Preterm Labor
&
PROM (OG13.2)
Learning objectives-
Define preterm labour and
PROM
Describeetiopathogenesis of
preterm labour and PROM
Discussneonatal complications
and management of preterm
labour.
Preterm Labor
When onset of labor prior to completion of
37 weeks (259 days) of pregnancy, after
the attainment of period of viability is called
preterm labor.
The lower limit varies in different countries
WHO- 22wks and 500gm
United kingdom- 24wks
India- 28wks
Incidence
It varies 5-15% in different part
of world & In
Aetiology
In >30% cases exact cause of
preterm labor is not known
Certain risk factors which
increases the incidence of
preterm labor.
Risk factors
Genitaltract infection- Group B streptococci
- Bacterial Vaginosis
- Chlamydia, Gonorrhea
Ante partum Hemorrhage
Overdistended Uterus- polyhydromnios
- Multiple pregnancy
Uterineanomalies -
unicornuate,Bicornuate
-septate,arcuate, Fibroid uterus
Incompetent Cervical os
Acute fever & maternal illness
Premature rupture of membrane
Lowsocioeconomic status, poor nutrition, &
anaemia
Smoking & tobacco addiction
U TI
Pervious H/o preterm labor (17-40%)
Iatrogenic- Induction of labor without
knowing
EDD
Diagnosis of PTL
Regular uterine contraction with or without
pain(at least one in every 10 minutes)
Cervical effacement >80%
Cervical dilatation > 2 cm
Length of cervix (measured byTVS) < 2.5
cm & funneling of internal OS
Management –
To
arrest preterm labour, if not
contraindicated
Management of labour.
Effective neonatal care.
Preterm Labor
Can be
1. Advanced PTL
2. Early PTL
3. Threatened PTL
Advance PTL
Diagnosis:
-Regular uterine
contraction >4 in 20 mts or
>8 in 60 mts
-Cervix >3 cm dilated
- 80% effaced
Management of Advanced PTL
Allow delivery if
-Cx is >4cm dilated
-Signs of chorioamnionitis
-Baby malformed
-Severe placental insufficiency
But if Cx is <4cm and none of the above is present
give tocolysis,corticosteroid & antibiotic if indicated
Aim – to give corticosteroid to prevent RDS &IVH in
baby & mother with fetus in utero can transfer to place
where neonatal care facility available
Early PTL
Diagnosis:
-Regular uterine contraction
-Cervix > 1 cm & <3 cm dilated
-Cervix > 80% effaced
Management of Early PTL
If there is signs of –
Chorioamnionitis
Congenital anomaly in fetus
Mother& fetus condition is not
good
Allow labour and delivery.
But if - Fetal condition is not compromised
- Maternal condition is good
- No signs of chorioamnionitis
- Membranes are intact
Then Expectant management includes-
Expactent management include—
- Bed rest in left lateral position
-hydration
- Antibiotic if infection is evident
-cervical cerclage( with prior
preterm birth and short cervix in
present pregnancy)
- Tocolysis
-Neuroprotection
- Corticosteroid if pregnancy < 34
weeks
Threatened PTL
When there are regular uterine
contractions,
but no cervical changes clinicaly,
length of cervix <2.5cm on USG &
GA <37 wks- Threatened PTL
Diagnosis is by – Clinical examination
- USG
- Detection of fetal
fibronectin
in cervical discharge
FFN in cervical discharge is usually absent
between 24-34wks , so if it is present it is
predictor of PTL
IfFFN is negative in cervical discharge
indicates no delivery with in 7 days.
If threatened PTL is diagnosed by clinically,
USG & FFN then give tocolysis and
corticosteroid to woman.
Doses of Corticosteroids
Betamethasone- 2 doses,12mg IMI,24 hours
apart.
OR
Dexamethasone- 6mg IMI 12 hrly total 4 doses
Corticosteroids are beneficial when delivery
occurs at least 48 hrs after 1st dose
Neuroprotection- 28 to<32
week
4gm i.v over 15 minute
continued by1gm/hour until
maximum 24 hour and
minimum for 4 hour.
Tocolytic Drugs
Various tocolytic drugs which
can be used are :-
* Nefedipine
* Betamimetics –
Isoxsuprine
-Terbutaline
- Retrodine
* Indomethacin
* Mgso4
* Nitroglycerine
Doses of Tocolytic drugs
Nefedipine
It is the best first line tocolytic
It
is a calcium channel blocker causes smooth
muscles relaxent
Doses – Initial 20-30mg orally followed by
10mg
4-6hrly till uterine contraction cease
f/b
10mg 8hrly for about 1wk.
Side effects- headach,hypotension,nausea
flushing
Bitamimetic Tocolytics
Turbutaline
It can be given IV or subcutaneous
For IV- Dissolve 5mg of terbutaline in 500ml
of RL, each ml contains 10ug
-Start with 5ug (o.5ml)/min. &
increase
the dose of 5ug every [Link]
uterine contraction stops.
-Maximum dose 30ug/min.
