PRETERM LABOUR

MANAGEMENT GUIDELINES
Dr somya srivastava
Under guidance
Dr K P Banerjee
Dr Reena Pant
Dr Rakhi Arya
 PRETERM LABOUR
• Onset of labour prior to completion of 37
weeks of gestation , in a pregnancy beyond 20
weeks of gestation(WHO)
• Threatened preterm labour : uterine
contraction without cervical dilatation
 CLASSIFICATION
DILATATION EFFACEMENT

EARLY >1 CM< 3CM >80%

ADVANCED >3 CM >80%

THREATENED <1 CM <80%

 10 COUNTRIES WITH GREATEST NUMBER
OF PRETERM BIRTH
brazil
congo
phillippines
bangladesh
usa
indonesia
pakistan
nigeria
china
india
0 500000 1000000 1500000 2000000 2500000 3000000 3500000 4000000
WHO 2015
CAUSES OF NEONATAL DEATH
PRETERM

BIRTH ASPHYXIA
33% 35%

SEPSIS

CONG.
9% MALFORMATION
20%
15% INFECTION
LIU et al LANCET 2012
 ETIOLOGY
• Spontaneous preterm labour-40 to 50%
• Preterm premature rupture of membranes-20
to 30%
• Cervical insufficiency-8-9%
• Iatrogenic -30%
Cervical insufficiency
previous history of preterm birth
congenital-DES
cervical surgery(cone biopsy, lletz,laser
ablation,trachelectomy
obstetric trauma-forcep,vacuum,mrp
multiple D&E
infection(bacterial vaginosis , GBS ,
mycoplasma,gonorrhea)
connective tissue disorders
ehler danlos ,marfan
uterine overdistension-extra pressure on
cervix
 RISK FACTORS
• H/O Prior preterm birth, use of assisted
reproductive technologies
• Threatened abortion Antepartum bleeding,
rupture of membranes,
• uterine factors ( uterine anomalies,fibroids, and
excisional cervical treatment for cervical
intraepithelial neoplasia
• Multiple pregnancy
• Hydramnios
•Lifestyle factors :
smoking,underweight,overweight
Young or advanced maternal age,poverty
depression stress anxiety, hard physical labour
Bacterial vaginosis
Intrauterine infection
Shorter interpregnancy interval
 PATHOPHYSIOLOGY
MATERNAL FETAL
UTERINE DISTENSION STRESS INFECTION
*EXPRESSION OF *EARLY RISE IN *CHORIODECIDUAL
CONTRACTILE MATERNAL CRH *SYSTEMIC
ASSOCIATED PROTEINS *RISE IN PLASMA *IMMUNE CELL
*GASTRIN RELEASING ESTROGEN RECRUITEMENT
PEPTIDES *CYTOKINE PRODUCTION

PRETERM LABOUR
 MANAGEMENT
• PREVENTION
• DIAGNOSIS
• TREATMENT
 MANAGEMENT
• Establish accurate gestational age
• Take history to include character of any pain, bleeding
,leaking or foul smelling discharge per vaginum, fetal
movements
• H/O fever , trauma , coitus
• Past medical, surgical ,occupational ,dietary , socioeconomic
• General physical examination :build and nutrition
temperature
pulse rate
blood pressure
pallor
icterus
edema
Painful or painless uterine contractions with cervical
effacement and dilatation.
Pelvic pressure
Menstrual like cramps
vaginal discharge
Lower back pain
• Abdominal palpation for temperature tenderness,
palpable contractions to include duration and
frequency, symphyseal-fundal height, fetal lie,
presentation and descent.
Auscultation
Vaginal examination:
P/S:rule out bleeding or leaking

