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ob.preterm-labor.v1PRODUCTION
ob.preterm-labor.v1

Preterm Labor (PTL) / Preterm Prelabor Rupture of Membranes (PPROM)

obstetricsacuteadultpregnancy
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Preterm labor (PTL) at 20+0 to 36+6 wk gestation defined by regular contractions + cervical change. PPROM is the variant in which membrane rupture precedes / accompanies contractions. Partition by GA tier (periviable 20-23+6 / extreme preterm 24-27+6 / very preterm 28-31+6 / moderate preterm 32-33+6 / late preterm 34-36+6) and membrane status (intact PTL vs PPROM). Distinguishes from term labor (≥ 37 wk; routine), term PROM (≥ 37 wk; ob.prom.v1 if authored, otherwise term PROM management inline), placental abruption (painful bleed + tachysystole; different mechanism), pre-eclampsia indicated preterm birth (BP-driven decision, routes to ob.pre-eclampsia.core.v1 / ob.preeclampsia-early-onset.v1), and Braxton-Hicks (irregular non-progressive contractions without cervical change).

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GA tier + membrane status tagged; PTL vs PPROM classification assigned

Patient inputs (26)

Maternal tachycardia > 100 supports chorio; sepsis flag if disproportionate to fever

Tachypnea > 22 is qSOFA component if sepsis emerging; magnesium toxicity tracked via RR < 12 + DTR loss

Hypoxemia is unusual in PTL — consider PE / pneumonia / AFE differential

FHR > 160 sustained × 10 min with maternal fever is chorio criterion; FHR baseline + variability informs fetal-status decision

ROM > 18 h is CDC IAP indication + chorio antecedent risk; informs latency-antibiotic decision in PPROM

Prior preterm birth (especially same or earlier GA) is strongest history risk factor; 15-30% recurrence; informs cerclage indications (history-indicated)

CL < 25 mm (treatment threshold < 20 mm) at 18-24 wk → vaginal progesterone in asymptomatic singleton; informs cerclage decision

Twin / triplet gestation → very high PTL risk; vaginal progesterone NOT effective for multiples (Romero 2018); cerclage controversial

GA partitions decision branches: < 24 wk periviable counseling; 24+0 - 33+6 corticosteroid window; < 32 wk magnesium neuroprotection; 34+0 - 36+6 late preterm steroids per ALPS 2016; ≥ 37 wk no longer PTL

PTL with intact membranes vs PPROM diverge: PPROM → latency abx (ampicillin + erythromycin × 7 d per NICHD-MFMU 1997) + closer chorio surveillance; PTL with intact membranes → tocolysis + corticosteroid window

WBC > 15K without antenatal steroids supports chorio (Higgins 2016); baseline before steroids + serial trend

Asymptomatic bacteriuria and pyelonephritis are PTL triggers — treat to reduce preterm birth (ACOG PB 130)

GBS status + chlamydia / gonorrhea screen — STI treatment reduces PPROM and chorio risk

Renal function for magnesium dosing (toxicity if CrCl < 30); LFTs for HELLP overlap; baseline before tocolysis

TVUS CL is the gold-standard cervical assessment; threshold < 25 mm for surveillance, < 20 mm for vaginal progesterone, < 15 mm + symptomatic = very high preterm-birth risk

Confirm GA + EFW + amniotic fluid index (oligohydramnios with indomethacin); placenta location for abruption ddx

Continuous EFM (Category I/II/III) once admitted with PTL or PPROM; umbilical Doppler if growth restriction concern

Fever is the trigger for chorio screening (Higgins 2016); ≥ 39.0 °C single OR 38.0-38.9 °C × 2 → routes to ob.chorioamnionitis.v1 with PTL/PPROM carryover

BP screens for superimposed pre-eclampsia (a major cause of indicated preterm birth) — routes to ob.pre-eclampsia.core.v1

GBS-positive OR unknown-GBS-with-PTL-or-ROM-risk → IAP penicillin G 5 mU IV load → 2.5-3 mU q4h until delivery (CDC Verani 2010 PMID 21088663 + ACOG CO 797 2020)

Anaphylaxis → vancomycin / clindamycin per GBS susceptibility; mild → cefazolin substitute (ACOG CO 797 2020)

Amniocentesis selectively for suspected subclinical IAI — Gram stain, culture, glucose < 14 mg/dL, IL-6 (Higgins 2016 confirmed Triple I criterion)

