Preterm Labor PROM Preterm Labor When onset of

Preterm Labor & PROM

Preterm Labor • When onset of labor prior to completion of 37 weeks (259 days) of pregnancy, after the attainment of period of viability is called preterm labor. • The lower limit varies in different countries Ø WHO- 22 wks and 500 gm Ø United kingdom- 24 wks Ø India- 28 wks

Incidence • It varies 5 -15% in different part of world & India Aetiology • In >30% cases exact cause of preterm labor is not known • Certain risk factors which increases the incidence of preterm labor.

Risk factors • Genital tract infection- Group B streptococci - Bacterial Vaginosis - Chlamydia, Gonorrhea • Ante partum Hemorrhage • Overdistended Uterus- polyhydromnios • Uterine anomalies - Multiple pregnancy - unicornuate, Bicornuate -septate, arcuate, Fibroid uterus

• • Incompetent Cervical os Acute fever & maternal illness Premature rupture of membrane Low socioeconomic status, poor nutrition, & anaemia Smoking & tobacco addiction UTI Pervious H/o preterm labor (17 -40%) Iatrogenic- Induction of labor without knowing EDD

Diagnosis of PTL • P/A- Regular uterine contractions > 4 in 20 minutes or >8 in 60 minutes, with changes in cervix • Cervical effacement >80% Cervical dilatation > 1 cm

Preterm Labor Can be 1. Advanced PTL 2. Early PTL 3. Threatened PTL

Advance PTL Diagnosis: -Regular uterine contraction >4 in 20 mts or >8 in 60 mts -Cervix >3 cm dilated - 80% effaced

Management of Advanced PTL • Allow delivery if -Cx is >4 cm dilated -Signs of chorioamnionitis -Baby malformed -Severe placental insufficiency • But if Cx is <4 cm and none of the above is present give tocolysis, corticosteroid & antibiotic if indicated • Aim – to give corticosteroid to prevent RDS &IVH in baby & mother with fetus in utero can transfer to place where neonatal care facility available

Early PTL Diagnosis: -Regular uterine contraction -Cervix > 1 cm & <3 cm dilated -Cervix > 80% effaced

Management of Early PTL • If there is signs of – Chorioamnionitis - Congenital anomaly in fetus - Mother& fetus condition is not good Allow labour and delivery.

• But if - Fetal condition is not compromised - Maternal condition is good - No signs of chorioamnionitis - Membranes are intact Then Expectant management includes- Bed rest in left lateral position - Antibiotic if infection is evident - Tocolysis - Corticosteroid if pregnancy < 34 weeks

Threatened PTL • When there are regular uterine contractions, Cervix is <1 cm dilated , length of cervix <2. 5 cm on USG & GA <37 wks- Threatened PTL • Diagnosis is by – Clinical examination - USG - Detection of fetal fibronectin in cervical discharge • FFN in cervical discharge is usually absent between 24 -34 wks , so if it is present it is predictor of PTL

• If FFN is negative in cervical discharge indicates no delivery with in 7 days. • If threatened PTL is diagnosed by clinically, USG & FFN then give tocolysis and corticosteroid to woman.

Doses of Corticosteroids • Betamethasone- 2 doses, 12 mg IMI, 24 hours apart. OR • Dexamethasone- 6 mg IMI 12 hrly total 4 doses • Corticosteroids are beneficial when delivery occurs at least 48 hrs after 1 st dose

Tocolytic Drugs Various tocolytic drugs which can be used are : * Nefedipine * Betamimetics –Isoxsuprine -Terbutaline - Retrodine * Indomethacin * Mgso 4 * Nitroglycerine

Doses of Tocolytic drugs Nefedipine • It is the best first line tocolytic • It is a calcium channel blocker causes smooth muscles relaxent • Doses – Initial 20 -30 mg orally followed by 10 mg 4 -6 hrly till uterine contraction cease f/b 10 mg 8 hrly for about 1 wk. • Side effects- headach, hypotension, nausea flushing

Bitamimetic Tocolytics Turbutaline • It can be given IV or subcutaneous • For IV- Dissolve 5 mg of terbutaline in 500 ml of RL, each ml contains 10 ug -Start with 5 ug (o. 5 ml)/min. & increase the dose of 5 ug every 10 -20 min. till uterine contraction stops. -Maximum dose 30 ug/min. • Subcutaneous dose-o. 25 mg every 3 -4 hours for 12 hrs • A maintenance dose-2. 5 -5 mg orally 4 -6 times/day

Ritodrine • Beta mimetic drug causes smooth muscle relaxation by B 2 receptor stimulation • Doses- given by IV infusion - Start with 100 ug/min. & increase the dose by 50 ug every 10 -20 min. till the uterine contraction stops or maximum dose of 350 ug - Continue infusion for 12 hrs after the contractions stop.

