determined by parents’ values and wishes > Active management of births <23 weeks’ gestation in non-tertiary hospitals falls outside the ZPD and is not recommended. ![[Pasted image 20250614001505.png]] ![[Pasted image 20250614002227.png]] # indications for tocolytic therapy - <34 weeks (to give steroids time to work) - viable bub - no evidence of fetal compromise on CTG or USS requiring delivery - no placental abruption - no chorioamnionitis - no pre-eclampsia - no antipartum haemorrhage ![[Pasted image 20240311224238.png]] ## tocolytic agents - NSAIDs - effective to delay delivery by 48 hours - indomethacin and ketorolac - ==nifedipine== - most effective if <32 weeks gestation - *20mg stat* and 2 further doses at 30 min intervals if contractions eprsist - 20mg TDS - contraindications - IV salbutamol - MgSO4 - GTN patch - other antihypertensive med - allergy - maternal cardiac disease - hypotension - hepatic dysfunciton - salbutamol infusion - somewhat effective but many side effects - MgSO4 - **NOTE** - terbutaline would only be used for ACUTE tocolysis for dealing with an emergency like cord prolapse. it is a risk for postpartum haemorrhage (reduces tone) ### nifedipine guide > **nifedipine** is the rupture of the membranes prior to 37 completed weeks gestation and prior to the onset of labour. *Dosage*: - Give an initial dose of 20mg of immediate-release nifedipine orally (NOT slow-release Nifedipine) - After 30 minutes, if contractions persist, give another 20mg oral dose - After a further 30 minutes, if still contracting, follow up with a further 20mg orally - If the woman’s blood pressure is stable, a maintenance dose of 20mg orally, 8 hourly for 48 hours may be given where indicated. The maximum dose of nifedipine is 160mg / day. # other drugs to give ## steroids prevent RDS - all women with PPROM <34 weeks gestation (and likely <37 weeks) - **betamethasone** injection 11.4mg IM Daily - 2 doses, 24 hours apart (Celestone Chronodose) ## abx - treat preterm PROM with erythromycin 250mg oral every 6 hours for 7 days PLUS amoxicillin 2g IV every 6 hours for 48 hours followed by amoxicillin 250mg oral every 8 hours for 5 days. - For patients hypersensitive to penicillin, give erythromycin 250 mg orally every 6 hours for 10 days ## Magnesium sulphate for neuroprotection - consider if <30 weeks and birth <24 hours - 20mmol (2 vials) or 4g