TheAnswerPage/Obstetrics & Gynecology Sunday 03/14/2010 This week: Preterm labor

A 42-year-old G₁P₀ presents with unexplained preterm labor at 26-6/7 weeks' gestation. You have confirmed a diagnosis of preterm labor, excluded any contraindications to expectant management, started GBS prophylaxis (and sent a GBS perineal culture), and administered antenatal corticosteroids. Intravenous magnesium sulfate tocolytic therapy has successfully delayed delivery for 48 hours. Her cervical exam is 2-cm dilated and 80% effaced with the presenting vertex at -2 station. She is experiencing rare contractions.

1. You are considering sending her home. Should you discharge her on maintenance tocolytics? If so, what agent would you choose and how would you administer it?
2. The patient asks you about bed rest and home uterine monitoring. What do you tell her?
3. Before you are able to send her home, the patientís contractions increase in frequency and intensity. Repeat examination shows her cervix to be 3-cm dilated, 90% effaced, and -1 station. She is now at 27-3/7 weeks' gestation. Should you restart tocolysis? If so, what agent would you use?
4. Despite reinstitution of intravenous magnesium sulfate tocolysis, the patientís contractions increase in intensity and further cervical change is documented. Should you add a second tocolytic agent?

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