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Prematurity

Specialties > Child health

Differential Diagnosis Schema 🧠

Maternal Factors

  • Infections: Intrauterine infections (e.g., chorioamnionitis) can trigger preterm labor.
  • Pre-eclampsia: Hypertensive disorders of pregnancy can necessitate early delivery.
  • Multiple gestations: Twins, triplets, or more increase the risk of preterm birth.
  • Previous preterm birth: Strong risk factor for subsequent preterm deliveries.
  • Maternal age: Both very young (35) are at increased risk.
  • Maternal medical conditions: Chronic conditions like diabetes, hypertension, or renal disease can contribute to prematurity.
  • Cervical insufficiency: Incompetent cervix can lead to early labor.
  • Substance abuse: Smoking, alcohol, and drug use are significant risk factors for preterm birth.
  • Short interpregnancy interval: Less than 6 months between pregnancies increases risk.
  • Placental problems: Placenta previa, placental abruption, and other abnormalities can lead to preterm delivery.
  • Socioeconomic factors: Low socioeconomic status is associated with higher rates of preterm birth.
  • Psychosocial stress: High stress levels are linked to increased preterm birth rates.
  • Poor prenatal care: Inadequate access to or use of prenatal care services increases risk.
  • Uterine anomalies: Structural abnormalities like fibroids or a bicornuate uterus can contribute to preterm labor.

Fetal Factors

  • Fetal growth restriction (IUGR): Poor fetal growth due to placental insufficiency or other factors often necessitates early delivery.
  • Fetal anomalies: Congenital abnormalities may lead to preterm labor or planned preterm delivery.
  • Polyhydramnios: Excessive amniotic fluid can stretch the uterus and trigger preterm labor.
  • Oligohydramnios: Low amniotic fluid levels can lead to complications requiring preterm delivery.
  • Fetal distress: Non-reassuring fetal heart rate patterns may necessitate early delivery.
  • Genetic conditions: Chromosomal abnormalities can increase the likelihood of preterm birth.
  • Intrauterine infection: Can lead to premature rupture of membranes and preterm labor.
  • Multiple gestations: Increased risk of preterm birth due to shared placental supply and uterine overdistension.
  • Umbilical cord issues: Cord prolapse or compression can necessitate early delivery.
  • Macrosomia: Large for gestational age fetuses can lead to complications requiring early delivery.
  • Isoimmunization: Severe hemolytic disease of the fetus can lead to early delivery.
  • Intrauterine death of one twin: Can lead to preterm delivery of the surviving twin.
  • Fetal surgery: In cases where in-utero surgery is performed, there is an increased risk of preterm labor.

Key Points in History 🥼

Maternal History

  • Previous preterm births: Strong predictor of future preterm delivery.
  • Infections: Recent history of urinary tract infection, sexually transmitted infections, or intrauterine infection.
  • Medical conditions: Diabetes, hypertension, renal disease, thyroid disorders, and autoimmune conditions.
  • Surgical history: Cervical procedures (e.g., LEEP, cone biopsy) or uterine surgery (e.g., myomectomy) can affect pregnancy.
  • Substance use: Smoking, alcohol, or illicit drug use during pregnancy.
  • Pregnancy complications: Multiple gestations, pre-eclampsia, or placental issues in the current or previous pregnancies.
  • Psychosocial factors: High stress levels, domestic violence, or lack of social support.
  • Nutritional status: Poor nutrition or specific deficiencies like folic acid or iron.
  • Medication use: Teratogenic or contraindicated medications during pregnancy.
  • Prenatal care: Regularity and quality of prenatal care received.
  • Cervical length: History of short cervix detected in the current or previous pregnancies.
  • Environmental exposures: Exposure to toxins, radiation, or infectious agents during pregnancy.
  • Family history: History of preterm birth, genetic conditions, or other pregnancy complications in the family.
  • Travel history: Recent travel to areas with high infection risk or limited access to medical care.

