Management of Mild Contractions with Closed Cervix and Negative Fetal Fibronectin at 28 Weeks
The patient should be discharged home with clear instructions on what symptoms should prompt medical attention, as she has minimal risk factors for imminent preterm delivery.
Assessment of Current Clinical Situation
The patient presents with:
- 28 weeks gestation (third trimester)
- Mild contractions (1 in 10 minutes)
- Normal fetal heart rate tracing
- Closed cervix on speculum exam
- No visible amniotic fluid
- Negative fetal fibronectin test
These findings collectively indicate a low risk for imminent preterm delivery, making outpatient management appropriate.
Evidence-Based Rationale for Discharge
The negative fetal fibronectin test is particularly significant in this case. Fetal fibronectin has high negative predictive value (96-99%) for preterm birth 1. This means that with a negative test, the likelihood of delivery within the next 1-2 weeks is extremely low.
The absence of cervical dilation and amniotic fluid on speculum exam further supports that this patient is not in active labor. According to ACOG guidelines, these findings, combined with the negative fetal fibronectin, indicate that the patient can be safely managed as an outpatient 2.
Discharge Instructions
When discharging the patient, provide clear instructions about symptoms that should prompt immediate return to medical care:
- Increased frequency of contractions (more than 4-6 per hour)
- Rupture of membranes (leaking fluid)
- Vaginal bleeding
- Decreased fetal movement
- Pelvic pressure or back pain
- Temperature above 100.4°F (38°C)
What NOT to Do
Prolonged monitoring for 24 hours is unnecessary and would be an inefficient use of resources given the low risk of preterm delivery based on current findings.
Quantifying contraction intensity by EFM would provide little additional useful information since the patient has minimal contractions and no cervical change.
Instituting a protocol for preterm delivery (corticosteroids, tocolytics, antibiotics, magnesium sulfate) is not indicated at this time since:
- The patient is not in active preterm labor
- The cervix is closed
- Fetal fibronectin is negative
- There are no signs of infection or membrane rupture
Follow-up Recommendations
- Schedule a follow-up appointment within 1 week
- Consider serial transvaginal ultrasound for cervical length if there are recurrent symptoms
- Educate the patient about the signs and symptoms of preterm labor
Potential Pitfalls and Caveats
- While the current risk is low, approximately 21% of pregnant women have bacterial vaginosis in early pregnancy, which can increase the risk of preterm birth 1. Consider screening if the vaginal discharge appears abnormal.
- Uterine contraction frequency alone has poor sensitivity and positive predictive value for preterm delivery 3, so the decision to discharge is appropriately based on multiple clinical factors rather than just contraction frequency.
- If symptoms worsen or recur, reevaluation is necessary as the clinical situation may change.
This approach prioritizes the patient's well-being while avoiding unnecessary interventions and hospitalization when the risk of imminent preterm delivery is low.