Dr Bantayehu Nega,(Assistant professor of

Obstetrics and Gynecology , Bahir Dar

University)
 Introduction
Definition: When labor starts before 37 completed weeks (<259
Days) from LNMP & after viability.
• It is significant cause of perinatal morbidity & mortality
• PTL is also a major determinant of short- and long-term
morbidity in infants and children.
Magnitude:
• Prevalence varies widely, Ranges between 5-15%( 10 %)
 Con’t …
• Neonates born before term can be small or large for
gestational age but are still preterm by definition
– Low birth weight (LBW) — BW less than 2500 g
– Very low birth weight (VLBW) — BW less than 1500 g
– Extremely low birth weight (ELBW) — BW less than 1000 g
 Con’t…
• Prematurity, represents incomplete development of various
organ systems at birth.
– The lungs are particularly affected and may be susceptible
to the respiratory distress syndrome
• Approximately 70 to 80 percent of PTBS occur spontaneously.
– 40 to 50 % due to preterm labor
– 20 to 30 % due to PPROM
• The remaining 20 to 30 percent of PTBS are due to
intervention for maternal or fetal problems
 Etiology Of PTL
• Cause is unknown in 50% of cases
• Cause is of multifactorial and associated with different
factors
 Risk factors for PTL

• Previous history of preterm labor, induced or

spontaneous abortion
• Asymptomatic Bactriuria/UTI
• Smoking
• Low socioeconomic status/ Nutritional status
 Risk factors- cont’d
Complications in current pregnancy: Maternal, fetal or
placental
• Maternal:
- Pregnancy complications: APH, PROM, Preeclampsia,
polyhydraminos
- Uterine anomalies: Cervical incompetence, malformations
of the uterus
- Medical & surgical illness: acute fever, appendicitis
- Genital tract infections: BV, chlamydial
 Risk- cont’d

• Fetal: Multiple pregnancy, Congenital malformations, IUFD

• Placental: Infarction, thrombosis, Abruption
Iatrogenic: wrong GA estimation, termination of pregnancy for
obstetric indications

Idiopathic: Half of cases

 Diagnosis
• History: lower abdominal pain /pushing down pain, leakage of
liquor, pelvic pressure
• Physical findings:
- Regular uterine contractions
- Progressive change in Cervical dilatation

- Change in effacement
 Diagnosis- cont’d
• Investigations:
- TVS: cervical length < 2.5 cm & funneling
- Fetal fibronectin from vaginal discharge
 It is a protein that binds fetal membranes to decidua.
- Other investigations based on etiologies like screening for

genital & other infections.

 Lab. investigations
• CBC for WBC with differential
• U/A, urine culture & sensitivity
• Cervical & vaginal swab for culture
• Ultrasound

• Blood sugar level

 Management

• Goals of treatment include:

o Prevent preterm labor
o Arrest preterm labor

o Appropriate management of labor

o Effective neonatal care
 Management…
• Four interventions that have been shown to reduce neonatal
morbidity and mortality:
1. Antenatal transfer of the mother and fetus to the most
appropriate hospital.
2. Antibiotics in labor to prevent neonatal infection
3. Antenatal administration of glucocorticoids to the mother
4. Administration of maternal magnesium sulfate
 TOCOLYTIC AGENTS
 Tocoloysis is inhibition of myometrial contractions

1. Prostaglandin synthase inhibitors. Eg. Indomethacin

2. Calcium Channel Blockers. Eg. Nifedipine
3. β- Adrenergic agonists. e.g. Ritodrine , terbutaline
4. Magnesium Sulfate
 Complications of preterm delivery

• RDS
• Birth injury
• IVH
• Metabolic complications: Hypocalcemia, hypoglycemia,
hypomagnesmia
• Hypothermia
• NEC
• Hyperbilirubinemia
• Infection
• Malnutrition
PROM (Premature rupture of membranes)
 Premature rupture of membranes

Definition: Spontaneous rupture of membranes after 28 weeks

of gestation before the onset of labor.
• Term PROM: Rupture of membranes after 37 weeks
• Preterm PROM: Before 37 weeks

• Prolonged PROM: Longer than 8hrs.

• Latency period: Time between rupture of membranes to
onset of labor.
 PROM- cont’d
Incidence: average around 10%, ranges 3-19 %.
Causes: Not known in majority. Possible causes include:
• Increased fragility of membranes
• Decreased tensile strength of membranes
• Polyhydraminos
• Cervical incompetence
• Multiple pregnancy
• Infection
• Emergent circlage
 PROM-Cont’d
Diagnosis:
• History: complaint of leakage of liquor as gush or slow leak
• Physical findings:
- Negative discrepancy
- If complicated, uterine contraction, tenderness
- Sterile speculum examination with or without valsalva
maneuver( leakage or pooling)
 Diagnosis-cont’d

Investigations:

• Nitrazine paper test

• Ferning pattern

• Ultrasound: support diagnosis & fetal wellbeing.

• Dye test: indigo carmine instillation

 PROM- investigations
• CBC
• U/A, urine Culture & Sensitivity
• High vaginal swab for culture
• Obstetric ultrasound

• CTG for nonstress test

• Routine test like VDRL,HbsAg,BG&Rh,PICT
 Differential diagnosis for PROM

• Urinary incontinence
• Leucorrhea gravidarum
• Perspiration
• Vaginal discharge-pathological

• Increased physiological vaginal discharge

 Complications of PROM

• Preterm Labor
• Ascending infection: one third
• Increased incidence of cord prolapse
• Fetal pulmonary hypoplasia

• Prematurity
• Abruption
 Management

• Accurate diagnosis
• Avoid digital vaginal examination
• Bed rest
• Management depends on:
- GA
- Presence or absence of labor
- Maternal condition
- Fetal condition
 Indications for pregnancy termination in PROM

• Term PROM
• Labor
• Presence of infection
• IUFD

• Congenital anomalies of fetus incompatible to life

• Abnormal fetal surveillance
 Preterm PROM
• GA > 34 weeks is controversial either conservative management
or termination
• GA< 34 weeks, conservative management

• Components of conservative management:

- Monitor maternal PR, Temp,BP ,RR, FHR every 4 hours

- CBC, U/A twice per week

- Corticosteroids if less than 37 weeks

- Administer antibiotics: Ampicillin, amoxacillin & azithromycin

- Follow with PROM and kick chart

 Chorioamnionitis

• Clinical or subclinical
• Criteria for clinical chorioamnionitis:
- Maternal temperature > 38o C
- Uterine tenderness

- Foul smelling amniotic fluid

- High WBC count >15k
- Maternal &/ or fetal tachycardia
 Sub clinical chorioamnionitis

• Amniocentesis: intramniotic infection is present if:

1. Culture: bacterial colony count > 102 / ml fluid
2. Presence of bacteria on gram stain

3. Glucose level<15 mg/dl

4. WBC> 100/ml
 Management of chorioamnionitis

• Antibiotics:
1. Ampicillin + clindamycin
2. Ampicillin + Gentamycin ± metronidazol

3. Ceftriaxone +/- metronidazole

• Terminate pregnancy: Vaginal route is preferred
Thanks