Preterm Labour and Preterm
Rupture of Membranes
By
Prof . Farouk Abdel Aziz
Preterm labour & premature
Rupture of Membranes
OBJECTIVES :
Define PTL and PMROM & describe their
signficance
List risk factors associated with PTL & PROM
Ouline initial evaluation of of PTL & PROM
Describe management of PTL &PROM
Discuss neonatal GBS prevention strategies
Preterm Labour
-Incidence ;
11.6 % of all deliveries
Rate increasing since 1980
Definition
Uterine contractions >3in 30 minutes
Presence of cervical change
Before 37 weeks of gestation
Risk factors in PTL
History :
-Previous PTL
-Maternal age
-Race
-Uterine anomalies
Trauma
Risk factors in PTL
-Current pregnancy:
-maternal infections
bacteriuria
pyelonephritis
genital tract
pneumonia
-Preterm PROM
-Uterine distension twin ,polyhydramnios
Prevention in high risk groups
[Link] programmes
[Link] activity management
[Link] of cervicaal length US
[Link] and treating BV
documented reduction in preterm birth
PROM
-Rupture of membranes at least 1hr before
ROMs
-2-17 % of pregnancies (average 8% )
-20-40 % before 37 ws
-Precise aetiology unknown :
multiple risk factors
Infection often plays a role
Patient History
-detailed history of labour
-history of fluid leakage
-review history for risk factors
-history of other medical conditions
-assessment of social history and home
support
Physical Examination
-Maternal vital signs signs of infection
-Foetal heart rate pattern
-Uterine contraction pattern
-Foetal size and presentation
No digital cervical examination if
membrane rupture is suspected
Sterile Speculum Examination
-
Assess for membrane rupture :
--pooling of fluid in vagina :Fern test & nitrazine
-assess cervix visually
-Obtain cervical cultures
-Obtain wet prep for vaginitis
-Obtain GBS culture of other vagina and rectum
Additional Tests
-CBC ,urinalysis assess for maternal infection
-Amniocentesis-
assess foetal lung maturity
-Ultrasound :
assess amniotic fluid index
determine gestational age - +/- 3 weeks
-Transvaginal scan for cervical length
-Cervicovaginal swab for foetal fibronectin
Management of PTL
Consider following factors :
- condition of foetus
-imminence of delivery
-availability of local resources
-availability of safe transport to referral
centre
-Maternal transport <32-34 weeks decreases
neonatal mortality by 60 %
-Treat underlying conditions
Bed rest and hydration ? benifit
Corticosteriods in PTL
-Effectively reduces RDS and infant
mortality at 24-34 ws of gestation
-Betamethasone 12 mg IM 2 doses q 24 hrs
-Dexamethasone 6 mg ,4 doses q 12 hrs
Tocolytics
- No evidence of long term suppression of
labour
-can be effective for 24-48hrs
allows time for maternal transfer or
administration of corticsteriods
Candidates for Tocolytics
-No contra-indication to drugs
-No contra-indication to prolonging
pregnancy
-Foetus currently healthy
-Clear diagnosis of PTL
-Cervix < 4 cm dilated
Drugs
-Terbutaline available in IV,SQ or PO
-ritodrine-only in IV
-Beta-Agonist cause palpitations ,chest
pain ,anxiety,trmor nausea pulmonary
oedema and also foetal tachycardia
Magnesium sulphate
Emperic use of antibiotics
In PTL with intact membranes :-
-conflicting results in delaying preterm
labour
-No short or long term benefits
demonstrated
Preterm Rupture of Membranes
-Mangt depends on gestation age ,foetal size
& lung maturity
-Foetus >36 ws or >2500 gm ,manage as
term PROM
-Foetus <36 ws or <2500 gm PROM
-Foetus 32-36 ws :clinical judgement
consider amniocentesis for lung maturity
PROM
-Delivery likely within 12-24 hrs
+ consult with perinatologist
+Plan site of delivery
+ Tocolytics and /or corticosteriods
+Antibiotics for group B streptococci
+Avoid digital vaginal examinations
Term Prom
-Expectant mgt if delivery not imminent :
+ No digital exam unless labour begins
+ Follow for signs of ifnection
+Corticosteriods if foetus is 24-34 ws
+Antibiotics controvercial in prolonging
latency
Continued
-Expectant mgt vs induction
+90 % spontaneous labour within 48 hrs
+induce if signs of infection
+prostaglandins if cx unfavouable
-Early oxytocins decreases infection rate
without increasing CS delivery rate
Delivery of the Premature Foetus
* Limit maternal narcotics
*Anticipate malpresentations
*Alert neonatal care team of impending
delivery
Newborn Management
*Look for symptoms of sepsis
*Full sepsis evaluation and antibiotics
*Baby asymptomatic & >35 ws :
- intrapartum antibiotics < 4 hrs
-limited sepsis evaluation ,CBS,blood
culture close observation for at least
48 hrs
