PRETERM LABOUR

AND
PREMATURE RUPTURE OF
MEMBRANES
Objectives
Definitions
Introduction, epidemiology and causes
Clinical example & Differential diagnosis.
Diagnosis and management of PTL, including tocolysis
and steroids prophylaxis.
Management of PT delivery.
Diagnosis & management of PROM

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).


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 8 28 of birth.
Perinatal mortality (PNM) rate = (SB+NND)/1,000 births
Introduction
Preterm labour (PTL) and preterm delivery is a
major complication of pregnancy (7%).
The commonest cause of perinatal mortality
(75%).

Introduction
One third(1/3
rd
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.

Etiology Of Preterm Labor
Idiopathic (30%)

Fetal factors
PROM (30%)
Multiple pregnancy
Polyhydramnios
Placental pathology
Fetal anomalies


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

Etiology Of Preterm Labor
Placental Factors
Antepartum hemorrhage
Placental insufficiency
So etiologies may be are fetal, maternal or
placental

Premature Rupture of Membranes
Incidence

10% at term ( 37 weeks)

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

Premature Rupture of Membranes
Etiologies and Risk Factors
Unexplained despite theories
Infection
Collagen abnormalities
Incompetent cervix or cervical insufficiency
Polyhydramnios

Premature Rupture of Membranes
Infection
Hemolytic streptococcus (group B)**
Bacterial Vaginosis (Gardnerella vaginalis)
Ureaplasma urealyticum
Mycoplasm hominis
STDs

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.

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
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.

Management of Preterm Labor
1. Admit to labor room
2. Start IV hydration
3. Sedation: Pethidine 50-100 mg IM/IV
4. CBC, Blood group and type and hold, Urinalysis
5. External cardiotocography
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

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.
Discuss with neonatologist
Availability of incubator.
Survival and morbidity.
Mode of delivery.
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.
Tocolysis
Attempt to stop uterine contractions using drug agents.
Effective only for 48 hours.
Indicated for
1. 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




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

Tocolysis
Contraindications

1. Maternal conditions requiring termination of the
pregnancy
Severe hypertension, preeclampsia or eclampsia.
Uncontrolled diabetes, especially with ketoacidosis.
Chorioamnionitis.
Severe vaginal bleeding, e.g., abruptio placentae.
Tocolysis
Contraindications
2. 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

-mimetic agents
Specific contraindications

Maternal cardiac rhythm
disturbance or other cardiac
disease

Poorly controlled diabetes,
thyrotoxicosis, or hypertension.


Complications

Hyperglycemia
Hypokalemia
Hypotension
Pulmonary edema
Cardiac Arrhythmias
Myocardial ischemia
Maternal death

Prophylactic Steroids
Reduction of
Respiratory distress syndrome
Intraventricular hemorrhage
Necortizing Enterocolitis
Neonatal Death

Prophylactic Steroids
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.
Prophylactic Steroids
No proven benefit for multiple gestation.
No proven benefit for weekly repeated courses
(recent evidence that it may cause neonatal
infection and mortality)

Prophylactic Steroids
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
Prophylactic Steroids
Contraindications to Steroid Therapy
1. Delaying delivery for 48 hours is not possible or
unadvisable
2. Gestational age of 34 weeks or greater
3. L/S ratio greater than 2
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.
Management of Preterm Delivery
1. The birth should be gentle and slow.
2. Episiotomy may reduce the pressure on the fetal
head.
3. Spontaneous delivery is preferred. Low forceps
may be used to guide head over perineum

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.
PROM Diagnosis
1. History

Sudden gush of fluid per vagina, wetting the thighs
with subsequent dripping.
No symptoms of UTI or urinary incontinence.
No H/O vaginal discharge / odour / itching.


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.
PROM Diagnosis
3. Ultrasound

Role is mainly confirmatory to speculum exam.

If history is suggestive but speculum is
negative,
finding of oligohydramnios on ultrasonography
is highly suggestive of ruptured membranes.
PROM Diagnosis
The following tests lack adequate sensitivity and/or
specificity:
Fetal Fibronectin: in vaginal secretions.
Fern test of 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 sulfate orange staining fetal squamous cells in the
suspected amniotic fluid.


Complications of PROM
Premature Labor
Chorioamnionitis
Cord prolapse
Cord compression and FHR decelerations.
Lung hypoplasia
Limb deformity
Malpresentations
Cesarean births
Hospitalization & costs


Management of PROM
Before 36 weeks: Conservative and expectant

At/After 36 weeks: Delivery after 24 hours
latency to allow onset of spontaneous labor; mode
of delivery depends on obstetrical factors
Conservative Management of PROM
I. Confirm diagnosis:
Ultrasound on admission
Assess AFV
Anomalies
Estimated weight


Conservative Management of PROM
II. Avoid Complications:
Bed rest.
Ampicillin 1 gram q 6hrs x 48 hrs.
Avoid pelvic exams.
Prophylactic steroids.


Conservative Management of PROM
III. Test for complications:
Instruct patient on symptoms of
chorioamnionitis, PTL, fetal movement.
Temperature every 6 hours.
CBC + differential.




Conservative Management of PROM
IV. Evaluate fetal well-being:
NST daily.
Ultrasound weekly for BPP, growth
every 2-3 weeks.



Conservative Management of PROM
V. Prepare for outcome:
Discuss prognosis with pediatrician.
Social and psychological support.



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
Symptoms and signs of chorioamnionitis
Fever > 38'C
Persistent maternal tachycardia
Leukocytosis
Purulent vaginal discharge
Uterine tenderness
Persistent fetal tachycardia
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 is
preferred.