PREPARED BY MOSES KAZEVU

PRETERM LABOR

PRETERM LABOR
• In pregnancy term refers to the gestational period from 37 weeks to 40+7 weeks
counting from first day of the last menstrual period, with preterm births
occurring between 24 weeks and 36+6 weeks.
• Although earlier births are referred to as miscarriages, occasional survivors
are seen after delivery at 23 weeks.
• Preterm labor (premature labor) is defined as labor (contractions with cervical
dilation) occurring before 37 completed weeks (<259 days) counting from the
first day of the last menstrual period.
• Late preterm labor is birth of an infant between 34 and 36 weeks gestation.
These infants do better than those born before 34 weeks.
• The lower limit of gestation is not uniformly defined; in developed countries
it is at 20 weeks while in developing countries it is at 28 weeks.
• It affects 5-10% of all pregnancies.
• It accounts for around 75% of perinatal mortality.

RISK FACTORS
• These include:
➢ Complications of pregnancy
o Maternal
▪ Hypertensive disorders of pregnancy (pre-eclampsia)
▪ Antepartum hemorrhage
▪ Premature rupture of membranes (PROM)
▪ Polyhydramnios
▪ Uterine anomalies: Cervical incompetence and Malformation the
uterus
▪ Maternal pyrexia, associated with urinary infection (bacterial
vaginosis, beta-hemolytic Streptococcus, Bacteroides, chlamydia
and mycoplasma), as well as asymptomatic bacteriuria or recurrent
UTIs.
▪ Maternal chronic disease: Hypertension, nephritis, diabetes,
decompensated heart lesion, severe anemia, low body mass
o Fetal
▪ Multiple pregnancy
▪ Congenital malformations
▪ Intrauterine death
o Placental
 ▪ Placenta previa
▪ Placenta abruption
▪ Infarction and thrombosis
➢ Maternal factors
o Abdominal operation
o Pregnancy following assisted reproductive techniques.
o Smoking
o Low socioeconomical and nutritional status
o Maternal stress
o Previous pre-term labor
o Previous history of induced or spontaneous abortion
➢ Iatrogenic: indicated preterm delivery due to medical or obstetric
complications.
➢ Idiopathic- the majority (50%), it is believed that the systems involved in
initiating labor at term are activated.

CAUSES
• There are 4 major causes:
➢ Stress
➢ Inflammation
➢ Placental abruption
➢ Abnormality in uterine distension

STRESS
• Includes both physical and emotional stress.
• The stress activates the hypothalamic-pituitary-adrenal axis in the mother.
• When the axis is activated the stress hormones activate preterm labor.
• If the fetus undergoes stress this also exacerbates the occurrence of preterm
labor and activates the fetal hypothalamic-pituitary-adrenal axis.
• Increased corticotrophin releasing hormone and cortisol increase the
production of PGE2, PGF2 alpha, thromboxane A2, leukotrienes, proteases,
collagenases, leucocyte elastase and decrease the activity of prostaglandin
dehydrogenase in the chorion, amnion and decidua.
• This leads to an increase in myometrial contraction, increase in cervical
ripening and increased cervical insufficiency resulting in preterm labor and
delivery.

INFLAMMATION
• May be as a result of an inflammatory condition or infection (urinary tract
infection, infection of fetal membrane, dental infection).
• Choriodecidual bacterial colonization results in inflammation and production
of TNF, IL-1, 6 and 8 which increases the production of PGE2, PGF2 alpha,
thromboxane A2, leukotrienes, proteases, collagenases, leucocyte elastase and
decrease the activity of prostaglandin dehydrogenase in the chorion, amnion
and decidua.
• This leads to an increase in myometrial contraction, increase in cervical
ripening and increased cervical insufficiency resulting in preterm labor and
delivery.
• Bacteria can also produce enzymes which can degrade the fetal membranes
and induce labor.

PLACENTAL ABRUPTION
• In response to bleeding between the placenta and the uterine wall, the uterus
contracts to clump the blood vessels in order to arrest the bleeding.
• This contraction results in induction of labor.

