PRETERM LABOR AND PRELABOR

RUPTURE OF MEMBRANES
(PROM)
PRETERM LABOR

 Definition
Regular uterine contractions accompanied by progressive cervical
dilatation and/or effacement at less than 37 weeks gestation

 Preterm labor (PTL) and delivery accounts for 75% of neonatal mortality.
The longterm sequel of prematurity include :
• CNS complicatios such as cerebral palsy
• Neurodevelopmental delay
• Respiratory complications such as bronchopulmonary dysplasia
• Blindness and deafness
 Etiology
• Idiophatic
• Antepartum hemorrhage
• Preterm pre-labor rupture of membrane
• Pelvic infection
• Chorioamnionitis
• Multiple pregnancy/polyhyoramnios
• Incompetent cervix/uterine anomaly
• Maternal disease such as malaria, tuberculosis
• Fetal anomaly
 Diagnosis
 Dilemma
Interventions to stop preterm labor are not particularly
effective - especially when not instituted early
 Solution
Diagnosis based on some degree of uterine activity
combined with a single cervical exam suggesting early
dilatation or effacement
 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 localization of placenta is known
 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
 Management - Prolongation of Pregnancy
 less than 40% of patients in preterm labor will be
candidates for tocolysis
 Evidence suggest that beta-sympathomimetics (ritrodine)
dan PG synthetase inhibitors (indomethacin) are the most
effective at delaying delivery for 48hours in order to
intitute glucocorticoids and nifedipin
 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
 Magnesium sulfate
small, poor quality trials; placebo and comparative
no benefit shown
 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)
 Highly effective for delaying delivery in the short term
 No evidenceof beneficial effects on fetus neonate
 Allow us of corticosteroids, transfer, expectant care
 Contraindications to Tocolysis
 Contraindications to continuing the pregnancy
 Contraindications to specific tocolytic agents

 Contraindications to prolongation of pregnancy

 Severe pregnancy induced hypertension
 Chorioamnionitis
 Mature fetus
 Imminent delivery
 Intra uterine fetal death (IUFD) or lethal fetal abnormality
 Contraindications to -mimetics
 Maternal cardiac disease - structural, ischemic, rhythm
 Significant antepartum haemorrhage
 Poorly controlled medical condition
 type I diabetes mellitus
 hyperthyroidism
 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
 Antenatal Glucocorticoid Therapy
Thebenefits of antenatal glucocorticoid therapy are now
definitively established. Betamethason and
dexamethasone cross the placenta and induced enzymes
that accelerate fetal pulmonary maturity. It takes 48 hours
for the full benefit to be achieved.
 Effect of Corticosteroids on Neonatal Outcomes

RDS

IVH

NEC

Perinatal Infection

Neonatal Death

0.1 1 10
Odds Ratio (95% Confidence Interval)
 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
 Recommendations
When should steroid therapy be given?
 lower gestation limit 22 - 24 weeks
 upper gestation limit 34 weeks
 prophylactic administration depends on diagnosis and risk
 repeated administration not determined
 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
 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
 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 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
 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
Prelabor Rupture of the Membranes
(PROM)
 Definition
 Rupture of the membranes before the onset of labor
 preterm - < 37 weeks gestation (PPROM)
 term -  37 weeks gestation (TPROM)
 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
 Etiology of PROM
 Idiopathic
 Infection (e.g. bacterial vaginosis)
 Polyhydramnios
 Cervical incompetence
 Uterine abnormality
 Following cervical cerclage or amniocentesis
 Trauma
 Diagnosis of PROM
 History
Approximately 30% of women with history of vaginal fluid leakage
will not have PROM
 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
 Complications of PROM - Term
 Fetal / neonatal infection
 Maternal infection
 Umbilical cord compression / prolapse
 Failed induction resulting in cesarean section
 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
 Management of PROM at any gestational age requires
 Assess maternal and fetal well-being
 Confirm diagnosis
 Determination of the presence of any associated condition which
requires concurrent management oe may indicate that delivery is
desirable at once
 Assesment of cervical status; however, digital examination
should be avoided whenever possible. This is especially true in
the preterm setting or when expectant management of term
PROM is to be undertaken
 The presence of temperature (38,5) or maternal or fetal
tachycardia
 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
 Management - Preterm (34-37 weeks)
 Avoid digital cervical exam
 Consider antenatal steroids
 Intrapartum antibiotic prophylaxis
 Surveillance for infection - clinical (monitor maternal
temperature and pulse, fetal heart rate)
 Appropriate antibiotics for chorioamnionitis if develops
 Management - Preterm (< 34weeks)
 Avoid digital cervical exam
 Steroids as in preterm labor
 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)
 Antibiotic options are:

Iv Penicillin G 5 million units q 4-6h preferred

or
Iv Ampiullin 2g followed by 1 g q 4h
or
IV Clindamyin 600 mg q 8h

 Women with suspected chorioamnitonitis require broader

range spectrum antibiotic coverage
THE END