P/V: If PPROM not suspected digital vaginal

examination to determine cervical consistency,
position, station of presenting part, effacement and
dilatation ,adequacy of pelvis
•Reassurance & counseling
Prognosis of preterm baby in writing
Monitoring : pulse ,temperature , uterine contraction
-frequency
-intensity
Investigation:
Mid-stream urinalysis to exclude infection. Send for culture
if positive for leucocytes and nitrites and treat with
antibiotics pending result (not co-Amoxiclav because of the
risk of Necrotising Enterocolitis
CBC, CRP
Vaginal swab for pH & culture and sensitivity
ULTRASOUND FOR CERVICAL LENGTH
• Transabdominal
• Transvaginal
• Transperineal
Disadvantages of transabdominal USG
1.The patient’s bladder must be full for to assess the
cervix adequately, but this may spuriously lengthen
the cervix by opposing the anterior and posterior
lower uterine segments and concealing cervical
shortening or funnelling.
TV ultrasound is performed with the bladder empty.
2.Visualization of the cervix is hampered significantly
by maternal obesity, shadowing from fetal parts, and
the need for lower frequency transducers.
Transvaginal ultrasonography is the preferred
route for cervical assessment to identify
women at increased risk of spontaneous
preterm birth and may be offered to women
at increased risk of preterm birth.
Transperineal ultrasonography may be offered
to women at increased risk of preterm birth
if transvaginal ultrasonography is either
unacceptable or unavailable
*Fetal fibronectin: Glycoprotein which helps in
intercellular adhesion during implantation & in
maintenance of placental adherence to uterine
decidua. Fibronectin levels >50 ng/ml are considered
as a possible marker of impending preterm labour.
sensitivity Specificity
fibronectin 58.8% 78.8% GOMEZ 2005

*Ambulatory uterine monitoring: does not predict

preterm birth.
*not recommended by ACOG 2012b
 PRETERM PREMATURE RUPTURE OF
MEMBRANES
H/O vaginal leakage of fluid either as a
continuous stream or a gush.
P/S:vaginal pooling of amniotic fluid , clear fluid
from cervical canal
DIAGNOSTIC TEST:
SENSITIVITY FALSE POSITIVE

NITRAZINE 90% 17%

FERN TEST 90% 6%

RCOG GREENTOP
GUIDELINE44 2011
USG: demonstrating oligohydramnios

Amnisure : rapid immunoassay with sensitivity-98.9%

specificity-100%
Placental alpha microglobulin -1
IGFBP1(insulin like growth factor binding protein)
-sensitivity:82%
-specificity:83%
-actim prom
ANTENATAL CORTICOSTEROIDS
• reduction in neonatal death , intraventricular
hemorrhage, respiratory distress , systemic
infection in pregnancies that deliver 24 hours after
and up to 7 days after administration of 2 doses of
antenatal corticosteroids(betamethasone12 mg im
24 hours apart)
• Neonatal death are reduced even when infants
are born less than 24 hours after the first dose.
• Offered to women between 24+0 and 34+6 weeks of
gestation who are at risk of preterm birth.
 RESCUE THERAPY
1.A single course of antenatal corticosteroids should be
considered in women before 34 weeks whose prior course
was administered at least 7 days previously(ACOG 2012a)
2.Those receiving multiple doses of corticosteroids
-weighed less at birth (2216 g versus 2330 g, P=0.0026),
-were shorter (44.5 cm versus 45.4 cm, P<0.001)
- smaller head circumference (31.1 cm versus 31.7 cm,
P<0.001).(MACS trial lancet 2008)
A regime of repeat doses should not be recommended
3. A single rescue course may be considered with caution in
pregnancies where the initial course was given
at less than 26+0 weeks of gestation. Senior opinion should be
sought if a rescue course is to be
considered. (RCOG GREENTOP GUIDELINES 2011)
TOCOLYTICS : Used when delaying pregnancy is useful
, either to complete a course of corticosteroids or to
transfer the patient to an institution with NICU
 MOA ROUTE & REGIMEN MATERNAL SIDE FETAL SIDE
EFFECTS EFFECTS
CA CHANNEL Inhibits Ca ORAL: 30mg stat Dizziness No change
BLOCKER reuptake by headache in
*NIFEDIPINE voltage 10 mg every 8 hours hypotension uteroplace
dependent ntal flow
Ca channels
BETA 2 INACTIVATE IV :50ug/min as infusion inc Tachycardia tremor Cross
AGONIST MLCK every 20min max 350ug palpitation placenta
*RITODRINE pulmonary beta
edema,hyperglyce adrenergic
*TERBUTALIN ORAL:2.5 mg -5 mg/4-6 hours mia,MI in fetus
E IV :5-10 ug/min max 80ug/min
SC:250ug/30min max 6 dose
ATOSIBAN Competitiv IV:6.75mg bolus over 1 min Nausea chest pain
e oxytocin dyspnea
antagonist 18 mg/hr infusion for 3 hours
at receptor for up to 45 hours
level,downr
egulates
oxytocin
receptors
 MOA ROUTE & REGIMEN MATERNAL SIDE FETAL SIDE
EFFECTS EFFECTS
MAGNESIUM Extracellular Mg IV:4g bolus Headache nausea Neuroprotective
SULFATE suppresses Ca followed by Drowsiness effect
influx across cell 1g/hour for 24 hour respiratory
membranes unless preceded by distress flushing
birth
COX 2 ARACHIDONIC ORAL:50-100mg Asthma peptic Constriction of
INHIBITOR ACID RECTAL:100-200mg ulcer hepatic and fetal ductal
*INDOMETH renal dysfunction arteriosus
ACIN 25-50mg/4-6 hours oligohydramnios
PG H2
*SULINDAC ORAL:200mg once

