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Rex M. Poblete, M.D.

,FPOGS
PRETERM LABOR

POST-TERM PREGNANCY

PROM(Premature Rupture of Membranes)

IUFD (Intrauterine Fetal Demise)


PRETERM LABOR
Single largest cause of perinatal morbidity
and mortality in infants without anomalies
in developed nations
Represent more than 70% of all perinatal
mortality and morbidity
40% of preterm births follow preterm labor
Prevalence:
US = 11%
Phil = 11.44% (POGS CNS)
PRETERM LABOR

PRETERM – refers to a fetus, a


pregnancy, or a neonate, that is less than
37 weeks gestation (WHO, ACOG) and
more than 20 weeks gestation
2 categories:
Indicated = 20%
Spontaneous = 80%
PRETERM LABOR: categories

INDICATED SPONTANEOUS
*Follow medical or obstetric *Occur when there is no
disorders that place the underlying maternal or fetal
illness
mother or the fetus at risk.
*Typically follow premature
*Preeclampsia (42%) rupture of membranes,
Fetal distress (26.7%) incompetent cervix,
Intrauterine growth chorioamnionitis…
restriction (10%) *Any prior spontaneous
preterm delivery carries a
Abruptio placenta (6.7%)
2.5 fold increased risk in a
Fetal demise (6.7%) current gestation and even
a 10.6 fold increase in
preterm delivery <28
weeks AOG
PRETERM LABOR: risk factors

Previous preterm Extremes of age (≤18


delivery or ≥40 years)
Low socioeconomic Genital colonization
status or infection
Absent/inadequate
Vaginal bleeding prenatal care
Nonwhite race Cervical injury or
Multiple gestation abnormality
Low body mass index Smoking
Bacteriuria Uterine abnormality
PRETERM LABOR: risk factors

Extremes of age (≤18 or ≥40


Previous preterm years)
delivery Genital colonization or
infection
Low socioeconomic status
Absent/inadequate prenatal
Vaginal bleeding care
Nonwhite race Cervical injury or abnormality
Multiple gestation Smoking
Low body mass index Uterine abnormality
Bacteriuria

* Nearly 50% of women with preterm


deliveries have no identifiable risk
factors…
PRETERM LABOR: diagnosis

CERVICAL CHANGES
*Characteristic cervical changes before
delivery: shortening, softening,
progressive dilatation
*Digital examination: failed to predict
preterm labor because of the great
variation between examiners
*Transvaginal UTZ of the uterine cervix is
a better predictor of preterm delivery
PRETERM LABOR: diagnosis

Preterm Prediction Trial, 1996


*2 findings consistently associated with an
increase in preterm birth:
1. Cervical length <25 mm (10th percentile) to
30 mm (25th percentile)
2. Appearance of a funnel that comprises
50% or more of the total cervical length
PRETERM LABOR: diagnosis

BIOCHEMICAL/ ENDOCRINE MARKERS


1. FETAL FIBRONECTIN (Ffn)
• A glycoprotein produced by the fetal chorion and
localized to the maternal decidua basalis
• When disruption of the choriodecidual junction
occurs, it is extravasated into cervical and vaginal
secretions
• Rarely identified after 21 weeks gestation
• Presence after 21 weeks AOG is strongly
associated with preterm delivery
PRETERM LABOR: diagnosis

2. SALIVARY ESTRIOL
* estriol – “estrogen of pregnancy”
* salivary estriol levels mirror the level of
biologically active (unconjugated) estriol in the
circulation
* elevated levels of maternal salivary estriol
(≥2.1 ng/ml) is predictive of preterm delivery
in high risk women
* studies show increased levels 2-4 weeks
before delivery, whether term or preterm
PRETERM LABOR: diagnosis

3. CORTICOTROPIN-RELEASING
HORMONE (CRH)
* a hypophysiotrophic hormone that
stimulates ACTH production in the
pituitary
* demonstrated to increase 100-fold in
maternal serum in the 3rd trimester before
parturition
PRETERM LABOR: management

TOCOLYTIC THERAPY

ANTIBIOTICS

STEROIDS
PRETERM LABOR: management

TOCOLYTIC THERAPY

Mainstay of hospital therapy once preterm labor


is suspected

Cannot be expected to prevent prematurity


because they treat the symptom
(contractions), not the underlying pathology
PRETERM LABOR: management

TOCOLYTIC THERAPY
Main benefit: temporarily delay delivery (48-72
hours) to allow:
1. Administration of glucocorticoid therapy to
improve neonatal outcome
2. Transfer of the mother to a tertiary facility
that can best take care of a premature infant
3. Time to allow other treatments to work (e.g.
antibiotics)
PRETERM LABOR: management

TOCOLYTIC AGENTS:
1.Beta-mimetics:
Terbutaline sulfate (Bricanyl)
Ritodrine hydrochloride
Isoxuprine hydrochloride (Duvadilan/Isoxilan)

**consistently demonstrated an ability to prolong


gestation by about 24-48 hours
**side effects include maternal pulmonary edema and
neonatal intravascular hemorrhage
PRETERM LABOR: management