Subcutaneous dose-o.25mg every 3-4 hours
Ritodrine
Betamimetic drug causes smooth muscle
relaxation by B2 receptor stimulation
Doses- given by IV infusion
- Start with 100ug/min. & increase
the
dose by 50ug every 10-20 min. till
the uterine contraction stops or
maximum dose of 350ug
- Continue infusion for 12hrs after
the
Isoxsuprine
Doses- 0.2-0.5mg/min I V infusion for
12hrs
followed by 10mg IMI every 6-8
hour for
24hours
Side effects of Beta mimetics
Headache
Palpitation , Tachycardia
Hypotension , Hypokalemia
Indomethacin
It is an excellent tocolytic but is not used as
first line because it causes constriction of
ductus arteriosis.
Dose – Initial dose 25-50mg orally followed
by 25mg every 4-6 hours for 3days.
Side effects – Heart burn, [Link]
Thrombocytopenia, asthma
Mgso4
Dose– 4-6 gm (20% solution) i.v. slow in
20-30
min. followed by an infusion of 1-
2gm/hr
& continue for 12 hrs after the
contraction
have stopped
Side effects- Headache , flushing
- Muscular weakness
- Rarely pulmonary oedema
Nitro-glycerine
Itis usually given in form of
patch
Dose – 0.1- 0.4 mg/ hr
Side effects – Tachycardia
- Headache
- Hypotension
Labour management-
Routien
caesarean delivery not
recommended
<34week with breech are
generally delivered by
caesarean section.
(PROM)
Premature Rupture Of Membranes
or
Prelabour Rupture Of Membranes
Spontaneous rupture of fetal membrane any
time after the period of viability but before
the onset of labor is called PROM. When it
occurs before 37 wks completed gestation it is
called PPROM.
Incidence – 10%
Neonatal complication-
Birth asphyxia
Hypothermia
Hypoglycemia
Hyperbilirubenemia
Retinopathy of prematurity
Meningitis
Necrotising enterocolitis
IVH
Causes of PROM
Polyhydromnios
Multiple pregnancy
Incompetent Cervix
Poorly applied presenting part in unstable
lie and malpresentations
Traumatic- ECV, amniocentesis
Weakness of chorion & amnion-
developmental or
inflammatory,chorioamnionitis
Diagnosis
H/O- discharge of fluid p/v
P/S-
examination shows liquor coming out
through cervical os it may be clear or
meconium stained.
Sometimes liquor is not appreciable through
os
D/D – liquor amnii
- urine
- vaginal discharge
Confirmatory Tests for liquor Amnii
Fern Test- Take the sample of vaginal fluid
on a slide & allow it to dry then look under
microscope. Crystallization of liquor looks
like fern.
Nitrazine Test- Normal vaginal PH is 4.5-
5.5 but PH of liquor is 7-7.5. Put the
Nitrazine paper on vaginal discharge Liquor
turns the Nitrazine paper deep blue.
Nile blue sulphate Test- when
centrifuged cells of watery
discharge is stained with Nile
blue sulphate it shows, orange
blue coloration of cells indicates
presence of exfoliating fetal
cells in liquor
Indigo-carmine Test- When other tests
are negative and still doubt of leaking.
Inject
2-3cc of indigo carmine in amniotic cavity
& put a tampon in vagina wt. for ½-1hr if
tampon turns blue indicate liquor.
Detection of fetal fibronectin in endocervix
& vagina between 24-34 wks of GA
indicates PROM
USG - Shows less liquor
Complications of PROM
Maternal-
- Increased liability to infection
- chorioamnionitis
- Premature placental
separation
- Postpartum endometritis
Fetal -
- Cord prolapse
- Premature labor & hyaline
membrane disease
Management ofPROM
Initial
Assessment- main
objective of the initial
assessment are:-
- Confirm the diagnosis of
PROM
- To determine the gestation of
the fetus
- To identify the women who
need to deliver
Management of PROM
If Pregnancy is ->37 weeks
- Congenital anomalies
- Fetal distress , cord prolapse or
- Signs of chorioamnionitis
Then deliver the patient.
Induction of labor- if no contraindication
Management of PPROM
Balance between risk of infection in expectant
management & Premature labor
Shift the patient where the facility for neonatal care is
available .
If pregnancy is >34 and <37 weeks
- Haemogram, cervical swab c/s
- Antibiotics
- Careful watch on signs of chorioamnionitis
Maternal & fetal conditions
- If no spontaneous labor in 24-48hrs-induction
of labor
If pregnancy <34 weeks
Expectant Management-
The aim is to prolong the pregnancy for fetal
maturity
- Bed rest
- send haemogram & Cervical swab c/s
- give corticosteroid & tocolysis if contraction
+nt
- Antibiotics
- Watch for signs of chorioamnionitis,
Maternal & fetal condition.
Signs of
chorioamnionitis
Temperature > 100.4*F and 2 or more of:
-Maternal tachycardia pulse >100/min.
-Uterine Tenderness
- Foul smelling vaginal discharge
- Leukocytosis15000cmm
- C-reactive protein >2.5mg%
- Fetal tachycardia >160 min
if there is no other site of infection
Thank
You…..