History-indicated, US-indicated, or exam-indicated cerclage — current pregnancy decision per Berghella Cochrane 2017

Smoking and substance use are modifiable PTL risk factors; substance-use disorder informs methadone / buprenorphine planning + naloxone availability

If maternal fever + SIRS / qSOFA features → bacteremia surveillance; routes to id.sepsis.core.v1

fFN at 22+0 - 34+6 wk symptomatic PTL with intact membranes — negative LR- ~ 0.1; positive LR+ ~ 2-3

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Severity triggers (10)

10 need judgement
  • informationallife_threateningplacental_abruption_overlap_ptl
    PTL features + painful vaginal bleeding + tachysystole + tender uterus + non-reassuring FHR → placental abruption overlay; life-threatening. Tocolysis CONTRAINDICATED. Routes to ob.placental-abruption.v1. Resuscitate + emergent delivery + DIC + MTP if hemorrhagic shock + cryoprecipitate if fibrinogen < 200.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereptl_under_32wk_magnesium_neuroprotection
    PTL or PPROM at < 32+0 wk gestation with imminent delivery → magnesium sulfate 4-6 g IV load + 1 g/h × 12-24 h for fetal neuroprotection (BEAM NEJM 2008 PMID 18753646 + Doyle Cochrane 2009 PMID 19160238) — reduces cerebral palsy in survivors. NOT a tocolytic — separate indication. Monitor toxicity hourly (RR < 12 / DTR loss / UO < 0.5 mL/kg/h → STOP + calcium gluconate 1 g IV antidote). Renal adjust if CrCl < 30 or AKI.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereptl_24_to_34wk_corticosteroid_window
    PTL or PPROM at 24+0 - 33+6 wk with imminent delivery within 7 d → betamethasone 12 mg IM × 2 doses 24 h apart OR dexamethasone 6 mg IM × 4 doses 12 h apart for fetal lung maturity (ACOG CO 713 + Roberts Cochrane 2017 PMID 28321847). Can extend to 34+0 - 36+6 wk for late preterm per ALPS NEJM 2016 PMID 26842679 if no prior course + delivery anticipated within 7 d + low chorio risk.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepprom_under_34wk_expectant_management
    PPROM < 34+0 wk + expectant management (no chorio, no abruption, no non-reassuring fetal status) → 7-day course of ampicillin + erythromycin (NICHD-MFMU Mercer JAMA 1997 PMID 9307346) — ampicillin 2 g IV q6h × 48 h then amoxicillin 250 mg PO q8h × 5 d + erythromycin 250 mg IV q6h × 48 h then 333 mg PO q8h × 5 d. AVOID amoxicillin-clavulanate (NEC risk per ORACLE-II Kenyon 2008). Concurrent corticosteroids + magnesium neuroprotection if < 32 wk. Close chorio surveillance (Higgins 2016).
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresuspected_chorio_in_pprom_or_ptl
    Maternal fever ≥ 39.0 °C OR 38.0-38.9 °C × 2 + ≥ 1 of (FHR > 160 sustained, WBC > 15K without steroids, purulent cervical discharge) in PPROM or PTL → suspected Triple I per Higgins 2016 PMID 26855098. Routes to ob.chorioamnionitis.v1 with PTL/PPROM carryover. Discontinue tocolysis (contraindicated in chorio). Start ampicillin + gentamicin empirics (ACOG CO 712 2017). Expedite delivery — chorio source IS the gravid uterus.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretocolytic_indomethacin_under_32wk_only
    Indomethacin for tocolysis ONLY at < 32+0 wk — CONTRAINDICATED at or after 32 wk due to oligohydramnios + ductal closure + neonatal pulmonary HTN risk. 50-100 mg PO load → 25-50 mg PO q6h × 48 h max. Monitor amniotic fluid index weekly if used > 48 h. Switch to nifedipine if approaching 32 wk or refractory.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereterbutaline_contraindication_chronic
    Terbutaline FDA black-box (2011) — restricts use to short-term acute tocolysis ≤ 48-72 h hospitalised setting only. NEVER oral or chronic (cardiac death risk). 0.25 mg SC q20 min × 3 doses for acute tocolysis if nifedipine and indomethacin both contraindicated or unavailable. Switch to nifedipine for sustained tocolysis.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepprom_at_or_after_34wk_delivery
    PPROM at 34+0 - 36+6 wk → induction of labor (or expectant management) per ACOG PB 188 2018 — favors delivery over expectant at ≥ 34 wk; balance neonatal RDS risk (low at ≥ 34 wk) against chorio + cord compression + cord prolapse risk from continued PPROM. Late preterm steroids per ALPS 2016 if no prior course + delivery anticipated within 7 d. GBS IAP intrapartum.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecervical_length_under_20mm_at_screening
    Asymptomatic singleton + transvaginal cervical length < 20 mm at 16-24 wk screening → vaginal progesterone 200 mg PV nightly through 36+6 wk (Romero AJOG 2018 PMID 29157866 + Hassan 2011 PMID 21472815) — reduces preterm birth before 33 wk. Also high-risk surveillance with serial TVUS CL q1-2 wk. Consider US-indicated cerclage if prior preterm birth + current CL < 25 mm. Vaginal progesterone is NOT effective in multifetal gestations.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateprior_preterm_birth_recurrence_prevention
    Prior spontaneous preterm birth (PTL or PPROM) → ~ 15-30% recurrence in subsequent pregnancy. Preconception MFM consultation. Early TVUS cervical length surveillance from 16 wk q1-2 wk. Vaginal progesterone if current CL < 20 mm. Cerclage indications per Berghella Cochrane 2017 (history-indicated for ≥ 3 prior 2nd-tri losses or preterm births; US-indicated for prior preterm birth + current CL < 25 mm; exam-indicated for dilation in 2nd tri without contractions). 17OHP-C is NOT recommended after PROLONG 2019 + FDA withdrawal 2023.
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Preterm labor + PPROM acute management — tocolysis + corticosteroids + magnesium neuroprotection + latency antibiotics + GBS IAP (ACOG PB 234 + PB 188 + CO 713 + CO 797 + BEAM 2008 + ALPS 2016 + NICHD-MFMU PPROM 1997)
axis: ptl_pprom_acute_managementstep tocolysis_nifedipine_first_line_24_to_33_wk - Tocolysis — nifedipine first-line 24+0 - 33+6 wk PTL intact membranes (ACOG PB 234)
Selected step "Tocolysis — nifedipine first-line 24+0 - 33+6 wk PTL intact membranes (ACOG PB 234)" — 24+0 - 33+6 wk PTL with intact membranes + no chorio + no abruption + no non-reassuring fetal status + goal is 48 h pregnancy extension for corticosteroid window
  • nifedipine
    first line
    calcium_channel_blocker
    20-30 mg PO load → 10-20 mg PO q4-6h (max 180 mg/day) • PO • q4-6h
    triggers: ptl_24_to_33wk_intact_membranes_no_contraindication
    First-line tocolytic per ACOG PB 234 — reduces preterm birth + improves neonatal outcome; preferred over indomethacin and terbutaline; avoid in maternal hypotension MAP < 65 or LV dysfunction
    rxcui 7417