ABNORMALITY IN UTERINE DISTENSION

• The uterus is more distended than it should be for the specific gestational age.
• The stretching of the myometrium triggers preterm labor (through release of
prostaglandins through increased activity of prostaglandin synthetase,
increased IL-8, and increase in the number of gap junctions between the
myometrial cells)
• Causes: multiple gestation, polyhydramnios, abnormalities with the cervix
(Cervical incompetence)
• There is an increase the production of PGE2, PGF2 alpha, thromboxane A2,
leukotrienes, proteases, collagenases, leucocyte elastase and decrease the
activity of prostaglandin dehydrogenase in the chorion, amnion and decidua.
• This leads to an increase in myometrial contraction, increase in cervical
ripening and increased cervical insufficiency resulting in preterm labor and
delivery.
DIAGNOSIS
• 50% of women who present with painful contractions before 37 weeks’
gestation will stop spontaneously.
• Conversely, preterm labor may be insidious.
• Diagnosis:
➢ Regular uterine contractions with or without pain (at least 1 in every 10
minute)
➢ Dilatation (≥2cm)
➢ Effacement (80%) of the cervix
➢ Length of the cervix (measured by transvaginal ultrasound ≤2.5cm) and
funneling of the os
o Preterm labor is unlikely when the cervical length is >3cm irrespective
of uterine contraction
➢ Pelvic pressure, backache and or vaginal discharge or bleeding
• The following plan is therefore recommended:
➢ Look for the cause for preterm labor
➢ If membranes are intact a vaginal examination should be performed
➢ The fetal heart rate and uterine activity should be electronically recorded
continuously.
➢ Repeat the vaginal examination 2 hours later if there are more than 2
contractions every 10 minutes. Change in cervical effacement or dilatation
confirms preterm labor.
➢ Check fibronectin levels in cervical fluid, elevation may indicate imminent
labor
o Fibronectin is a glycoprotein that binds the fetal membranes to the
decidua. Normally it is found in the cervicovaginal discharge before 22
weeks and again after 37 weeks of pregnancy. Presence of fibronectin
in the cervicovaginal discharge between 24 and 34 weeks is a predictor
of preterm labor.
 o When the test is negative it reassures that delivery will not occur within
the next 7 days.
• Assessment of cervical dilation over the first few hours after admission will
show if there is progressive cervical dilation and the need for uterine
suppression.

HISTORY
• History of risk factors:
➢ Previous preterm delivery
➢ Multiple gestation
➢ Polyhydramnios
➢ Acute local or systemic inflammation (i.e. appendicitis), UTI and/or
pyelonephritis, STI, Bacterial vaginosis
➢ Vaginal bleeding
➢ Placental abruption
➢ Uterine anomalies
➢ Incompetent cervix
➢ Tobacco and illegal drug use
➢ Lower socioeconomic status
➢ Extremes of age, poor nutrition and poor antenatal care
• Physical examination:
➢ Cervical dilation
➢ Effacement

INVESTIGATIONS
• Full blood count
• Urine for urinalysis, microscopy, culture and sensitivity
• Cervicovaginal swab for culture and fibronectin
• Ultrasound for fetal well-being, cervical length and placental localization
➢ Transvaginal ultrasound for cervical length (short cervix ≤ 2.5cm before
32 weeks into pregnancy is a good predictor of preterm labor)
• Serum electrolytes and glucose levels when tocolytic agents are to be used.
• Biophysical predictors of preterm labor:
PREDICTORS OF PRETERM LABOR
➢ Uterine contractions 4 or more per hour
➢ Bishop score 4 or more • Clinical
➢ Cervical length less than 2.5cm by ➢ History of preterm birth
➢ Multiple pregnancy
transvaginal ultrasound ➢ Genital tract infection
• Biochemical indicators of preterm labor: ➢ Symptoms of PTL
➢ Fetal fibronectin in cervico-vaginal discharge • Biophysical
➢ Uterine contractions more than 4 per
➢ Others- IL-6, IL-8, TNF-alpha hours
➢ Bishop score more than 4
MANAGEMENT ➢ Cervical length less than 2.5cm
• Principles of management: • Biochemical
➢ Fetal fibronectin in cervicovaginal
➢ Prevent onset of labor if possible
discharge
➢ Arrest preterm labor if contraindicated ➢ Other: IL-6, IL-8 and TNF alpha
➢ Appropriate management of labor
o Glucocorticoids to the mother to reduce neonatal respiratory distress
syndrome, intraventricular hemorrhage and necrotizing enterocolitis
o Antenatal transfer of the mother with the fetus to a center with an
equipped NICU
o Tocolytic drugs to the mother for a short period unless contraindicated
o Antibiotics to prevent neonatal infection with group B streptococcus
o Magnesium sulfate to the mother to reduce neonatal cerebral palsy
when pregnancy is <34 weeks.
o Careful intrapartum monitoring, minimal trauma and presence of a
neonatologist during delivery
o Vaginal delivery is preferred unless otherwise indicate for cesarean
birth
➢ Effective neonatal care

