Preterm Labor

International

Preterm Labor
 Preterm Labor
International

Objectives
Definition and Incidence
Etiology
Diagnosis
Management
- Delaying delivery
- Promoting fetal maturity
- When to transfer
- Delivery
 Preterm Labor
International

Definition
regular uterine contractions accompanied by
progressive cervical dilatation and/or
effacement at less than 37 weeks gestation
 Preterm Labor
International

Diagnosis
establish dates
history of contractions, risk factors
abdominal exam for uterine activity
cervical exam - serial if reasonable
sterile speculum exam alone should be done in PPROM
defer digital exam if there is undiagnosed vaginal
bleeding until _______ of placenta is known
 Preterm Labor
International

Establishing the EDD - LMP

Naegele's Rule can be used in conjunction with the
LMP if:
- first day of last menses is known
- period was 'normal'
- cycle is regular and between 24 and 35 days
- no recent hormonal contraception, lactation or
pregnancy (3 subsequent spontaneous periods)
 Preterm Labor
International

Establishing the EDD - When ultrasound is

available
Ultrasound should be used when the LMP is unknown
or criteria are not fulfilled for its use in calculating the
EDD
U/S dating accuracy decreases as gestational age
increases
- 7 - 12 weeks GA 5 days
- 13 - 20 weeks GA 1 week
- 21 - 30 weeks GA 2 weeks
- > 30 weeks GA 3 weeks
 Preterm Labor
International

Establishing the EDD

please tell someone the EDD!
- inform woman of EDD from LMP if appropriate and
reinforce at time of dating and/or 18 week
ultrasound
- document EDD on antenatal forms
- document dates and findings of each ultrasound on
antenatal (include placental location)
good dating is useless if no one but you knows the
EDD and you are not available
 Preterm Labor
International

Incidence

preterm delivery occurs in about 7% of pregnancies

there has been little change in this rate despite new
technologies
 Preterm Labor
International

Significance

preterm birth accounts for 75% of perinatal mortality

significant longterm neonatal/pediatric sequelae
- CNS and neurodevelopmental
- respiratory
- blindness and deafness
 Preterm Labor
International

Etiology
Idiopathic
Antepartum haemorrhage
Preterm prelabor rupture of membranes
Chorioamnionitis
Multiple pregnancy / Polyhydramnios
Incompetent cervix / Uterine Anomaly
Maternal disease
Fetal anomaly
 Preterm Labor
International

Prevention
Effective intervensions
- screening and treating for asymptomatic bacteriuria
- screening and treating for BV in women who have had
a prior preterm birth
Ineffective intervensions
- risk scoring
- bedrest
- avoiding coitus
- home uterine monitoring
 Preterm Labor
International

Predictors

New initiatives and technplogies

- fetal fibronectin
- endovaginal cervical sonography
 Preterm Labor
Fibronectin Test
International

Outcome Sensitivity specificity

Delivery <37 52% 85%

Delivery <34 53% 89%

Delivery within 1 Week 71% 89%
Delivery within 2 Week 67% 89%

Delivery within 3 Week 59% 92%

Leitich & Kaider ,BJOG. 2003 Apr;110 , 20:66-70. Meta-Analysis 40 studies

 Preterm Labor
International

14
 Shortening of the cervix
22 mm
Preterm Labor
International

V shaped cervical dilatation

33 weeks

Residual cervix 9 mm

Funnel shaped expansion of the cervical canal.