Fetal History

  • Fetal growth: Monitoring of fetal growth patterns, any detection of IUGR.
  • Fetal anomalies: Identified congenital abnormalities or genetic conditions.
  • Amniotic fluid levels: History of polyhydramnios or oligohydramnios.
  • Fetal movement: Decreased or absent fetal movements, especially in late pregnancy.
  • Fetal heart rate: Any abnormalities detected in routine monitoring.
  • Multiple gestations: Presence of twins or higher-order multiples.
  • Placental issues: Any abnormalities in placental structure or function detected on imaging.
  • Umbilical cord abnormalities: Cord prolapse, true knots, or other cord issues.
  • Fetal infections: Intrauterine infections (e.g., CMV, toxoplasmosis) that may affect fetal development.
  • Fetal therapy: Any in-utero interventions or surgeries performed during pregnancy.
  • Genetic screening: Results of any genetic tests or screenings performed.
  • Immunological factors: Isoimmunization or Rh incompatibility issues.

Possible Investigations 🌡️

Maternal Investigations

  • Full blood count (FBC): To check for anemia, infection, or other abnormalities.
  • Urinalysis: To detect urinary tract infections or proteinuria indicative of pre-eclampsia.
  • Blood glucose: Screening for gestational diabetes, especially in women with risk factors.
  • Vaginal swabs: To detect infections like Group B Streptococcus (GBS) that could lead to preterm labor.
  • Cervical length measurement: Using transvaginal ultrasound to assess the risk of preterm labor.
  • Blood pressure monitoring: To detect hypertension or pre-eclampsia.
  • TORCH screen: To check for infections that may affect the fetus (Toxoplasmosis, Rubella, Cytomegalovirus, Herpes).
  • Coagulation profile: Particularly in women with a history of thromboembolic events or antiphospholipid syndrome.
  • Blood type and antibody screen: To detect Rh incompatibility or other alloantibodies.
  • Thyroid function tests: To assess for hyperthyroidism or hypothyroidism, which can complicate pregnancy.
  • Serum ferritin: To assess iron stores and guide supplementation in women with anemia.
  • Serology for infections: Screening for specific infections like syphilis, HIV, and hepatitis.
  • Genetic testing: If indicated by family history or abnormal screening results.
  • Urine culture: To detect asymptomatic bacteriuria, which can lead to pyelonephritis and preterm labor.
  • Liver function tests (LFTs): Important in women with pre-eclampsia or HELLP syndrome.
  • Amniocentesis: If indicated, to assess for fetal lung maturity or infection.
  • Cardiotocography (CTG): To monitor fetal well-being, particularly in high-risk pregnancies.
  • Cervical culture: To identify infectious agents that could precipitate preterm labor.
  • Blood cultures: If maternal sepsis is suspected, to identify the causative organism.
  • Nuchal translucency and serum screening: Early screening for chromosomal abnormalities.

Fetal Investigations

  • Ultrasound scans: Routine and targeted scans to assess fetal growth, amniotic fluid levels, and structural abnormalities.
  • Fetal echocardiography: Indicated in women with a history of congenital heart disease or diabetes.
  • Doppler studies: To assess uteroplacental blood flow, particularly in cases of IUGR or pre-eclampsia.
  • Amniocentesis or chorionic villus sampling (CVS): Consider if there is a high risk of chromosomal abnormalities or genetic conditions.
  • Fetal MRI: Safe for detailed imaging of the fetal brain or other organs when ultrasound findings are inconclusive.
  • Non-stress test (NST): To assess fetal heart rate patterns and identify potential fetal distress.
  • Biophysical profile (BPP): Combines ultrasound and NST to assess fetal well-being.
  • Amniotic fluid index (AFI): To monitor for polyhydramnios or oligohydramnios.
  • Cordocentesis: Fetal blood sampling for genetic studies, infection, or anemia assessment.
  • Karyotyping: If chromosomal abnormalities are suspected.
  • Genetic counseling: For families with a history of genetic disorders or abnormal prenatal screening results.
  • Fetal lung maturity tests: If early delivery is being considered, particularly before 34 weeks gestation.
  • Thrombophilia screen: Consider in cases of unexplained fetal loss or IUGR.
  • Infectious disease screening: For intrauterine infections like CMV, toxoplasmosis, and others.
  • Placental biopsy: In rare cases where placental pathology is suspected to cause fetal compromise.

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