PRETERM BIRTH

CLASSIFICATION
ETIOLOGY
CLINICAL FEATURES
GESTATIONAL AGE
BIRTH WEIGHT
1) Infection mostly subclinical
1. Cramping lower ab pain
infxn of choriodecidual space
that starts irregular & with
Mild preterm
Low birth weight:
2)
Overdistension
of
uterus

<2.5kg
Late preterm: 34-36th wk
time in freq & intensity &
polyhydromnios, multiple
Very low birth weight:
Moderate preterm: 32becomes more regular.
pregnancy
<1.5kg
2. Low back ache
33rd wk
3) Vascular (placental
Extremely low birth
3. Bloody vaginal discharge
abnormalities)
Very preterm: 28-31st wk Weight: <1kg
4) Intercurrent illness
Extremely preterm: 24pyelonephritis, pneumonia. By
27th wk
either direct spread or indirect
chemical triggers eg endotoxins.
5) Cervical weakness
6) Idiopathic esp in mild preterm
births
7) Iatrogenic
MANAGEMENT
INVESTIGATIONS
1. Admit at least 24h
1. Sterile speculum exam amniotic fluid pooling
2. According to GA
2. Transvaginal USS asses cervical dilation.
<34wks antenatal steroids (given in 2 doses 12h apart)
Normal cervix ~3.5cm in length.
3. Prophylactic antibiotics (erythromycin until culture indicates
3. Vaginal swab for GBS
otherwise)
4. Urinalysis & culture (UTI main cause of preterm
4. Tocolytics for 48h until steroids works or till transfer to a hosp
labor)
with good NICU facility
6. fetal fibronectin (fFN)
When to ask?
- cervical length >3.5cm& not in labor no need
- cervical length <2n5cm & in labor no need
- 2.5 < cervical length < 3.5cm need fFN
Braxton-Hicks contraction @ False Labor @ Practice Contractions - Sporadic uterine contractions that start around 6
weeks, to aid body in its preparation in birth. Infrequent, irregular, only mild cramping.
(Preterm labor progressively & becomes more intense & regular with time)

PREMATURE RUPTURE OF MEMBRANE

Amniorrhexis (spontaneous rupture of membranes) before the onset of uterine contractions.
Preterm PROM (PPROM) preterm (<37 wks) with ruptured membrane, with or without contractions.
RISK FACTOR
HX & PE
LAB TESTS
CONSIDERATIONS
o Hx of previous
Hx: Vaginal loss of fluid
Pulm
Management depends a
R/O episodic urinary incontinence, leukorrhea or
maturation
lot to GA at time of memb
PPROM
loss of cervical mucus plug.
studies.
rupture.
o Vaginal & cervical
PE:
Pooling
of
amniotic
fluid
in
posterior
vaginal
Gram
stain
&
Also quantity of remaining
infxn
culture.
amniotic fluid.
o Antepartum bleeding fornix.
Confirm by:
o Cigarette smoking
1) NItrazine paper (alkali blue)
Amniotic fluid index (AFI):
have a particularly
2)
Microscopic
exam
(ferning)
Vertical axis of amniotic
strong association
Sterile
vaginal
speculum.
fluid present in four
with PPROM
*No digital vaginal exam!!
quadrants. Abnormal is
o Abnormal memb
USS:
R/O
fetal
anomalies,
assess
GA
&
amniotic
<5cm.
physiology
fluid
volume.
o Incompetent cervix
o Nutritional
deficiencies
MANAGEMENT
GA <24 wks (Pre24wks > GA > 36wks (Preterm PROM)
GA 36wks or
viable PROM)
more
(PROM)
Risk of dev of
A] Conservative Expectant Management - To continue pregnancy until the lung profile is Induce labor
pulmonary
mature. Diagnose chorioamnionitis at an early stage to minimize fetal & maternal risks. after 6-12h
hypoplasia due
Chorioamnionitis Maternal temp >38C with no other sites of infxn, fetal tachy,
if no
to fetal crowding
tender uterus, uterine irritability on NST. Presence of bacteria by Gram/culture.
spontaneous
with thoracic
Ampicillin/erythromycin prolongs interval of delivery in pt with PPROM.
contractions
compression,
When diagnosed, ampicillin + gentamycin after taken enough cultures. Then induce
occur.
restriction of fetal labor.
breathing and
C-section if cervix unfavorable, fetal involvement or presence of active genital herpes.
disturbances of
B] Tocolytic Therapy To gain time for pulm maturation. Unsuccessful if with infection.
pulm fluid
C] Cortisteroids Use - Given to pt with PPROM only up to 32 wks GA.

production & flow.

Positional skeletal
abnormality eg
talipes
equinovarus.

D] Outpatient Management
Can consider after inpatient observ for 2-3d without any evidence of infxn.
Rules of eligibility: Pt reliable, fully informed of risks, prepared to participate in her own
care. Fetus vertex. Cervix closed.
Restrict physical activity. No coitus. Monitor temp at least 4x/d. Rush to hosp if >37.8C.
Seen weekly to measure temp, NST after 28wk, evaluate baseline fetal heart rate & AFI.
Contraindicated in oligohydramnios.