outpatient playbook — drug actions (5)

  1. 1. vaginal progesterone antepartum (short cervix)
    rxcui 8727
    200 mg PV nightly from CL < 20 mm diagnosis through 36+6 wk • PV • nightly
    trigger: Asymptomatic CL < 20 mm singleton at 16-24 wk
    Romero AJOG 2018 + Hassan 2011 — reduces preterm birth before 33 wk
  2. 2. aspirin prophylaxis if high-risk for pre-eclampsia
    rxcui 1191
    81-150 mg PO daily from 12 wk through 36 wk • PO • daily
    trigger: High risk per USPSTF 2021 (prior PE, chronic HTN, DM, CKD, autoimmune)
    ASPRE 2017 + USPSTF 2021 — reduces preterm PE specifically
  3. 3. iron repletion if antepartum anemia or postpartum
    rxcui 24947
    Ferrous sulfate 325 mg PO TID; IV iron if severe • PO/IV • TID PO or per infusion protocol
    trigger: Hgb < 11 g/dL
    Restore iron stores; reduce fatigue + improve recovery
  4. 4. contraception postpartum
    Per ACOG MEC + patient preference (LARC, COC, POP, DMPA) • PO/IM/implant/IUD • per agent
    trigger: Patient request + medical eligibility
    Interpregnancy interval ≥ 18 mo associated with reduced PTB recurrence
  5. 5. Tdap, influenza, COVID per ACIP
    Per ACIP • IM • per schedule
    trigger: Postpartum or antepartum per gestational age
    Standard ACIP

