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Definitions

Prematurity: delivery before 37 weeks

Preterm Labor: Onset of labor at gestation less than 37

completed weeks from the first day of the last menstrual

period.

Preterm Delivery: Birth before 37 weeks.

Premature rupture of membranes: Spontaneous rupture of

membrane prior to the onset of labor (= Pre-labor rupture

of membrane). It can be either at term (PROM) or preterm

(PPROM).

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Definitions

Low birth weight (LBW): < 2500 grams .

Very LBW: < 1000 grams.

Stillbirth (SB): Intrauterine death after 20 weeks. Neonatal death (NND): death within 28 days after birth.

Early NND: death in first 7 days of birth.

Late NND: death between days 828 of birth. Perinatal mortality (PNM) rate = (SB+NND)/1,000 births

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Introduction

Preterm labour (PTL) and preterm delivery is a

major complication of pregnancy (7%).

The commonest cause of perinatal mortality

(75%).

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Introduction

One third(1/3rd of PTL cases are associated with

preterm premature rupture of membranes

(PPROM).

PPROM increases the risk of maternal and fetal

infection & as well as PTL.

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Etiology Of Preterm Labor

Maternal Factors

Prior history of preterm labor increases risk of

PTL with each pregnancy (16-32%)

Socioeconomic status(low)

Maternal disease(medical illnesses)

Uterine anomalies and tumours

Dilated cervix

Smoking & cocaine use

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Etiology Of Preterm Labor

Placental Factors

Antepartum hemorrhage

Placental insufficiency

So etiologies may be are fetal, maternal or

placental

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Premature Rupture of Membranes

Incidence

10% at term (37 weeks)

30% at preterm (Preterm PROM) < 37 weeks.

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Etiologies and Risk Factors

Unexplained despite theories

Infection

Collagen abnormalities

Incompetent cervix or cervical insufficiency

Polyhydramnios

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Infection

Hemolytic streptococcus (group B)**

Bacterial Vaginosis (Gardnerella vaginalis)

Ureaplasma urealyticum

Mycoplasm hominis

STDs

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Clinical Example

A 30 year old woman presents at 31 weeks

gestations having lower abdominal pain and

leaking clear fluid from the vagina.

Discuss her management.

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Differential Diagnosis

DDx Of vaginal leaking

PROM PTL

Urine Incontinence

Vaginal discharge

DDx of lower abd. Pain

PTL PROM

Braxton-Hicks contractions

Placental abruptio

UTI

Musculoskeletal

Fibroid or adnexal pathology Non-gyn e.g. appendicitis

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Preterm labor

Diagnosis

Uterine contractions: 4 in 20 minutes or 8 in 60 minutes. OR

The cervix is dilated to 2 cm or is effaced at least 80 percent. OR

Serial examinations, preferably by the same observer, reveal

changes in the cervix. OR

The membranes are ruptured with contractions.

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Management of Preterm Labor

6. Establish diagnosis

Assess uterine activity

Assess condition of cervix

Rule out other differential diagnosis

7. Establish gestational age by reviewing date and

ultrasound

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Management of Preterm Labor

Two possible scenarios:

1. Diangnosis not confirmed

No active treatment

Bed Rest

Transfer to ward and home when pain settled

2. Diagnosis confirmed

Tocolysis is started if indicated

Prophylactic steroids for pulmonary maturity

Ampicillin 1 g q 6 hr IV

Consult neonatologist to discuss prognosis

Plan mode of delivery.

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Discuss with neonatologist

Availability of incubator.

Survival and morbidity.

Mode of delivery.

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Perinatal morbidity:

Respiratory distress. Infection: lung,blood,csf,urine

Intraventricular hemorrhage.

Necrotizing enterocolitis.

Chronic lung disease

Cerebral palsy

Developmental delay

Retinopathy and hearing deficits.

Feeding issues.

Other complications.

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Tocolysis

Attempt to stop uterine contractions using drug agents.

Effective only for 48 hours.

Indicated for1. Allowing prophylactic steroids to act

2. During transfer of patient to another center

3. Treating uterine hypercontractions

4. Around surgery during pregnancy e.g. appendectomy

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Tocolysis

Agents used:

Betamimetic drugs; mainly Ritodrine (Yutopar) and

Terbutaline Prostaglandin synthetase inhibitions; indomethacin and aspirin.

Calcium antagonists e.g. magnesium sulphate & nifidipine

Oxytocin receptor blockers e.g atosiban

Glyceryl trinitrate

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Tocolysis

Contraindications

1. Maternal conditions requiring termination of thepregnancy

Severe hypertension, preeclampsia or eclampsia.

Uncontrolled diabetes, especially with ketoacidosis.

Chorioamnionitis. Severe vaginal bleeding, e.g., abruptio placentae.

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Tocolysis

Contraindications2. Fetal conditions

Fetal death. Fetal malformation incompatible with extrauterine survival.