TOCOLYTIC AGENTS:
2.Magnesium sulfate
**nonspecific calcium antagonist
**studies show no significant differences in delay in
delivery when compared to beta-mimetics
**1st line of treatment in the US
**side effects include maternal hypocalcemia
**monitor for signs of magnesium toxicity
.
PRETERM LABOR: management

TOCOLYTIC AGENTS:
3.Calcium-channel blockers (Nifedipine)
**contraindicated in maternal hypotension (<90/50)
4. Prostaglandin synthetase inhibitors:
Indomethacin
Sulindac
Ketorolac
5. Oxytocin antagonist – Atosiban
.
PRETERM LABOR: management

ANTIBIOTICS
*Studies have linked urinary tract infections, intrauterine
infections, and vaginal microflora including bacterial
vaginosis, with an increased risk for spontaneous
preterm birth
*Proposed pathogenesis of infection-induced preterm
labor: ascent of microorganisms from the cervix or
vagina colonization of fetal membranes and
decidua release of toxins production of cytokines
 production of prostaglandins which stimulate
myometrial contractionPRETERM LABOR
PRETERM LABOR: management

ANTIBIOTICS
*In PTL with intact membranes:
*shown to be of no beneficial effect
DISCOURAGED
*In PTL with Premature Rupture of Membranes
*shown to improve outcome for both mother and fetus
*beneficial in prolonging pregnancy and in decreasing
neonatal infectious morbidity
.
PRETERM LABOR: management

STEROIDS
*Use prior to preterm delivery has been shown
to significantly decrease respiratory distress and
neonatal mortality
*There is not enough evidence to evaluate the
utilization of repeated doses of corticosteroids
*Present recommendation is only for a single
course
*Dexamethasone, Betamethasone
POST-TERM PREGNANCY

TERM gestation: 37-42 weeks


POST-TERM: >294 days or 42 weeks
• Frequency: 4-14% (2-7% at 43 weeks)
• Parturition occurs at 280 days (40 weeks)
after 1st day of last menses only in 5%
• Associated with increased perinatal morbidity
and mortality
POST-TERM PREGNANCY: diagnosis

Reliability of the Last Menstrual Period


(LMP)
Use of ultrasound measurements (early =
done <24 weeks gestation)
Assessment of amniotic fluid:
*Volume – oligohydramnios?
* Character – stained?
POST-TERM PREGNANCY: diagnosis

ULTRASOUND:
*Fetal biometry/
fetal aging
*Amniotic fluid
assessment
POST-TERM PREGNANCY: diagnosis

OLIGOHYDRAMNIOS:
*AFI is below 5 cm
*Associated with higher
rates of intrapartum
fetal distress and
cesarean section
*Meconium-staining:
occurs in 37% of post-
term pregnancies with
normal AFI;
increase to 71% when
AFI is diminished
POST-TERM PREGNANCY

FETAL COMPLICATIONS:
• Aberrations in fetal growth:
• Postmature-dysmature syndrome – wasting of
subcutaneous tissue, meconium-staining, peeling
of skin (undernourished neonate)
• Macrosomia - >4000 grams birth injuries
• Meconium-staining & pulmonary aspiration
• 3-fold higher increased incidence in post-term
POST-TERM PREGNANCY:
management

If (+)favorable cervix: labor induction


between 41-42 weeks
If (+)unfavorable cervix: (a) do cervical
ripening followed by labor induction; or (b)
do twice weekly fetal monitoring 
DELIVERY if with fetal compromise
Use of UTZ: Biophysical Profile/ Score
PREMATURE RUPTURE OF
MEMBRANES (PROM)

Spontaneous rupture of the membranes that


occur before the onset of labor

Preterm PROM
Rupture of the membranes before 37 weeks
PREMATURE RUPTURE OF
MEMBRANES: diagnosis
Diagnosis of membrane rupture is
mainly clinical

*other causes of vaginal discharge must be


excluded
PREMATURE RUPTURE OF
MEMBRANES: diagnosis
Diagnostic tests:
1. Nitrazine paper – insert a sterile cotton tip
applicator deep into the vagina  touch it to
the nitrazine paper
pH > 6.5 consistent with ruptured membranes
False positive nitrazine paper test:
increased pH such as in cases contaminated
by blood, semen or alkaline substance, or if
with bacterial vaginosis
PREMATURE RUPTURE OF
MEMBRANES: diagnosis

2. Ferning
false positive result:
if the specimen is contaminated with
cervical mucus (sample should be taken
from the cul de sac or lateral vaginal
walls)
PREMATURE RUPTURE OF
MEMBRANES: diagnosis

3. Ultrasound evaluation
Ultrasound finding of oligohydramnios
without fetal urinary tract malformation or
fetal growth restriction  highly
suggestive of membrane rupture
PREMATURE RUPTURE OF
MEMBRANES: management
* Gestational age should be established as
soon as possible
Clinical history and UTZ – estimate the gestational age,
fetal weight, fetal position & residual amniotic fluid

* Evaluatefor presence of advanced labor,


chorioamnionitis, abruptio placenta, fetal
distress
Expeditious delivery regardless of age
PREMATURE RUPTURE OF
MEMBRANES: management
* If conservative management is pursued,
patient must be admitted to a tertiary
hospital
* Provisions for 24-hour neonatal
resuscitation & intensive care
GOOD DA Y