NITRIC OXIDE Smooth muscle ORAL headache

DONORS relaxant TRANSDERMAL
*NITROGLYCE IV
RINE
 CONTRAINDICATIONS OF TOCOLYTICS
• Advanced labour(cervix>4 cm)
• Chorioamnionitis
• Severe preeclampsia and eclampsia
• Abruptio placenta
• Fetal demise
• Hyperthyroidism
• Severe anemia
• Fetal maturity
• Heart disease(ventricular outflow
obstruction,cardiac rhythm disorders
 ANTIBIOTICS
Subclinical infection is implicated in a large
proportion of preterm births, so theoretically,
the acute use of antibiotics could eradicate
the infection, prolong the pregnancy and
improve neonatal outcome.
Alternatively, antibiotics might suppress the
infection, thus prolonging the pregnancy, but
leaving the fetus in a hostile inflammatory
environment
• For women at risk of preterm labour:no reduction in
preterm delivery
*Women with clinical evidence of infection are
treated with antibiotics since clinical chorioamnionitis
remains an important cause of maternal, fetal and
neonatal death.

*Women with spontaneous preterm labour with

intact membranes and no evidence of overt infection
should not routinely be prescribed antibiotics
because there is evidence that antibiotics given under
these circumstances increase the risk to their
offspring of functional impairment and cerebral palsy.
SIP Opinion Paper No. 33 2013 rcog
•Erythromycin has been recommended as an
antibiotic of choice after being tested by the ORACLE.
Co–amoxiclav should be avoided in women at risk of
preterm delivery due to increased risk of neonatal
necrotising enterocolitis

*Women with spontaneous preterm labour and intact

membranes may be considered at increased risk of
Group B Streptococcus infection (GBS). However, the
RCOG does not recommend routine prophylaxis
in this situation.
 PRETERM PREMATURE RUPTURE OF
MEMBRANES
Avoid digital cervical examination
Management depends on gestational age
<24 24 to 33+6 34 weeks
weeks weeks or more

Expectant Induction of labour

management Group b
Expectant streptococcal
Group b streptococcal
management prophylaxis prophylaxis
Single course steroids
ACOG 2013
ANTIBIOTIC :ampicillin 2g iv followed by 1g iv 6 hourly for 48
hours followed by amoxicillin 250 mg 8 hourly for 5 days.
Erythromycin 250mg 6 hourly should be given for 10 days
following the diagnosis of PPROM(RCOG GREEN TOP GUIDELINES 44)

TOCOLYSIS has no role.