Fetal distress.

Intrauterine growth retardation (IUGR).

3. Gestational age over 34 weeks or the fetal weight is over 2500

g, or pulmonary maturity is established

4. Imminent delivery. Cervical dilatation greater than 4 cm

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Prophylactic Steroids

Reduction of

Respiratory distress syndrome

Intraventricular hemorrhage Necortizing Enterocolitis

Neonatal Death

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No increased risk of maternal or neonatal

infection if single dose.

Best benefit for deliveries up to 34 weeks.

Best benefit if treatment to delivery interval is 24

hours to 7 days.

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No proven benefit for multiple gestation.

No proven benefit for weekly repeated courses(recent evidence that it may cause neonatal

infection and mortality)

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Available agents

Betamethazone 12 mg IM q 24 hrs x 2 Dexamethazone 6 mg IM q 12 hrs x 4

Hydrocortisone 2 g IM x 1

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Contraindications to Steroid Therapy

1. Delaying delivery for 48 hours is not possible or

unadvisable2. Gestational age of 34 weeks or greater

3. L/S ratio greater than 2

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Management of Active Preterm

Labor

1. Oxygen by mask to mother.

2. Continuous fetal monitoring.3. Cautiously use analgesics and sedatives.

4. Epidural block is the analgesic of choice.

5. Delay rupturing the membranes.

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Management of Preterm Delivery

1. The birth should be gentle and slow.

2. Episiotomy may reduce the pressure on the fetalhead.

3. Spontaneous delivery is preferred. Low forceps

may be used to guide head over perineum

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Management of Preterm Delivery

4. Breech is at risk of cord prolapse and trauma and

cesarean section is indicated.

5. Cephalic can have vaginal birth.

6. Lower uterine segment is not well formed in

extreme prematurity and cesarean can be

difficult.

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PROM Diagnosis

1. History

Sudden gush of fluid per vagina, wetting the thighswith subsequent dripping.

No symptoms of UTI or urinary incontinence.

No H/O vaginal discharge / odour / itching.

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PROM Diagnosis

2. Sterile speculum examination

Escape of fluid from the cervix.

The most diagnostic; sensitive & specific test.

Swab for general culture as well as for GBS.

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PROM Diagnosis

3. Ultrasound

Role is mainly confirmatory to speculum exam.

If history is suggestive but speculum isnegative,

finding of oligohydramnios on ultrasonographyis highly suggestive of ruptured membranes.

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PROM Diagnosis

The following tests lack adequate sensitivity and/or

specificity:

Fetal Fibronectin: in vaginal secretions.

Fern testof cervical mucus due to high estrogen content in the

amniotic fluid bathing the cervical mucus

Nitrazine Test: Paper changes color if exposed to a more

alkaline media (amniotic fluid).

Nile blue sulfateorange staining fetal squamous cells in the

suspected amniotic fluid.

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Complications of PROM

Premature Labor

Chorioamnionitis

Cord prolapse

Cord compression and FHR decelerations.

Lung hypoplasia

Limb deformity

Malpresentations Cesarean births

Hospitalization & costs

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Management of PROM

Before 36 weeks: Conservative and expectant

At/After 36 weeks: Delivery after 24 hourslatency to allow onset of spontaneous labor; mode

of delivery depends on obstetrical factors

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Conservative Management of PROM

I. Confirm diagnosis:

Ultrasound on admission

Assess AFV

Anomalies

Estimated weight

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II. Avoid Complications:

Bed rest.

Ampicillin 1 gram q 6hrs x 48 hrs.

Avoid pelvic exams.

Prophylactic steroids.

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III. Test for complications:

Instruct patient on symptoms ofchorioamnionitis, PTL, fetal movement.

Temperature every 6 hours.

CBC + differential.

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IV. Evaluate fetal well-being:

NST daily.

Ultrasound weekly for BPP, growth

every 2-3 weeks.

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V. Prepare for outcome:

Discuss prognosis with pediatrician.

Social and psychological support.

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Chorioamnionitis / Endometritis

May present with or without generalized sepsis

Risks factors

Length of latent period (PROM to delivery).

Mode of delivery, higher in cesarean section.

Maternal bacterial colonization e.g. GBS

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Symptoms and signs of chorioamnionitis

Fever > 38'C

Persistent maternal tachycardia

LeukocytosisPurulent vaginal discharge

Uterine tenderness

Persistent fetal tachycardia

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Management of chorioamnionitis

Vaginal and blood cultures are taken

Wide-spectrum IV antibiotics:

Ampicillin 2g q6hrs + Gentamicin 80 mg q8h +metronidazole 500 mg q8hr OR

Clindamycin 600 mg q8 hr + Gentamicin

Termination of pregnancy; vaginal delivery ispreferred.

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PROM 1.ppt

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