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Regular uterine contractions ≥ 4 in 20 min OR ≥ 8 in 60 min between 20+0 and 36+6 wk (ACOG PB 130 2012); New low-back ache / pelvic pressure / vaginal pressure at < 37 wk — supportive PTL feature (ACOG PB 130); Patient reports gush of clear or blood-tinged fluid; speculum shows pooling + nitrazine-positive + ferning OR commercial PPROM assay positive (ACOG PB 188 2018).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Preterm Labor (PTL) / Preterm Prelabor Rupture of Membranes (PPROM)** (ob.preterm-labor.v1).
Phenotype framing: Braxton-Hicks (irregular, non-progressive, no cervical change), placental abruption (painful bleed + tachysystole + tender uterus → ob.placental-abruption.v1; tocolysis CONTRAINDICATED), chorioamnionitis (fever + Higgins 2016 → ob.chorioamnionitis.v1; tocolysis contraindicated in confirmed chorio), pre-eclampsia with indicated preterm birth (BP ≥ 140/90 + proteinuria → ob.preeclampsia-early-onset.v1 if < 34 wk), urinary tract infection (asymptomatic bacteriuria / pyelonephritis can present with contractions — treat per UA / culture), gastroenteritis with cramping (vital signs + GI features), round ligament pain (unilateral, sharp, related to movement; benign), term PROM (≥ 37 wk; routine).
Scope: Preterm labor (PTL) at 20+0 to 36+6 wk gestation defined by regular contractions + cervical change. PPROM is the variant in which membrane rupture precedes / accompanies contractions. Partition by GA tier (periviable 20-23+6 / extreme preterm 24-27+6 / very preterm 28-31+6 / moderate preterm 32-33+6 / late preterm 34-36+6) and membrane status (intact PTL vs PPROM). Distinguishes from term labor (≥ 37 wk; routine), term PROM (≥ 37 wk; ob.prom.v1 if authored, otherwise term PROM management inline), placental abruption (painful bleed + tachysystole; different mechanism), pre-eclampsia indicated preterm birth (BP-driven decision, routes to ob.pre-eclampsia.core.v1 / ob.preeclampsia-early-onset.v1), and Braxton-Hicks (irregular non-progressive contractions without cervical change).

No severity triggers fired against current inputs.

Plan

Regimen axis: **Preterm labor + PPROM acute management — tocolysis + corticosteroids + magnesium neuroprotection + latency antibiotics + GBS IAP (ACOG PB 234 + PB 188 + CO 713 + CO 797 + BEAM 2008 + ALPS 2016 + NICHD-MFMU PPROM 1997)** — step "Tocolysis — nifedipine first-line 24+0 - 33+6 wk PTL intact membranes (ACOG PB 234)".
1. nifedipine 20-30 mg PO load → 10-20 mg PO q4-6h (max 180 mg/day) PO q4-6h (calcium_channel_blocker, first line) — First-line tocolytic per ACOG PB 234 — reduces preterm birth + improves neonatal outcome; preferred over indomethacin and terbutaline; avoid in maternal hypotension MAP < 65 or LV dysfunction

Setting playbook (outpatient) — Antepartum surveillance for high-risk patients (prior preterm birth, short cervix, multifetal gestation); 6-week postpartum visit + preterm-birth-specific anticipatory guidance + preconception MFM counseling for next pregnancy; newborn outpatient follow-up especially for late preterm with developmental tracking through 12 mo + extreme preterm tracking through 18-22 mo
2. vaginal progesterone antepartum (short cervix) 200 mg PV nightly from CL < 20 mm diagnosis through 36+6 wk PV nightly — Asymptomatic CL < 20 mm singleton at 16-24 wk (Romero AJOG 2018 + Hassan 2011 — reduces preterm birth before 33 wk)
3. aspirin prophylaxis if high-risk for pre-eclampsia 81-150 mg PO daily from 12 wk through 36 wk PO daily — High risk per USPSTF 2021 (prior PE, chronic HTN, DM, CKD, autoimmune) (ASPRE 2017 + USPSTF 2021 — reduces preterm PE specifically)
4. iron repletion if antepartum anemia or postpartum Ferrous sulfate 325 mg PO TID; IV iron if severe PO/IV TID PO or per infusion protocol — Hgb < 11 g/dL (Restore iron stores; reduce fatigue + improve recovery)
5. contraception postpartum Per ACOG MEC + patient preference (LARC, COC, POP, DMPA) PO/IM/implant/IUD per agent — Patient request + medical eligibility (Interpregnancy interval ≥ 18 mo associated with reduced PTB recurrence)
6. Tdap, influenza, COVID per ACIP Per ACIP IM per schedule — Postpartum or antepartum per gestational age (Standard ACIP)

