PAIN IN PREGNANCY
A 28-year-old woman nulliparous woman is admitted to the labour ward at 31 weeks and 6 days’ gestation, with abdominal pain.
In this pregnancy she has had chronic low back pain for which she has been under the physiotherapist. She has also been treated for confirmed urinary tract infections on two occasions. She underwent two large-loop excisions of the transformation zone (LLETZ) procedures some years ago. Since then her smears have been normal, the most recent being 10 months ago.
Yesterday she noticed an increase in her discharge with some dark vaginal bleeding and abdominal discomfort. She thought the symptoms may have related to something she had eaten but she now feels intermittent abdominal pain every few minutes, with no pain in between episodes. Fetal movements are normal.
There is no history of leaking of liquor. She has urinary frequency, though this has not worsened recently. She is always constipated.
The woman is apyrexial with blood pressure 109/60 mmHg and heart rate 96/min. Symphysiofundal height is 30 cm and moderate contractions are palpated lasting approxi- mately 35 s. The fetus is breech on palpation and the presenting part feels engaged.
No liquor is visible on speculum examination. On vaginal examination the cervix is effaced and 3 cm dilated, with the breech felt –2 cm above the ischial spines and mem- branes intact.
· What is the diagnosis?
· What factors predispose to this?
· How would you manage this woman?
The woman is in premature labour – she has regular painful contractions (as confirmed by the history, palpation and uterine activity demonstrated on CTG) and the cervix is effaced and dilated.
In this history the possible risk factors are the LLETZ procedures and urinary tract infec- tions, raising the possibility that she could be in premature labour due to a further untreated urinary tract infection. However, many women in premature labour have no obvious risk factors.
· Prevention of respiratory distress syndrome (RDS):
· antenatal corticosteroids (usually betamethasone intramuscular) prior to delivery reduce the incidence of RDS in premature infants, and ideally two doses should be administered 12 h apart prior to delivery.
· tocolysis (with atosiban, a beta-agonist or nifedipine) should be started immedi- ately to try and delay labour in order for the steroids to be maximally effective (24 h), and then discontinued. The other indication for tocolysis is to settle contrac- tions long enough for in utero transfer of the mother to a unit with facilities to care for a 31-week baby. In other situations tocolysis does not seem to improve fetal outcome, even though it may prolong time to delivery.
· Mode of delivery: although there is evidence that full-term singleton breech babies should be delivered by Caesarean section (rather than vaginally), there is no clear evidence that this applies to preterm infants, and as premature delivery is generally reasonably quick, vaginal delivery should be considered. The contraindications to this would be signs of fetal compromise on CTG, or maternal objection.
· Postnatal care: the paediatric team should be informed of any woman in actual or threatened preterm labour, in order that appropriate arrangements are made for care of the infant after delivery.