MEASURES TO ARREST PRETERM LABOR

• Should be done when fetus and maternal status are good because most times
preterm labor is associated with maternal and/or fetal complicating factors
where the early expulsion of the fetus may be beneficial.
• Regimen is as follows:
➢ Bed rest (lie preferably on the left lateral position)
➢ Adequate hydration
➢ Prophylactic antibiotics are not routinely given unless infection is evident
or culture reports suggests infection.
➢ Prophylactic cervical cerclage for woman with prior preterm birth and
short cervix in the present pregnancy may be beneficial.
 ➢ Dose schedule of magnesium sulfate and monitoring are same as used for
seizure prophylaxis in pre-eclampsia (4g IV over 3-5 minutes followed by
an infusion of 1g/hr)
➢ Tocolytic agents: these can be used as short term (1-3 days) or long-term
therapy. Tocolytics should preferably be avoided as there is no clear
benefit.
o Short therapy: is meant to delay delivery for at least 48 hours for
glucocorticoid therapy to the mother to enhance fetal lung maturation
as well as delay delivery in utero as patient is being transferred to a
facility with an advanced NICU.
o Contraindications for tocolytics:
▪ Maternal: uncontrolled diabetes, thyrotoxicosis, severe
hypertension, cardiac disease, hemorrhage in pregnancy e.g.
placenta previa or abruption
▪ Fetal: fetal distress, fetal death, congenital malformation, pregnancy
beyond 34 days
▪ Others: Rupture of membranes, chorioamnionitis, cervical dilation
more than 4cm.
➢ Glucocorticoid therapy: given when pregnancy is <34 weeks to help fetal
lung maturity so to reduce the risk of RDS, IVH and NEC. This is
beneficial when the delivery is delayed beyond 48 hours of the first dose.
Benefit persists as long as 18 days.
o Betamethasone (steroid of choice) 12mg IM OD for 2 doses
o Dexamethasone 6mg IM BD for 4 doses
o Risks of antenatal corticosteroid use: PROM especially with evidence
of infection as the infection may flare up, insulin dependent DM where
patients need insulin dose readjustment, transient reduction of fetal
breathing and body movement.