Non-pharmacologic actions:
- Antepartum lifestyle counseling — smoking cessation, substance use reduction, glycemic control if DM, BP control if HTN, weight management
- Mental health counseling / therapy if EPDS ≥ 10 or PCL-5 elevated; peripartum PTSD risk elevated after preterm + NICU
- Cerclage placement per Berghella Cochrane 2017 indications (history-, US-, exam-indicated)
- Preconception MFM consultation for next pregnancy planning — early CL surveillance, vaginal progesterone planning, cerclage indication review, optimization of maternal comorbidities
- Pediatric follow-up coordination for late preterm + very preterm + extreme preterm — 24-48 h post-discharge peds for late preterm; first-year developmental tracking; AAP NRN framework
- Lactation support continued for breastfeeding (PTL/PPROM regimens not contraindicated per LactMed)
- VTE prophylaxis follow-up if extended postpartum thromboprophylaxis prescribed (cesarean + chorio + immobility increase VTE risk)

AVOID / contraindication checks:
- Tocolysis CONTRAINDICATED in chorio abruption non reassuring fetal status severe PE IUFD (ACOG PB 234)
- Indomethacin CONTRAINDICATED at or after 32 wk PDA constriction and oligohydramnios (ACOG PB 234)
- Terbutaline FDA black box no chronic or oral use cardiac death risk (FDA 2011)
- Nifedipine avoid if maternal hypotension MAP lt 65 or LV dysfunction (ACOG PB 234)
- Magnesium toxicity RR lt 12 OR DTR loss OR UO lt 0.5mL per kg per h antidote calcium gluconate 1g IV (ACOG PB 234)
- Magnesium renal adjust if CrCl lt 30 or AKI (ACOG PB 234)
- Avoid amoxicillin clavulanate in PPROM NEC risk (ORACLE II Kenyon 2008)
- No digital cervical exam in PPROM until delivery anticipated ascending infection risk (ACOG PB 188)
- No NSAIDs intrapartum PDA constriction and bleeding (ACOG PB 188)
- 17OHP C not recommended PROLONG 2019 and FDA withdrawal 2023 no benefit for recurrent PTB (PROLONG PMID 31652479)
- Vaginal progesterone not effective for twins or triplets per Romero 2018 meta analysis (Romero AJOG 2018)
- GBS IAP clindamycin only if susceptible per antibiogram resistance 15 to 20 percent (CDC Verani 2010)
- Cefazolin cross reactivity low 1 to 2 percent in mild pen allergy no anaphylaxis (Macy 2014; ACOG CO 797 2020)
- Late preterm ALPS steroids only if no prior course and no chorio (ALPS NEJM 2016)
- Rescue corticosteroid course allowed if gt 14 days since prior and still lt 34 wk and new imminent delivery (ACOG CO 713)

Monitoring

Regimen monitoring:
- Maternal vitals q15 min during active PTL or magnesium load; q1 h post-load; q4 h stable
- Continuous EFM during PTL admission (Category I/II/III interpretation)
- Magnesium toxicity surveillance hourly — DTR + RR + UO; STOP and calcium gluconate 1 g IV if RR < 12 / DTR loss / UO < 0.5 mL/kg/h
- Daily CBC + CMP if expectant PPROM management; serial maternal temperature q4 h (chorio surveillance)
- Cervical length serial US (e.g., weekly during expectant management)
- Amniotic fluid volume serial US weekly for PPROM expectant management
- Fetal growth US q2-4 wk if expectant PPROM management
- Newborn handoff: maternal antibiotic timing + GBS IAP adequacy + corticosteroid course + magnesium exposure → peds / neonatology (AAP Puopolo 2018)

Setting (outpatient) monitoring:
- 6-week postpartum visit; additional 1-2 wk visit if cesarean wound concern or extended episiotomy
- Antepartum TVUS CL q1-2 wk in high-risk patients during 16-24 wk
- NST + BPP weekly from 32-34 wk if high-risk
- Maternal mental health re-screen at 6 wk + 3 mo + 6 mo (peripartum PTSD risk elevated)
- Newborn outpatient peds at 24-48 h then 1 wk then 1 mo for late preterm
- Very preterm + extreme preterm developmental tracking at 4 / 12 / 18-22 mo (AAP NRN framework + Shankaran 2005 if HIE history)
- Preconception MFM consultation when contemplating next pregnancy

