PRETERM LABOR

DR. SHABNAM NAZ

MBBS, MCPS, FCPS
ASSISTANT PROFESSOR
OBGYN
SHAHEED MOHTARMA
BENAZIR BHUTTO
MEDICAL UNIVERSITY LARKANA
OBJECTIVES
 Define PTL and describe their significance
 List risk factors associated with PTL
 Outline initial evaluation of PTL
 Describe management of PTL
 Discuss neonatal GBS prevention
strategies.
Preterm labor

• Labor before 37 completed weeks of

gestation
 TERMINOLOGY
• Preterm birth:  24-36+6wks
• Indicated preterm birth
• Spontaneous preterm birth
(3contractions/10 min +cervical changes)
• Preterm premature rupture of membrane
• Premature ROM(1 hr or more before onset of labour)
• PPROM(premature ROM before 37 wks)
 Classification of preterm birth
• Mildly preterm birth - 32 - 36 weeks
• Very preterm birth - 28 - 31 weeks
• Extremely preterm birth - 24 - 27 weeks
Incidence
• Accounts for 85% of all perinatal mortality
and morbidity.
• 8-12% of all deliveries are preterm.
• 71.2% 34-36 weeks
• 13% 32-33 weeks
• 10% 28-31 weeks
• 6% <28 weeks
Survival in Premature Infants

survival chance is directly proportional to the maturity

• 26 wks – 80%
• 27 wks – 90%
• 28-31 wks – 90 to 95%
• 32-33 wks – 95%
• 34-36 wks –
approaches term
survival rates
Complications of Prematurity
• RDS
• IVH
• Feeding difficulties/NEC
• Apnea
• PDA
• Infection
• Jaundice
• Hypothermia
• Neurobehavioral
• ROP
• Anemia
Pathogenesis
• Premature activation of maternal or fetal
HPA axis

• Decidual hemorrhage

• Inflammation/infection

• Pathological uterine distention

Mechanisms For Preterm Labor
Penyebab Persalinan Preterm
Can preterm labor be
predicted?
 Prediction
1. Assessment of risk factors
2. Vaginal examination to assess the cervical status
3. Ultrasound visualization of cervical length and dilatation
4. Detection of fetal fibronectin in cervicovaginal secretions
Risk factors for preterm birth
Risk factors Relative risk
2-Vaginal examination

Digital examination is the traditional method

used to detect cervical maturation, but
quantifying these changes is often
difficult.
 3-Vaginal U/S

Vaginal Ultrasonography allows a

more objective approach to
examination of the cervix.
Sonographic Cervical Length

80-100% of women who

deliver early have cervix
<30mm

• 50% delivery rate within one

week have cervix < 15 mm or
less
 Fetal Fibronectin
• Fetal Fibronectin (fFN)- it is a glue like protein binding
choriodecidual membrane
• Present in vaginal secretions between 23-34 weeks
and signifies onset of labor
• Bedside test can be done – if negative it rules out
preterm labor in next two weeks
• P/V examination gives false positive result for 24 hours

• Between 24-32 weeks

• fFN – 25ng/ml + cervical length of 25 mm
shows significant risk
Prevention of
preterm labor
Prevention of PTB
• Reduce/eliminate risk factors, if possible
• Not proven to be effective: bedrest, home uterine
monitoring, prophylactic tocolytics, prophylactic
antibiotics, abstinence.
• Supplemental progesterone
• Women with previous spontaneous preterm delivery at
less than 34 weeks gestation
• Weekly 17OHprogesterone IM or daily vaginal
progesterone suppositories
• Start at 16-20 wks gestation, continue through 36 weeks
Treatment Of Vaginosis
Treatment of asymptomatic abnormal vaginal flora
and bacterial vaginosis with vaginal
clindamycin or oral metronidazole early
in the 2nd trimester significantly reduces the rate
of late miscarriage and spontaneous preterm
birth.
 DIAGNOSIS
OF
PRETERM LABOR
 Diagnosis

Three criteria to document PTL(20-37wks)

1-Regular uterine contractions occur at 4/20 min. or
8/60 min. Plus: progressive change in the cervix.
2- Cervical dilatation > 1 cm
3- Effacement >80%.
Four Questions:

• Is the patient in labor?

• Are the membranes ruptured?

• Is the fetus preterm?

• What risk factors are present?