31weeks 15
 Preterm Labor
International

Management of Preterm Labor

Four Objectives:
1. Early diagnosis of preterm labor
2. Identify and treat the underlying cause of
preterm labor if possible
3. Attempt to stop labor when appropriate
4. Minimize neonatal morbidity and mortality
 Preterm Labor
International

Management - Prolongation of Pregnancy

less than 40% of patients in preterm labor will be
candidates for tocolysis

Goal of Tocolytic Therapy

Delay delivery when appropriate
- gain 48 hours for corticosteroids
- transport
- optimize personnel
 Preterm Labor
International

Management - Tocolysis Contraindicated

contraindication to continuing pregnancy
e.g. severe pregnancy induced
hypertension, chonoamnionitis intra-
uterine fetal death
contraindication to specific tocolytic agents
 Preterm Labor
International

Tocolytics - No strong evidence for efficacy

Fluid bolus - small trial (n=48), no detected effect
Ethanol
- small trials, no benefit over placebo
- ritodrine more effective in comparative trials
- concerns re: adverse effects
Sedation - no evidence, concern re: adverse effects
 Preterm Labor
International

Tocolytics - No strong evidence for efficacy

Magnesium sulfate
- small, poor quality trials; placebo and comparative
- no benefit shown
 Preterm Labor
International

Tocolytics - Good evidence for efficacy

-sympathomimetics (ritodrine)
- highly effective for delaying delivery in the short term
- no demonstrated effect on neonatal outcome
PG synthetase inhibitors (indomethacin)
- more effective than placebo in delaying delivery
>48 hours and beyond
- no demonstrated positive effect on neonatal outcome
- small trials, concern re: adverse effects
Calcium channel blockers (e.g. nifedipine)
 Preterm Labor
International

Side Effects of -mimetics

tachycardia - maternal and/or fetal
headache and nasal congestion
hyperglycemia / hypokalemia
hypotension
pulmonary edema
- multiple gestation
- other interventions
- infection
myocardial ischemia
 Preterm Labor
International

Contraindications to -mimetics
Maternal cardiac disease - structural, ischemic, rhythm
Significant antepartum haemorrhage
Poorly controlled medical condition
- type I diabetes mellitus
- hyperthyroidism
Contraindication to prolongation of pregnancy
- preeclampsia or other medical indication
- chorioamnionitis, suspected fetal compromise
- mature fetus / imminent delivery / IUFD or anomaly
 Preterm Labor
International

Minimizing Neonatal Adverse Outcomes

Respiratory distress syndrome (RDS) is a major
concern with preterm delivery
Incidence of RDS has improved due to newer therapies
RDS plays a role in several other conditions
- intraventricular haemorrhage (IVH)
- necrotising enterocolitis (NEC)
- persistent pulmonary hypertension (PPHN)
- other respiratory conditions
 Preterm Labor
International

Meta-analysis of Antepartum Steroids

15 trials evaluating antenatal glucocorticoids for the

reduction of RDS in preterm infants (>24 weeks and
< 34 weeks)
an incomplete course of steroids may still be beneficial

P. Crowley CCPC Review No. 02955

 Preterm Labor
International

Effect of Corticosteroids on Neonatal Outcomes

RDS
IVH
NEC
Perinatal Infection

Neonatal Death
0.1 1 10
Odds Ratio (95% Confidence Interval)
P. Crowley CCPC Review No. 02955
 Preterm Labor
International

Recommendations
Which steroid ?
betamethasone 12 mg IM q 24h x 2 doses (or q 12h)
dexamethasone 6 mg IV q 12h x 4 doses (or q 6h)

Beware
steroids in the presence of infection
steroids in combination with tocolytics in multiple
gestation or diabetes
 Preterm Labor
International

Recommendations
When should steroid therapy be instituted?
lower gestation limit 22 - 24 weeks
upper gestation limit 34 - 36 weeks
prophylactic administration depends on
diagnosis and risk
repeated administration unknown
 Preterm Labor
International

Recommendations
Who is a candidate for antenatal steroid therapy?
Considerations
preterm labour YES cause
preterm PROM YES infection
hypertensives YES urgency
diabetics YES type, sugars
IUGR YES urgency
multiple gestation YES pulmonary edema
 Preterm Labor
International

Decision to Transport
Available level of neonatal or obstetrical care
Available transport and skilled personnel
Travel time
Risk of journey - maternal and fetal/neonatal well-being
Risk of delivery en route
- Parity, length of previous labour
- State of cervix
- Contractions
- Response to tocolytics
 Preterm Labor
International

