Preterm Labor and

PPROM
Michelle Schroeder, MD
Busitema University Faculty of Health Sciences

S
 Definitions

 Preterm labor- uterine contractions causing cervical dilation of

at least 3cm before 37 weeks

 PROM- Preterm Rupture of Membranes

 Rupture of membranes prior to the onset of uterine contractions
AFTER 37 weeks

 PPROM- Preterm Premature Rupture of Membranes

 Rupture of membranes prior to the onset of uterine contractions
BEFORE 37 weeks
Preterm Labor

S
 Risk Factors
History
History of
of
Prior
Prior preterm
preterm
abortion/
abortion/ Genetic
Genetic factors
factors Black
Black race
race
birth
birth
evacuation
evacuation

Chronic
Chronic
Extremes
Extremes of
of Cervical
Cervical Uterine
Uterine
medical
medical
Age
Age surgery
surgery malformations
malformations
conditions
conditions

Assisted
Assisted Multifetal
Multifetal Decidual
Decidual
Short
Short cervix
cervix
reproduction
reproduction Gestation
Gestation hemorrhage
hemorrhage

Asymptomatic
Asymptomatic Periodontal
Periodontal Genital
Genital tract
tract
Malaria
Malaria
Bacturia
Bacturia disease
disease infection
infection

Short
Short interval
interval
Stress
Stress
pregnancy
pregnancy
 Pathogenesis

 Activation of maternal HPA axis

 Stress
 Anxiety or depression

 Activation of fetal HPA axis

 Placental pathology- vascular damage, bleeding

 Increased ACTH secretion  stimulates estrogenic compounds

and prostaglandins  activated myometrium
 Pathogenesis

 Infection and Inflammation

 Genital/ urinary tract infections
 Chorioamnionitis

 Decidual hemorrhage
 Local thrombin generation
 Induces myometrial contractions

 Uterine distention
 Multiple gestation, polyhydramnios
 Enhanced stretching of myometrium  upregulates oxytocin
receptors  produces inflammatory cytokines
 Clinical Signs/ Symptoms

Menstrual-
Menstrual- like
like
cramping
cramping contractions
contractions Low
Low back
back ache
ache

Vaginal
Vaginal discharge
discharge
Pressure
Pressure sensation
sensation (clear,
(clear, pink,
pink,
bloody
bloody show)
show)
 Clinical Investigations

Determine
Determine Maternal
Maternal well-
well- Fetal
Fetal well-
well-
gestation
gestation age
age being
being being
being
• LMP • Review risk • FHR
• Ultrasound factors • Position
• Clinical
signs/
symptoms
• Vital signs
• Assess
contractions
 Diagnosis/ Investigations

Speculum
Speculum Ultrasound
Ultrasound
Digital
Digital exam
exam
exam
exam (CL
(CL <20mm)
<20mm)

Evaluate
Evaluate for
for
Urinalysis
Urinalysis
STIs
STIs
 Management <34 weeks

 Administer corticosteroids
 Dexamethasone 6mg Q12hrs x4 doses (or Betamethasone 12mg Q24 hours x 2 doses)

 Hydrate with Normal Saline

 Tocolysis- only effective for 48 hours which steroids are being given
 Cycloxygenase inhibitors- indomethacin
 Do not give after 32 weeks (risk of closure of ductus arteriosis)
 Reduce prostaglandins
 Calcium Channel blockers- Nifedipine
 Block influx of calcium ions through cell membrane
 Watch for hypotension!
 Magnesium Sulfate- competes with calcium at cell membrane
 Beta-agonists- Ritodrine, Terbutaline
 Myometrial relaxation by binding beta-2 adrenergic receptors
 Increases maternal heart rate and hypotension (also fetal tachycardia)
 Tocolysis Dosing

 Indomethacin
 Loading dose of 50- 100mg PO
 Followed by 25mg PO q 4-6 hours

 Nifedipine
 Loading dose of 20-30 mg PO
 Followed by, 10- 20mg every 3-8 hours

 Magnesium sulfate- same dosing as for PreEclampsia

 14 mg loading dose (4 IV + 5 IM in each buttock)

 Terbutaline
 0.25mg subcutaneously every 20- 30 min up to 4 doses
 Maintenance- give every 3-4 hours
 Management >34 weeks

 Admit patient for delivery

 Consider treatment with corticosteroids (controversial)

 Tocolytics are NOT indicated

 If after several hours there is no cervical change, consider

discharge home
 Must confirm fetal well being
 Must exclude other obstetrical complications
 Case #1

 A 25yo G3P2+0 at 31w 3d presents with labor like contractions

for the past 2 hours. She denies leakage of fluid or vaginal
bleeding. She reports good fetal movements. On exam, she is
dilated 3cm and 50% effaced. You palpate contractions every 4
minutes.
 No significant medical or surgical history

1. Describe initial work up and investigations

2. Which medications would you give and why? Be specific with
dosages, duration, etc.
3. Explain further management once contractions have stopped.
PROM

S
 Clinical Evaluation
Determine
Determine Maternal
Maternal well-
well- Fetal
Fetal well-
well-
gestation
gestation age
age being
being being
being
• LMP • Fever • FHR
• Ultrasound • Tachycardia • Position
• Uterine • Meconium?
tenderness
• Foul-smelling
discharge
• Vaginal exam?
 Diagnosis/Investigations

Speculum
Speculum
exam
exam Vaginal
Vaginal pad
pad Nitrazine
Nitrazine test
test
(pooling)
(pooling)

Indigo
Indigo
Ferning
Ferning test
test Ultrasound
Ultrasound
carmine
carmine test
test
Nitrazine Test / Ferning
 Indigo carmine test

Remove
Removegauze
gauze
Instill
Instill1mL
1mLofof Inject
Injectinto
into Place
Placegauze
gauzein
in in
in20
20mins
minsand
and
indigo
indigocarmine
carmine amniotic
amnioticfluid
fluid vagina
vagina check
checkforforblue
blue
in
in9mL
9mLofofNS
NS staining
staining
 Management

 Delivery
 TermPROM study – 50,000 women

Complication Intervention Expectant

Chorioamnionitis 3% 12%

Endometritis 1% 3.6%

Neonatal sepsis 0.3% 1.1%

PPH 7% 21.8%
 Management

 Induction of Labor
 Oxytocin
 Misoprostol
 Longer time to delivery
 Prefer oral administration to avoid repeat VE

 Cesarean delivery only for maternal or fetal indications!