ESTABLISHED PRETERM LABOR

• Open a partograph and monitor fetal heart rate and contractions.
• IV line with NS at maintenance rate, given mother oxygen by mask.
• Send investigations:
➢ FBC
➢ Urinalysis
➢ Urine culture
➢ Rectovaginal cultures for Group B streptococcus (GBS)
➢ Cervical culture for GC and chlamydia
➢ Wet prep for trichomonas and bacterial vaginosis
• Ultrasound for presentation, amniotic fluid index (AFI), placental location,
estimated fetal weight (EFW), Estimated gestational age (EGA) and anatomy.
• GBS prophylaxis:
➢ Obtain rectovaginal cultures (Results are valid for 5 weeks) if available
➢ Treat with penicillin IV (erythromycin if allergy to penicillin)
➢ If cultures are negative, then stop penicillin
• Steroids for decreased risk of respiratory distress syndrome, necrotizing
enterocolitis and intraventricular hemorrhage.
➢ Treat at 23-34 weeks gestation unless fetal lung maturity is confirmed
➢ Betamethasone 12mg IM every 24 hours x 2 doses, or
➢ Dexamethasone 6mg IM every 12 hours x 4 doses.
• Give steroids even if delivery is expected within 24 hours. Nurse/midwife may
give first dose without doctor if patient meets eligibility criteria.
• Tocolytic medication to delay delivery for steroids.
➢ At < 4cm dilation they may delay delivery for 24- 48 hours in order to
allow times for steroids to act or for the woman to be transferred to a
delivery site with a neonatal intensive unit.
• First stage of labor:
➢ Patient is put to bed to prevent early rupture of membranes
➢ Adequate oxygenation of the fetus by giving the mother oxygen by mask
➢ Epidural analgesia is of choice
➢ Labor should be carefully monitored preferably with continuous EFM
➢ C-section is done for obstetric reasons only (hypertension, abruption or
malpresentation)
➢ NICU is a sine qua non for good outcome
• Second stage of labor:
➢ Birth should be gentle and slow to avoid rapid compression and
decompression of the head
➢ Episiotomy may be done to minimize head compression if there is perineal
resistance
➢ Tendency to delay is curtailed by low forceps. As such, routine forceps is
not indicated.
➢ The cord is to be clamped immediately at birth to prevent hypervolemia
and hyperbilirubinemia
➢ To shift the baby to NICU under the care of a neonatologist
• Note: Routine C-section is not recommended. Preterm fetuses before 34 weeks
presented by breech are generally delivered by cesarean section. Lower
segment vertical or “J”-shaped incision may have to be made to minimize
trauma during delivery. This is due to poor formation of the lower uterine
segment.
PREPARED BY MOSES KAZEVU

DELIVERY AND NEONATAL CARE

• Inform NICU so that neonatologist or pediatrician may attend delivery
• Deliver with intact membranes if possible
• Minimize trauma by easing out the head in second stage of labor.
• Forceps may be used to assist delivery, avoid vacuum extraction.
• Suction neonatal airway immediately, avoid hypothermia and transfer neonate
to NICU as soon as possible
• Consider caesarean delivery if breech presentation.

PREVENTION OF PRETERM LABOR AND DELIVERY

• Primary care: aimed to reduce the incidence of preterm labor by reducing the
high-risk factors e.g. infection.
• Secondary care: Screening tests for early detection and prophylactic treatment
e.g. tocolytic, as well as treatment of asymptomatic bacteriuria.
• Tertiary care: aimed to reduce perinatal morbidity and mortality after
diagnosis e.g. use of corticosteroids.
• If previous preterm delivery and current singleton gestation, then treat with 17
−hydroxyprogesterone caproate 250mg IM every week at 16-36 weeks’
gestation if available.
• Interventions with inconsistent evidence: treatment of asymptomatic bacterial
vaginosis, cervical cerclage.
 PREMATURE RUPTURE OF MEMBRANES

PREMATURE RUPTURE OF MEMBRANES

(PROM)
• Premature/prelabor rupture of membranes (PROM) is rupture of the fetal
membranes and draining of amniotic fluid before the onset of labor after
viability (24 weeks).
• It can happen either at term (after 37 weeks) or preterm (before 37 weeks).
• Rupture of membranes for >24 hours before delivery is called prolonged
rupture of membranes.
• In 80% of patients labor ensures within 24 hours.
• Once the membrane has ruptured the barrier to ascending infection is gone and
if labor does not follow within 24-48 hours, induction of labor to prevent
chorioamnionitis in the mother and systemic neonatal infection is usual.
• Preterm PROM (PPROM) is when the membrane rupture occurs before 37
weeks and induction of labor may not be optimal management.
• Preterm PROM is associated with significant maternal and neonatal morbidity
and mortality.
• Spontaneous rupture of membranes >24 weeks’ gestation complicates 2-3%
of pregnancies.
• PROM affects 10% of all pregnancies.