Transport Plan
Copies of antenatal forms, lab results, ultrasounds
Communication
- with patient and family
- with receiving physician re: indication, stabilization,
optimization, mode of transport, E.T.A.
Appropriate attendant
IV access, indicated medications, appropriate equipment
Assess patient immediately prior to transport
 Preterm Labor
International

Preterm Delivery
caesarean not indicated on basis of prematurity
recommendation for C/S of breech < 31 weeks not
based on good evidence
prophylactic outlet forceps not indicated
routine episiotomy not indicated
personnel skilled in neonatal resuscitation present
 Preterm Labor
International

Location of Preterm Birth

Best Level III Hospital (Nicu)

Level II Hospital

Level I Hospital

During Transport
Worst
 Preterm Labor
International

Conclusion
Prompt and accurate diagnosis
Identify and treat underlying cause if possible
Attempt to prolong pregnancy if appropriate
Intervene to minimize neonatal mortality and morbidity
- antenatal steroid therapy
- maternal transport
- optimize local resources if unable to transport
 Preterm Labor
International

Prelabor Rupture of the

Membranes (PROM)
 Preterm Labor
International

Objectives

Definition

Diagnosis

Management - Preterm and Term

 Preterm Labor
International

Definition

rupture of the membranes before the onset of labor

preterm - < 37 weeks gestation (PPROM)
term - 37 weeks gestation (TPROM)
 Preterm Labor
International

Latent Period
time from rupture until onset of labor
earlier the gestation the longer the latent period

At term - 90% go into labor within 24 hours

At 28 - 34 weeks
50% go into labor within 24 hours
80 - 90% go into labor within 1 week
 Preterm Labor
International

Etiology of PROM
idiopathic
infection (e.g. bacterial vaginosis)
polyhydramnios
cervical incompetence
uterine abnormality
following cervical cerclage or amniocentesis
trauma
 Preterm Labor
International

Diagnosis of PROM
history
sterile speculum exam ( avoid digital exam)
glistening, washed out vagina
fluid pooling in posterior fornix
free flow from cervix
pH testing of fluid (nitrazine paper) - non specific
ferning
ultrasound - PROM less likely if normal fluid volume
 Preterm Labor
International

Complications of PROM - Term

fetal / neonatal infection

maternal infection

umbilical cord compression / prolapse

failed induction resulting in cesarean section

 Preterm Labor
International

Complications of PROM - Preterm

preterm labor and delivery
fetal / neonatal infection
maternal infection
umbilical cord compression / prolapse
failed induction resulting in cesarean section
pulmonary hypoplasia (early, severe oligohydramnios)
fetal deformation
 Preterm Labor
International

Management - General
assess maternal and fetal well-being
confirm diagnosis
assess cervical status by speculum exam (sterile)
avoid digital cervical exam
assess for conditions requiring concurrent management
e.g. presence of temperature or maternal or
fetal tachycardia
assess for indications for immediate delivery
 Preterm Labor
International

Management - Term (> 37 weeks)

avoid digital cervical exam
assess for infection
consider need for antibiotics if prolonged
PROM .
expectant or active management depending on
circumstances and patient preference
 Preterm Labor
International

Management - Preterm (34-37 weeks)

avoid digital cervical exam, consider antenatal strd.
Antibiotic prophylaxis for GBs ampisilin 3 x 500 mg
p.o and erithromicyn 3x250mg po for 7 days.
surveillance for infection - clinical (monitor maternal
temperature and pulse, fetal heart rate)
appropriate antibiotics for chorioamnionitis if develops
 Preterm Labor
International

Management - Preterm (< 34weeks)

avoid digital cervical exam
steroids
antepartum and intrapartum antibiotics to mother
surveillance for infection - clinical (monitor maternal pulse and
temperature, fetal heart rate, presence of uterine irritability)
appropriate antibiotics for chorioamnionitis if develops
consider transfer to higher level of care center if appropriate
expectant management (possibly outpatient)