 Antibiotics
No signs of
infection

< 18 hours > 18 hours

No abx Ampicillin
2gm IV Q6h

Stop after
delivery
 Antibiotics
Chorioamnionitis

Ampicillin 2gm IV Q6h and

Gentamicin 5mg/kg/IV Q24h

SVD C/S

Stop after Cont abx + Metronidazole

delivery 500mg IV Q8h

Stop after 48h afebrile

 Case #2

20yo G3P1+1 at 38wks of gestation presents

complaining of leaking of non-foul smelling cloudy
liquor for 3 hours. She denies labor pains, vaginal
bleeding fevers or chills. Reports good fetal
movement.

1. Explain how you would confirm your suspected diagnosis.

2. When would you give this patient antibiotics and why? Which ones
would you give.

3. Describe your delivery plan.

PPROM

S
 Risk Factors
Previous
Previous
Cervical
Cervical Genital
Genital tract
tract
PPROM
PPROM (13-
(13-
Insufficiency
Insufficiency infection
infection
30%)
30%)

Antepartum
Antepartum Cigarette
Cigarette
Trauma
Trauma
bleeding
bleeding smoking
smoking

Polyhydramnios
Polyhydramnios None!
None! (>50%)
(>50%)
 Complications

Infection
Infection (33%)
(33%) Abruption
Abruption (5%)
(5%) Cord
Cord prolapse
prolapse

Umbilical
Umbilical cord
cord
Malpresentation
Malpresentation Preterm
Preterm Birth
Birth
compression
compression
 Fetal Complications

Fetal
Fetal death
death Neonatal
Neonatal death
death
(10%)
(10%) (latency
(latency == 17d)
17d)

Pulmonary
Pulmonary Limb
Limb deformities
deformities
Hypoplasia
Hypoplasia (9%)
(9%) (7%)
(7%)
*most
*most dependent
dependent onon *most
*most dependent
dependent on
on
gestational
gestational age
age duration
duration of
of ROM
ROM
 Management

No signs of
infection

For 2 DAYS:
Give Dexamethasone 6mg IM Deliver at 34
Q12h x 4 doses IV Erythromycin 250mg Q6h + IV weeks
Ampicillin 2g Q6h

Then, For 5 Days:

PO Erythromycin 333mg Q8h+
PO Amoxicillin 500mg Q8h
 Management

Infection

No Same management as
corticosteroids amnionitis

Immediate
Delivery
 Management

 Tocolytics?
 Controversial
 May give for 48h to give steroids only
 Contraindications:
 Infection
 Abruption
 Labor or cervix >4cm
 Non-reassuring fetal status
 Risk of cord prolapse
 Timing of Delivery

 Deliver at 34 weeks
 Benefits outweigh risks of remaining pregnant

 Earlier if complications

 Induction of labor
 Give prophylactic antibiotics at delivery
 Case #3

A 22yo G2P1+0 at 32wks presents with leaking of clear non-foul

smelling liquor for 1 hour. She denies vaginal bleeding, labor
pains, fevers or chills. States fetus is “very active”.

 Pregnancy complicated by history of chlamydia

 She has had 1 previous preterm SVD at 35wks and he is alive and healthy

1. Name possible complications to the patient/ fetus.

2. What medications would you give the patient and why? Give dosages.

3. State your plan for delivery.

Previable PPROM

S
 Maternal complications

Chorioamnionitis
Chorioamnionitis Placental
Placental
abruption Classical
Classical C/S
C/S
(50%)
(50%) abruption (40%)
(40%)

Postpartum
Postpartum
Retained
Retained placenta
placenta
endometritis
endometritis
(15%)
(15%)
(40%)
(40%)
 Management options

 Pregnancy termination

 Risk of complications > benefit or likelihood of fetal survival

 Misoprostol 600-800mcg PV loading dose

 Misoprostol 400mcg PV Q4h until delivery

 Dilation & Evacuation

 Management options

 Expectant management

 10-14% have “resealing” of fetal membranes

 25% will have partial reaccumulation of amniotic fluid

 Expectant Management

 Can discharge home to monitor for complications

 No prophylactic antibiotics, tocolysis, or corticosteroids

 Return to hospital when viable (~28wks)

 Give antibiotics, corticosteroids
 Inpatient management until delivery
 Case #4

17yo G1P0 at 25wks presents with leaking of clear liquor

since yesterday. She denies fever or chills, vaginal
bleeding or discharge, labor pains. Reports minimal fetal
movement since leaking began.

1. Describe how you would explain the risks of remaining pregnant to the mother. Use
terms she will understand.

2. If the mother chooses to continue the pregnancy, explain your management plan up
until 28 weeks.

3. Describe your management and delivery plan after 28 weeks.

 Prevention

 Up to 30% recurrence rate

 Offer weekly 17 Hydroxyprogesterone 250mg IM

 16wks to 36wks
 Shown to decrease preterm birth by approximately 30%

 Monitor for cervical insufficiency

 Cervical length at 16wks
 Cervical cerclage if < 25mm