Strict vigil for CHORIOAMNIONITIS : Fever is the only reliable

indicator . Other signs:
maternal tachycardia
leucocytosis(15000)
uterine tenderness
foul smelling liquor
fetal tachycardia
CRP(>4gm /dl)
Delivery is planned whenever there is any evidence of
clinical infection.
TISSUE SEALANTS : Unproven safety &efficacy
 INTRAPARTUM MANAGEMENT
• Electronic fetal monitoring : fetal tachycardia is an
indicator of sepsis
• Vaginal & rectal swabs for GBS
• Episiotomy &forceps offer no additional protection
to fragile preterm head.
• Ventouse is contraindicated
• Caesarean section :only for obstetric indication.
• Delivery to be attended by a neonatologist
• Early cord clamping
 PREVENTION
Primary prevention : to lower the incidence of
premature labour by improving maternal
health and by avoiding risk factors before and
during pregnancy
• Nutritional counseling
• Lower workload for women with stressful job
• Smoking cessation
Secondary prevention : Early identification of pregnant
women at a risk of preterm labour and help them to carry
their pregnancy to term.
1.Cerclage :

rescue prophylactic

prophylactic: offered to women with three or more

previous preterm births and/or second-trimester losses if
the cervix is 25 mm or less before 24 weeks of gestation.
( gtg60)
The insertion of an ultrasound-indicated cerclage is
not recommended in women without a history of
spontaneous preterm delivery or second-trimester
loss who have an incidentally identified short cervix
of 25 mm or less

RESCUE CERCLAGE:
Salvage procedure
Done in cases of premature cervical dilatation with
exposed fetal membranes in vagina
20-24 weeks
 Insertion of a rescue cerclage may delay
delivery by a further 5 weeks on average
compared with expectant management/bed rest
alone. It may also be associated with a two-fold
reduction in the
chance of delivery before 34 weeks of gestation.
However, there are only limited data to support
an associated improvement in neonatal
mortality or morbidity.
RCOG GREEN TOP GUIDELINE 60 2011
MULTIPLE PREGNANCY:
The insertion of a history- or ultrasound-indicated cerclage
in women with multiple pregnancies is not
recommended, as there is some evidence to suggest it may
be detrimental and associated with an
increase in preterm delivery and pregnancy loss
Contraindication to cerclage insertion:
1.active preterm labour
2.clinical evidence of chorioamnionitis
3.continued vaginal bleeding
4.pprom
5.evidence of fetal compromise
6.lethal fetal defect
7.fetal death
 REMOVING THE CERCLAGE

1.A transvaginal cervical cerclage should be

removed before labour, usually between 36+1
and 37+0 weeks of gestation, unless delivery is by
elective caesarean section, in which case suture
removal could be delayed until this time.
2.In women presenting in established preterm
labour, the cerclage should be removed to
minimise potential trauma to the cervix(bucket
handle tear)
2. Bed Rest: no evidence to support the use of bed
rest.
Thromboembolic complications(kovacevich 2000)
significant bone loss(promislow 2004)
3. Progesterone Supplementation
PROGESTERONE : significant reduction in rate of
preterm birth when given to women with
* short cervix (<25 mm) on tvs done in 2nd
trimester
* singleton pregnancy with previous preterm
delivery

MOA:Decreases the number of myometrial oxytocin

receptors
inhibits prostaglandin production by amnion chorion
decidua
reduces cervical stromal degradation
reduces gap junction formation
SIDE EFFECTS OF PROGESTERONE
Maternal : headache
breast tenderness
nausea
cough
Route & regimen:200mg oral capsule BD
200mg capsule vaginally
 LABOUR PAIN < 37 WEEKS

PRETERM LABOUR PPROM

CORTICOSTEROIDS CORTICOSTEROIDS
TOCOLYTICS ANTIBIOTICS
CHORIOAMNIONITIS