Follow-up plan: 6-week postpartum visit + preterm-birth-specific anticipatory guidance: recurrence ~ 15-30% in subsequent pregnancy; preconception MFM consult for next pregnancy planning (early CL surveillance, vaginal progesterone planning, cerclage indication review per Berghella Cochrane 2017). Mental health screen (EPDS for postpartum depression; PCL-5 for peripartum PTSD especially after extreme preterm or NICU outcomes). Contraception counseling + interpregnancy interval ≥ 18 mo. Immunization audit (Tdap, flu, COVID per ACIP). Newborn outpatient peds visit 24-48 h post-discharge if late preterm; first-year developmental tracking if very preterm or extreme preterm (cerebral palsy + BPD + IVH risk monitoring per AAP NRN framework).
- Close-out criterion: Postpartum visit complete; preconception MFM counseling delivered; mental health + immunization + newborn developmental tracking arranged

Monitoring phase: Continuous EFM intrapartum (Category I/II/III); maternal vitals q15 min during active labor or magnesium loading; q1 h post-load; q4 h stable. Magnesium toxicity surveillance: hourly DTRs + RR + UO (toxicity if RR < 12 / DTR loss / UO < 0.5 mL/kg/h; calcium gluconate 1 g IV antidote). Daily CBC + CMP if expectantly managing PPROM. Maternal temperature q4 h (chorio surveillance). PPROM amniotic fluid volume serial US weekly. Cervical length serial if expectant PTL. Continuous EFM during corticosteroid administration + magnesium load (transient fetal-heart-rate variability reduction expected).

Disposition

Current setting: outpatient — Antepartum surveillance for high-risk patients (prior preterm birth, short cervix, multifetal gestation); 6-week postpartum visit + preterm-birth-specific anticipatory guidance + preconception MFM counseling for next pregnancy; newborn outpatient follow-up especially for late preterm with developmental tracking through 12 mo + extreme preterm tracking through 18-22 mo

Disposition criteria:
- Resolution: 6-wk postpartum visit complete, mental health stable, contraception in place, immunizations up to date, newborn developmental tracking in place → discharge to routine primary care + preconception MFM for next pregnancy when contemplated

Escalation triggers (move to higher acuity):
- Antepartum bleeding / cramping / decreased fetal movement → return to L&D / ED
- Postpartum fever / chills / uterine tenderness / foul lochia → endometritis workup (ED visit + broad-spectrum + imaging)
- New mental health crisis (PHQ-9 ≥ 15 or PCL-5 with suicidal ideation) → urgent mental health referral
- Newborn high-risk features (persistent feeding issues, neurodevelopmental concerns, persistent jaundice) → urgent peds visit / ED

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] PTL features + painful vaginal bleeding + tachysystole + tender uterus + non-reassuring FHR → placental abruption overlay; life-threatening. Tocolysis CONTRAINDICATED. Routes to ob.placental-abruption.v1. Resuscitate + emergent delivery + DIC + MTP if hemorrhagic shock + cryoprecipitate if fibrinogen < 200.
- [SEVERE] PTL or PPROM at < 32+0 wk gestation with imminent delivery → magnesium sulfate 4-6 g IV load + 1 g/h × 12-24 h for fetal neuroprotection (BEAM NEJM 2008 PMID 18753646 + Doyle Cochrane 2009 PMID 19160238) — reduces cerebral palsy in survivors. NOT a tocolytic — separate indication. Monitor toxicity hourly (RR < 12 / DTR loss / UO < 0.5 mL/kg/h → STOP + calcium gluconate 1 g IV antidote). Renal adjust if CrCl < 30 or AKI.
- [SEVERE] PTL or PPROM at 24+0 - 33+6 wk with imminent delivery within 7 d → betamethasone 12 mg IM × 2 doses 24 h apart OR dexamethasone 6 mg IM × 4 doses 12 h apart for fetal lung maturity (ACOG CO 713 + Roberts Cochrane 2017 PMID 28321847). Can extend to 34+0 - 36+6 wk for late preterm per ALPS NEJM 2016 PMID 26842679 if no prior course + delivery anticipated within 7 d + low chorio risk.