PATIENT HISTORY
 Detailed history of labor.
 History of fluid leakage.
 Dating of pregnancy.
 Review history for risk factors.
 History of other medical problems.
 Assessment of social history and home
support.
PHYSICAL EXAMINATION
 Maternal vitals: signs of infection.
 General physical exam.
 Fetal heart rate pattern.
 Fetal size and presentation.
 No digitals cervical exam if membrane
rupture suspected.
STERILE SPECULUM
EXAMINATION
 Assess for membrane rupture:
• Pooling of fluid in vagina.
• Nitrazine and fern test.
 Assess cervix visually.
 Obtain cervical cultures.
 Obtain wet prep for vaginitis, if no ROM.
 Obtain GBS culture of outer vagina and
rectum.
ADDITIONAL TESTS

 CBC, Urinalysis.
 Evaluate for maternal infection.
 Amniocentesis.
 Assess fetal lung matunity.
 Ultrasound
 Assess amniotic fluid index.
 Determine (+/ - 3 weeks) gestational age.
 Transvaginal scan for cervical length.
• Normal cervical length = 35 mm
• Significant cervical length = 25 mm
• Funnelling of membrane
 Cervioovaginal swab for fetal
fibronection.
 MANAGEMENT
OF
PRETERM LABOR
MANAGEMENT OF PRETERM
LABOUR
• Prophylactic management
• Management in labour
• Management after
delivery
Prophylactic
Management
Good antenatal care.

 All diseases should be controlled well.

 In multiple pregnancy rest and sedatives
very
important
 In incompetent Cx. Circlage stitches.
 Diabetic treatment.
 Tocolytic therapy
Management of Acute
Preterm Labour
• Sedation and hydaration
• Bed rest and hydration are commonly
recommended, but without proven efficacy.
(risk of DVT in bed rest).

• Probable role of hydration  decrease

secretion of ADH + oxytocin from post
pitutary

• Steroids
• Antibiotics
• Tocolysis
Role of Steroids

• Single course of antenatal steroids b/w 24 and

34 wks of gestation with intact membranes and
24-32 wks in PPROM reduces the risk of
RDS,IVH, NEC, Sepsis and neonatal mortality
by 50%.

• Dose
Betamethasone 12mg i/m B.D for 24 hrs.
Dexamethasone 6 mg i/m every 6 hours for 24
hours.
MOA of steroids.
1. Stimulates type II pneumocyctes to produce surfactant.
2. Structural development of lungs
3. Accelerated maturation of fetal intestines (Prevent NEC).
effect on myocardium (Prevent IVH)
Repeated Dose increased sepsis in PPROM.
Restricted fetal body and brain growth .
Adrenal Suppresssion.
Increase risk of NND
TRH, Vitamine K , Phenobarbitone
• The use of thyrotropin-releasing hormone (TRH), vitamin
K and phenobarbitone to improve neonatal outcome has
been studied in randomized trials, but has not been
shown to be beneficial.
Role of Antibiotics
(Oracle Trail)
• Administration of antibiotics to the mother
do not delay delivery.

• Only positive health benefit is a reduction

in maternal infection rates.
 TOCOLYSIS
Is Tocolysis Better Than No Tocolysis For
Preterm Labor?

• It is reasonable not to use tocolytic drugs, as there is no

clear evidence that they improve outcome. However,
tocolysis should be considered if the few days gained
would be put to good use, such as
• completing a course of corticosteroids,
• or in utero transfer
 Tocolytics

• There is no reliable data to suggest tocolytics agent is

able to delay the delivery for longer than 48 hours.

• No single agent has a clear therapatic advantage.

• Maintenance tocolysis beyond 48 hours is not

recommended, it has not been shown to delay delivery
and is associated with Significant adverse effect.
Tocolytics
• Recent meta analysis suggest that
maintenance tocolytic with nifedipine may
be beneficial.
• Concurrent use of tocolytics has no more
effective than single agent alone and has
more S.E so not recommended.
• Most authorities do not recommend use of
tocolytics at or after 34 weeks' .
• There is no consensus on a lower gestational
age limit for the use of tocolytic agents.
CANDIDATES FOR TOCOLYSIS
 No contraindications to drug.
 Fetus currently healthy.
 Clear diagnosis of preterm labor.
 Cervix < 4cm dilatation.
 Gestational age between 24 -34 weeks.
Contraindication of Tocolysis
• Severe pregnancy induced
hypertension
• Uncontrolled diabetes mellitus
• Placental abruption
• Cardio-pulmoary diseases
• Multiple gestation
• Maternal hyperthyroidism
• Rhesus iso-immunisation
• Sickle cell disease.
• Severe anaemia.
Choice Of Tocolytic Drug
 B –Sympathomimetic
(Ritodrine)
 Magnesium sulphate
 Indomethacin = Indocid

 Nifedipine = Adalate retard

 Atosiban= Tractocile
Choice Of Tocolytic Drug

If a tocolytic drug is used, ritodrine no longer seems the best

choice.

Atosiban or nifedipine appear preferable

as they have fewer adverse effects and seem to have comparable
effectiveness.
 B -Sympathomimetic Agents.

• Use of beta-agonists should be restricted to the

management of preterm labor between 20 and 35
completed weeks, including women with ruptured
membranes.
(Grade A)
Side Effects of B -Sympathomimetic
Agents.
• Maternal: pulmonary edema, myocardial
ischemia, arrhythmia, and even maternal
death.

