PRETERM LABOUR

AND
PRELABOUR RUPTURE OF
MEMBRANES
DR K P BANERJEE
SENIOR PROFESSOR
ZENANA HOSPITAL JAIPUR
 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 OF PRETERM LABOUR
DILATATION EFFACEMENT

EARLY >1 CM< 3CM >80%

ADVANCED >3 CM >80%

THREATENED <1 CM <80%

 ETIOLOGY

SPONTANE PPROM CERVICAL IATROGENIC

OUS 20-30% INSUFFICIE 30%
40-50% NCY
8-9%
 RISK FACTORS
1. H/O Prior preterm birth
2. Use of assisted reproductive technologies
3. Threatened abortion
4. Antepartum bleeding
5. Uterine factors : uterine anomalies,fibroids, and
excisional cervical treatment for cervical
intraepithelial neoplasia
6. Multiple pregnancy
7. Hydramnios
8.Lifestyle factors : Smoking
Underweight,Overweight
Young or advanced maternal age,
Poverty depression stress anxiety,
Hard physical labour
9.Shorter interpregnancy interval
10.Retained IUCD
11.Intrauterine infection
12.Bacterial vaginosis
 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 pallor
pulse rate icterus
blood pressure oedema
• Abdominal palpation for temperature , tenderness,
palpable contractions to include duration and
frequency, symphyseal-fundal height, fetal lie,
presentation and descent.
Auscultation :fetal heart rate & pattern
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:
1.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)
2.CBC, CRP
3.Vaginal swab for pH & culture and sensitivity
4.Ultrasound for cervical length:transabdominal
transvaginal
transperineal
5.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

INTERVENTIONS
1.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 effects in
E IV :5-10 ug/min max 80ug/min fetus
SC:250ug/30min max 6 dose
ATOSIBAN Competitiv IV:6.75mg bolus over 1 min Nausea chest pain none
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
2.ANTENATAL CORTICOSTEROIDS
• Inj. Betamethasone12 mg i.m. in 2 doses 24 hours
apart
• Effects: reduction in neonatal death ,
intraventricular hemorrhage, respiratory distress in
babies that deliver 24 hours after and up to 7 days
after administration of betamethasone.
• 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.
3.ANTIBIOTICS:
EFFECT:no reduction in preterm delivery
*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.
*Clinical evidence of chorioamnionitis:
I.v. antibiotics

SIP Opinion Paper No. 33 2013 rcog

 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
2.Progesterone
3.Bed rest
 PRELABOUR 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
1.USG: demonstrating oligohydramnios

2.Amnisure : rapid immunoassay with sensitivity

98.9%
specificity-100%
consists of Placental alpha microglobulin -1
3.IGFBP1(insulin like growth factor binding protein)
-sensitivity:82%
-specificity:83%
-actim prom(brand name)
4.nile blue sulphate test:tests the fetal cells in liquor.
 MANAGEMENT
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.
 SUMMARY
LABOUR PAIN <37 WEEKS

MEMBRANES+ MEMBRANES ABSENT

•EXPLAIN PROGNOSIS EXPLAIN PROGNOSIS

•CORTICOSTEROIDS •ANTIBIOTICS
•TOCOLYTICS •CORTICOSTEROIDS
•WATCH FOR
CHORIOAMNIONITIS