RISK FACTORS
• Prior PROM and preterm labor
• Increased friability of the membranes and decreased tensile strength of the
membranes.
• Unexplained vaginal bleeding
• Placental abruption
• Cervical incompetence
• Vaginal or intra-amniotic infection
• Amniocentesis
• Smoking
• Multiple pregnancies
• Polyhydramnios
• Chronic steroid treatment
• Connective tissue diseases
• Anemia
• Low socioeconomic status, low BMI <19kg/m2
• Cervical length <2.5cm

ETIOLOGY
• Unknown but hypothesized causes include:
➢ Vaginal and cervical infections
➢ Incompetent cervix
➢ Nutritional deficiencies

CLINICAL PRESENTATION
• Typical history is a sudden gush of copious vaginal fluid or trickle causing a
woman to be constantly wet (draining).
➢ Draining should not be confused with hydrorrhea gravidarum (A state
where periodic watery discharge occurs probably due to excessive decidual
glandular secretion) and incontinence of urine especially in later months.
• Physical examination should include abdominal and sterile speculum
examination:
➢ On external examination, clear fluid is flowing out of the vagina.
➢ On speculum liquor can be visualized escaping out through the cervix
especially when the mother bears down or coughs.
➢ A pool of vaginal fluid-clear, watery, amniotic fluid is seen in the posterior
vaginal fornix.
➢ Nitrazine positive- the fluid turns nitrazine paper from yellow to blue. (pH
of amniotic fluid is 7.0-7.5 compared with vaginal pH 4.5-5.5)
➢ Microscopic ‘ferning’ of vaginal fluid- the fluid displays a ferning pattern
when allowed to dry on a microscopic glass slide. It refers to crystallization
of sodium chloride in amniotic fluid on drying
• Note: bimanual examination should not be done if possible because they
promote ascending intra-amniotic infection.
• Oligohydramnios is seen on ultrasound examination.
• Latency: refers to the interval between PROM and the onset of labor:
➢ 50% of women with PROM at term will go into labor within 12 hours
➢ 70% within 24 hours
➢ 85% within 48 hours
➢ 95% within 72 hours
• Latency is influenced by, severity of oligohydramnios (Severe
oligohydramnios is associated with shortened latency), multiple pregnancy
(twins have a shorter latency period than singletons) and gestational age:
➢ 50% of women with PROM will go into labor within 24- 72 hours
 ➢ 70-90% within 7 days

DIAGNOSIS
• Diagnosis is clinical.
• PROM is diagnosed by sterile speculum examination meeting the following
criteria:
➢ History: continuous draining of fluid.
➢ Sterile speculum examination:
o A pool of vaginal fluid-clear watery, amniotic fluid is seen in the
posterior vaginal fornix.
o Nitrazine positive- fluid turns nitrazine paper from yellow to blue. (pH
of amniotic fluid is 7.0-7.5 compared with vaginal pH 4.5-5.5)
o Microscopic ‘ferning’ of vaginal fluid

• Transvaginal ultrasound may show low liquor volume. It is also used to assess
fetal well-being.
• Workup includes:
➢ Full blood count and CRP
➢ Urinalysis, urine microscopy, culture and sensitivity for
UTI/asymptomatic bacteriuria.
➢ Cervical test or culture for C. trachomatis or N. gonorrhea.
➢ Hight vaginal swabs for bacterial vaginosis (BV) and trichomoniasis
➢ Rectal culture for Group B streptococcus
➢ Consider collecting vaginal pool for assessment of fetal lung maturity
(Estimation of phosphatidyl glycerol and Lecithin and syphingomyelin
ratio).
➢ Ultrasound for fetal biophysical profile (it is not done to support diagnosis).
➢ Cardiotocography for non-stress test.
DIFFERENTIAL DIAGNOSIS
• Hydrorrhea gravidarum- a state where periodic watery discharge occurs
probably due to excessive decidual glandular secretion.
• Urinary incontinence
• Liquefied sperms after intercourse
• Vaginal discharge

MANAGEMENT
GENERAL MANAGEMENT
• Confirm diagnosis with sterile speculum examination and also note the state
of the cervix and detect any cord prolapse. AVOID Vaginal examination.
• Admit patient to antenatal ward or labor ward.
• Bed rest and placing a sterile vulval pad to observe further leakage
• Monitor uterine activity and fetal heart.
• Check maternal, PR and temperature every 4 hours.
• Assess for labor, chorioamnionitis and placental abruption at least daily.
• Ultrasound for presentation, anatomy and liquor volume
• Definitive management dependent on:
➢ Gestation age of the fetus
➢ Whether the patient is in labor or not
➢ Any evidence of sepsis
➢ Prospect of fetal surgical in that institution if delivery occurs