Isoxsuprine • Doses- 0. 2 -0. 5 mg/min I V infusion for 12 hrs followed by 10 mg IMI every 6 -8 hour for 24 hours Side effects of Beta mimetics • • Headache Palpitation , Tachycardia Hypotension , Hypokalemia Pulmonary oedema & Cardiac failure

Indomethacin • It is an excellent tocolytic but is not used as first line because it causes constriction of ductus arteriosis. • Dose – Initial dose 25 -50 mg orally followed by 25 mg every 4 -6 hours for 3 days. • Side effects – Heart burn, G. I. bleeding Thrombocytopenia, asthma

Mgso 4 • Dose – 4 -6 gm (20% solution) i. v. slow in 20 -30 min. followed by an infusion of 1 -2 gm/hr & continue for 12 hrs after the contraction have stopped • Side effects- Headache , flushing - Muscular weakness - Rarely pulmonary oedema

Nitro-glycerine • It is usually given in form of patch • Dose – 0. 1 - 0. 4 mg/ hr • Side effects – Tachycardia - Headache - Hypotension

(PROM) Premature Rupture Of Membranes or Prelabour Rupture Of Membranes • Spontaneous rupture of fetal membrane any time after the period of viability but before the onset of labor is called PROM. When it occurs before 37 wks completed gestation it is called PPROM. • Incidence – 10%

Causes of PROM • • Polyhydromnios Multiple pregnancy Incompetent Cervix Poorly applied presenting part in unstable lie and malpresentations • Traumatic- ECV, amniocentesis • Weakness of chorion & amnion- developmental or inflammatory, chorioamnionitis

Diagnosis • H/O- discharge of fluid p/v • P/S- examination shows liquor coming out through cervical os it may be clear or meconium stained. • Sometimes liquor is not appreciable through os D/D – liquor amnii - urine - vaginal discharge

Confirmatory Tests for liquor Amnii • Fern Test- Take the sample of vaginal fluid on a slide & allow it to dry then look under microscope. Crystallization of liquor looks like fern. • Nitrazine Test- Normal vaginal PH is 4. 5 -5. 5 but PH of liquor is 7 -7. 5. Put the Nitrazine paper on vaginal discharge Liquor turns the Nitrazine paper deep blue. • Nile blue sulphate Test- when centrifuged cells of watery discharge is stained with Nile blue sulphate it shows, orange blue coloration of cells indicates presence of exfoliating fetal cells in liquor

• Indigo-carmine Test- When other tests are negative and still doubt of leaking. Inject 2 -3 cc of indigo carmine in amniotic cavity & put a tampon in vagina wt. for ½-1 hr if tampon turns blue indicate liquor. • Detection of fetal fibronectin in endocervix & vagina between 24 -34 wks of GA indicates PROM • USG - Shows less liquor

Hazards of PROM • Maternal- Increased liability to infection - chorioamnionitis - Premature placental separation - Postpartum endometritis • Fetal - Cord prolapse - Premature labor & hyaline membrane disease - Intrauterine Infection

Management of. PROM • Initial Assessment- main objective of the initial assessment are: - Confirm the diagnosis of PROM - To determine the gestation of the fetus - To identify the women who need to deliver

Management of PROM • If Pregnancy is ->37 weeks - Congenital anomalies - Fetal distress , cord prolapse or - Signs of chorioamnionitis Then deliver the patient. • Induction of labor- if no contraindication

Management of PPROM • Balance between risk of infection in expectant management & Premature labor • Shift the patient where the facility for neonatal care is available. • If pregnancy is >34 and <37 weeks - Haemogram, cervical swab c/s - Antibiotics - Careful watch on signs of chorioamnionitis Maternal & fetal conditions - If no spontaneous labor in 24 -48 hrs-induction of labor

• If pregnancy <34 weeks Expectant Management- The aim is to prolong the pregnancy for fetal maturity - Bed rest - send haemogram & Cervical swab c/s - give corticosteroid & tocolysis if contraction +nt - Antibiotics - Watch for signs of chorioamnionitis, Maternal & fetal condition.

Signs of chorioamnionitis • Temperature > 100. 4*F and 2 or more of: -Maternal tachycardia pulse >100/min. -Uterine Tenderness - Foul smelling vaginal discharge - Leukocytosis 15000 cmm - C-reactive protein >2. 5 mg% - Fetal tachycardia >160 min if there is no other site of infection