Citations

- ACOG Practice Bulletin 234 (2021, reaffirmed 2024) Antepartum Fetal Surveillance + ACOG PB 188 (2018, reaffirmed) Prelabor Rupture of Membranes + ACOG CO 713 (2017, reaffirmed) Antenatal Corticosteroids 24-33+6 wk + ACOG PB 130 (2012, reaffirmed) Prediction and Prevention of Preterm Birth + ACOG CO 797 (2020) Prevention of GBS Early-Onset Disease + ACOG CO 871 (2020) Magnesium Sulfate Before Anticipated Preterm Birth + BEAM Rouse NEJM 2008 (PMID 18753646) Magnesium for Neuroprotection + Doyle Cochrane 2009 (PMID 19160238) Magnesium meta-analysis + Roberts Cochrane antenatal corticosteroids 2017 (PMID 28321847) + Liggins 1972 (PMID 4561295) Original Betamethasone RCT + ALPS Gyamfi-Bannerman NEJM 2016 (PMID 26842679) Late-Preterm Steroids + NICHD-MFMU Mercer JAMA 1997 (PMID 9307346) PPROM Latency Antibiotics + ORACLE-I Kenyon Lancet 2001 (PMID 11293640) + Hassan Ultrasound Obstet Gynecol 2011 (PMID 21472815) Vaginal Progesterone + Romero AJOG 2018 (PMID 29157866) Vaginal Progesterone Meta-Analysis + PROLONG Blackwell 2020 (PMID 31652479) 17OHP-C No Benefit + CDC GBS Verani 2010 (PMID 21088663) + Higgins NICHD/ACOG/SMFM 2016 (PMID 26855098) Chorio Overlap + SSC 2026 (sepsis-pathway carryover) [PMID:18753646](https://pubmed.ncbi.nlm.nih.gov/18753646/)
- Cited evidence (PMID 19160238) [PMID:19160238](https://pubmed.ncbi.nlm.nih.gov/19160238/)
- Cited evidence (PMID 28321847) [PMID:28321847](https://pubmed.ncbi.nlm.nih.gov/28321847/)
- Cited evidence (PMID 4561295) [PMID:4561295](https://pubmed.ncbi.nlm.nih.gov/4561295/)
- Cited evidence (PMID 26842679) [PMID:26842679](https://pubmed.ncbi.nlm.nih.gov/26842679/)

Last reconciled with current guidelines: 2026-05-15.
References
  • ACOG Practice Bulletin 234 (2021, reaffirmed 2024) Antepartum Fetal Surveillance + ACOG PB 188 (2018, reaffirmed) Prelabor Rupture of Membranes + ACOG CO 713 (2017, reaffirmed) Antenatal Corticosteroids 24-33+6 wk + ACOG PB 130 (2012, reaffirmed) Prediction and Prevention of Preterm Birth + ACOG CO 797 (2020) Prevention of GBS Early-Onset Disease + ACOG CO 871 (2020) Magnesium Sulfate Before Anticipated Preterm Birth + BEAM Rouse NEJM 2008 (PMID 18753646) Magnesium for Neuroprotection + Doyle Cochrane 2009 (PMID 19160238) Magnesium meta-analysis + Roberts Cochrane antenatal corticosteroids 2017 (PMID 28321847) + Liggins 1972 (PMID 4561295) Original Betamethasone RCT + ALPS Gyamfi-Bannerman NEJM 2016 (PMID 26842679) Late-Preterm Steroids + NICHD-MFMU Mercer JAMA 1997 (PMID 9307346) PPROM Latency Antibiotics + ORACLE-I Kenyon Lancet 2001 (PMID 11293640) + Hassan Ultrasound Obstet Gynecol 2011 (PMID 21472815) Vaginal Progesterone + Romero AJOG 2018 (PMID 29157866) Vaginal Progesterone Meta-Analysis + PROLONG Blackwell 2020 (PMID 31652479) 17OHP-C No Benefit + CDC GBS Verani 2010 (PMID 21088663) + Higgins NICHD/ACOG/SMFM 2016 (PMID 26855098) Chorio Overlap + SSC 2026 (sepsis-pathway carryover) — PMID:18753646
  • Cited evidence (PMID 19160238) — PMID:19160238
  • Cited evidence (PMID 28321847) — PMID:28321847
  • Cited evidence (PMID 4561295) — PMID:4561295
  • Cited evidence (PMID 26842679) — PMID:26842679