PROM (>24 HOURS)

• Obtain cervical culture start broad-spectrum therapeutic IV antibiotics and
initiate prompt delivery (C-section if previous cesarean delivery).
➢ Amoxicillin 500mg TDS or erythromycin 250mg QID or
➢ Amoxicillin 500mg TDS and metronidazole 400mg TDS or
➢ Amoxicillin 500mg TDS and erythromycin 250 mg QID
• If no infection is present management will be based on gestational age:
➢ Before viability (<28 weeks) outcome is dismal.
o Consultant input is strongly recommended.
o If GA 26-27 weeks then steroids: Dexamethasone 6mg IM BD for 4
doses.
o Options:
▪ Labor induction with high dose IV oxytocin and/or oral or vaginal
misoprostol.
 ▪ D & E after cervical ripening with misoprostol 400mcg PV 3 hours
or SL 2-3 hours before procedure
o If management is conservative: Closely monitor for infection, labor or
placental abruption, strict pelvic rest, modified bed rest with bathroom
privileges, serial ultrasound and oral antibiotics for latency. Risk of fetal
pulmonary hypoplasia is high.
➢ With preterm viability (28-31 weeks):
o Conservative management.
o Hospitalize the patient, bed rest,
o Administer IM betamethasone 12mg OD 2 doses or Dexamethasone
6mg BD IM 4 doses to enhance fetal lung maturity
o Obtain cervical cultures, FBC on admission and start 7-day course of
prophylactic ampicillin/amoxicillin and erythromycin 250mg QID.
o At term initiate prompt delivery. If vaginal delivery is expected, use
oxytocin or prostaglandins as indicated. Otherwise perform Cesarean
delivery.
• In term PROM if uterine contractions occur, Tocolysis is contraindicated.
• Caesarean delivery if previous caesarean delivery.
COMPLICATIONS
IF FETUS REMAINS UTERO
• Neonatal conditions:
➢ Infection and sepsis
➢ Deformations
➢ Malpresentation, cord prolapse and Umbilical cord compression
➢ Fetal pulmonary hypoplasia especially in preterm PROM
➢ Placental abruption
• Maternal conditions:
➢ Chorioamnionitis, sepsis
➢ Deep venous thrombosis (DVT)
➢ Psychosocial separation

IF PRETERM DELIVERY OCCURS

• Neonatal conditions associated with prematurity:
➢ Respiratory distress syndrome (most common)
➢ Patent ductus arteriosus
➢ Intraventricular hemorrhage
➢ Necrotizing enterocolitis
➢ Retinopathy of prematurity
➢ Bronchopulmonary dysplasia
➢ Cerebral palsy

CHORIOAMNIONITIS
• Diagnosis:
➢ Maternal fever
➢ Uterine tenderness in the presence of confirmed PROM in the absence of
an upper respiratory or urinary tract infection.
• Management
➢ Ampicillin 2g IV every 6 hours until 48 hours afebrile.
➢ Gentamicin 80mg IV every 8 hours until 48 hours afebrile.
➢ Metronidazole 500mg IV every 8 hours until 48 hours afebrile, start after
delivery
➢ After IV medication continue oral drug
PREPARED BY MOSES KAZEVU
PREPARED BY MOSES KAZEVU

PRETERM PREMATURE RUPTURE OF MEMBRANES

PRETERM PREMATURE RUPTURE OF

MEMBRANES
• PPROM is rupture of membranes before the onset of labor <37 weeks of
gestation.