• Fetal : arrhythmia, cardiac septal

hypertrophy , hydrops, pulmonary edema,
and cardiac failure. hypoglycemia,
periventricular-intraventricular
hemorrhage, and fetal and neonatal death.
 Magnesium Sulphate
Magnesium sulphate is ineffective at delaying birth or
preventing preterm birth, and its use is associated with an

increased mortality for the infant.

Nitric Oxide Donors

There is insufficient evidence to support the routine

administration of nitric oxide donors

(nitroglycerin patch )in the treatment of preterm labor.

 Indomethacin
Compared with ritodrine there is insufficient evidence for any
differential effect on delay in delivery, but indomethacin
does seem to have fewer maternal adverse effects than the
beta-agonists
Fetal risk: (Common with high dose and prolonged exposure)
• Premature closure of the ductus arteriosus.
• Renal and cerebral vasoconstriction.
• Necrotising enterocolitis
 Indomethacin
Indomethacin therapy for
 < 48 hours
 < 30-32 weeks' gestation)
 Not > 200mg/day.

appears to be a relatively safe and effective tocolytic agent

Indomethacin can be used as a second-line tocolytic agent

in early gestational age preterm labors.
 Indomethacin
Indomethacin may be a first-line tocolytic in:
• Associated polyhydramnios:
( to have renal effects of indomethacin)

Capsule 25mg oral

Amp 50mg

Rectal Supp 100 mg

50 mg Loading dose
Then 25-50mg /6hs
 Atosiban: Tractocil
Atosiban, a synthetic peptide, is a competitive antagonist of oxytocin at
uterine oxytocin receptors.

Atosiban - compared with beta-agonists- has:

Little difference in the effect of these agents on delayed
delivery
Fewer maternal adverse effects than beta-agonists, such as
chest pain, palpitations , tachycardia , hypotension ,
dyspnoea ,vomiting , and headache.
Nifedipine
Nifedipine- compared with ritodrine - has:
Higher delaying of delivery for >48 H.
Lower risk of RDS &Neonatal jundice.
Lower admission to NICU
Fewer maternal adverse effects
When tocolysis is indicated for women in preterm labor, calcium channel
blockers are preferable to other tocolytic agents compared, mainly
betamimetics.
Further research should address the effects of different dosage regimens
and formulations
Nifedipine

Dose:
20mg initial
10-20 mg /4-6 h

Available forms
Adalate capsule : 10mg

Adalate retard Tablet: 20 mg

Group B Streptococci (GBS) Prophylaxis
All patients in preterm labor are considered at high risk for neonatal GBS
sepsis and should receive prophylactic antibiotics regardless of culture
status.

ACOG Advises Screening All Pregnant Women for Group B Strep.

The goal of this strategy is to prevent neonatal sepsis, and not to prevent
preterm birth.

All patients in preterm labor are considered at high risk for neonatal GBS
sepsis and should receive prophylactic antibiotics regardless of culture
status.
Management after Tocolysis

• If maternal and fetal conditions are stable, can be

managed at home

• Avoid excessive physical activity; most advocate pelvic

rest
Delivery of Preterm Fetus
• Every effort for in utero transfer to an
tertiary care obstetric unit linked with NICU
Mode of Delivery

• If the presentation is Cephalic and normal fetal heart rate

pattern  Vaginal Delivery
• No evidence of routine C-section
• No evidence for elective forceps delivery.
• Episiotomy rarely required
• If abnormal F.H.R pattern C-section
( Hypoxia pelivemtricular leucomalacia)
 Preterm Breech
(Obstetric Dilemma)

• Mode of delivery of preterm breech will need to be made

on a case to case by obstetrician at that time.

• C-section in preterm breech already in vagina may be

more traumatic then vaginal delivery
Summary
• Oral metronidazole significantly lowers the risk of
preterm birth, by 60% in high risk women positive
for bacterial vaginosis.

• Asymptomatic bacteriuria carries an increased risk

of preterm birth, the risk is reduced by appropriated
antibiotic treatment.

• Mothers at risk of preterm delivery should be

screened for GBS colonization. If positive, intra
partum antibiotics should be offered.

• When based on historical factors alone, cervical

cerclage improves outcomes only in women with
three or more previous very early deliveries.
• Hospitalization for bed rest leads to an increase in
preterm births .

• Tocolytics have no significant benefit on perinatal

mortality or the prolongation of pregnancy to term, but do
reduce the number of women delivering within 48 hours
by 40 percent.
continue

• A single course of maternal steroids given b/w 28 and 34

wks gestation and received within 7 days of delivery
results in markedly improved neonatal outcomes.

• There is no evidence of benefit and some evidence of

harm associated with the use of antibiotics in
uncomplicated preterm labor with intact membrane
Thanks