RISK FACTORS
• Prior PPROM
• Unexplained vaginal bleeding
• Placental abruption
• Cervical incompetence
• Vaginal or intra-amniotic infection
• Amniocentesis
• Smoking
• Multiple pregnancies
• Polyhydramnios
• Chronic steroid treatment
• Connective tissue diseases
• Anemia
• Low socioeconomic status
• Note: coitus, cervical examinations, maternal exercise and parity are not
associated with PPROM

DIAGNOSIS
• Similar to PROM difference is PPROM is <37 weeks.
• PPROM is diagnosed by sterile speculum examination meeting the following
criteria:
➢ History: continuous draining of fluid.
➢ Sterile speculum examination:
o A pool of vaginal fluid-clear watery, amniotic fluid is seen in the posterior
vaginal fornix.
o Nitrazine positive- the fluid turns pH-sensitive paper blue (pH of amniotic
fluid is 7.0-7.7 compared with vaginal pH of 4.5)
o Microscopic ‘ferning’ of vaginal fluid
PREPARED BY MOSES KAZEVU

MANAGEMENT
GENERAL MANAGEMENT
• Admit patient to antenatal ward or labor ward
• Monitor uterine activity and fetal heart
• Check maternal PR and temperature every 4 hours
• Assess for labor, chorioamnionitis and placental abruption at least daily
• Ultrasound for presentation, anatomy and liquor volume.
• Send investigations:
➢ High vagina swab
➢ Endocervical culture
➢ Urine culture
➢ Full blood count: WBC count in pregnancy and up to 7 days after antenatal
corticosteroids (i.e.dexamethasone)
• Oral antibiotics for latency:
➢ Erythromycin 250 mg QID or Azithromycin 1g PO OD and amoxicillin
500mg TDS for 7days (if possible, start preferably with ampicillin 2g IV every
6 hours for 48hours plus amoxicillin for 5 days)
32-36 WEEKS
• Induce/ augment if no spontaneous labor within 24 hours
• Misoprostol if not contraindicated
• Steroids: dexamethasone 6mg every 12 hours BD x 4 doses. Nurse/midwife may
give first dose if patient meets eligibility criteria.
• Send amniotic fluid to evaluate fetal lung maturity (FLM) if available:
➢ If L:S ≥2 or results indicate Fetal lung maturity (FLM), then deliver
immediately.
➢ If results indicate immaturity or FLM is unknown, then treat with steroids and
oral antibiotics and deliver at 35 weeks gestation
28-31 WEEKS
• Consultant input strongly recommended
• Determine GA to provide a realistic appraisal of outcomes.
• Expectant management
• Steroids: dexamethasone 6 mg every 12 hours BD x 4 doses.
• Minimize mobility, encourage leg exercises and/ or anti-embolic measures.
• Treat with steroid and oral antibiotics and deliver at 35 weeks.
PREPARED BY MOSES KAZEVU

• Send FBC upon admission and repeat if indicated.

• If GA 26-27 weeks, then steroids: dexamethasone 6mg every 12hours BD x 4
doses.
• Options include:
➢ Labor induction with high dose IV oxytocin and/or oral or vaginal misoprostol
➢ D & E after cervical ripening with misoprostol 400mcg PV 3 hours or
sublingual 2-3 hours before procedure
➢ Conservative management with: close monitoring for infection, labor or
placental abruption, strict pelvic rest, modified bed rest with bathroom
privileges, serial ultrasounds, and oral antibiotics for latency.
OUTPATIENT CARE
• Only for very compliant patients with PPROM who understands risk.
• Consultant input required.
• Discharge can be considered if there are no signs of labor and inpatient
observation are satisfactory after 1 week.
• Strick pelvic rest (no coitus)
• Check maternal temperature twice daily, return for temperature ≥ 38.
• Attend the antenatal day unit or labor ward for FBC and CTG twice weekly.
• Attend antenatal care clinic BO2 weekly
• HVS for any alteration in vaginal loss
• Review signs and symptoms of chorioamnionitis with patient and advise her to
return for any concerns.

COMPLICATIONS
• Neonatal complications are related to prematurity:
➢ Respiratory distress syndrome
➢ Intraventricular hemorrhage
➢ Sepsis
➢ Pulmonary hypoplasia (Especially with PPROM <22 weeks) and skeletal
deformities (Related to severity and duration of PPROM)
• Maternal complications: increased cesarean delivery (due to malpresentation,
cord prolapse), intra-amniotic infection and postpartum endometritis.