Discussion of PTD

1. Preterm delivery :
PTL and PPROM
Labour pain and fluid leaking
during mid pregnancy

2. LEARNING OBJECTIVES
• To understand the extent of the problem, its
causes and consequences.
• To be aware of the limitations of our current
understanding.
• To appreciate the problems and potential
complications associated with our current
management of preterm labour.
• To grasp the potential for improvements in our
management of preterm labour.

3. Case scenario
Rawshan is 26 years old pregnant lady
in her 31 weeks gestation presented to
labour room with history of colicky
abdominal pain of few hours duration, back
pain with thick vaginal discharge & good
fetal movement

4. Definitions
• In pregnancy, the gestational age of viability is 24wks.
• Currently, the ‘grey zone’ for viability is around 23 weeks.
o Occasional survivors are seen after delivery at 23 weeks, which has
become the ‘grey zone’ for viability.
• In pregnancy, term refers to the gestational period from 37+0 to 41+6 wks.
• Preterm labour (PTL) is the onset of labour before 37 weeks’ gestation.
o PTL are those that occur between 24+0 and 36+6 weeks gestation.
• Second trimester or late miscarriage occurs between 12 and 23 weeks
gestation.
o A more practical definition of late miscarriage is one occurring between
17 and 23 weeks.

5. Early births
Spontaneous deliveries:
the mother develops
spontaneous contractions or
membrane rupture earlier
than normal
spontaneous
preterm labour
(PTL)
preterm prelabour
rupture of
membranes
(PPROM)
Indicated deliveries :
delivery is felt to be in
the best interests of the
mother or baby

6. Categories
1. Spontaneous PTL 50%
2. PPROM 25%
3. Delivery for maternal or fetal indications 25%
Iatrogenic or medically-indicated deliveries
1. Pre-eclampsia
2. Maternal cardiac or renal conditions or malignancies .
3. Chorioamnionitis
4. APH
5. Fetal growth restriction (FGR)

7. According to etiology, outcome and recurrence
risk, it is divided into three gestational periods:
1) Extremely preterm births : 24+0 to 27+6 weeks.
2) very preterm births : 28+0 to 31+6 weeks.
3) Mildly preterm births : 32+0 to 36+6 weeks.
Classification of preterm births

9. 1. Teenagers and women with advanced maternal age
(Parity 0 or >5)
2. Higher incidence of preterm deliveries in first
pregnancies.
3. Socioeconomic factors
4. Marital status
5. Genetic and environmental factors
6. Cigarette smoking, illegal substance (i.e. cocaine)
abuse, alcohol
7. Poor nutrition
8. Previous preterm
The risk of PTD

11. Labour vs PTL
• Labour at term and prior to it share a common
pathway involving:
1. uterine contractility,
2. cervical effacement and dilatation
3. membrane rupture.
• At term, the activation of this pathway is
physiological.
• spontaneous preterm labor is an enigmatic
process that occurs when the normal labor
pathway is triggered through various pathologic
mechanisms.
• a variety of pathologies underlie labour remote
from term.
• It has been suggested by some authors that
preterm labour be considered a syndrome, in
order to emphasize its multifactorial nature.

12. Endocrinology and biochemistry of labour
1. During pregnancy the uterus undergoes marked
biochemical and physiological changes while
expanding to accommodate the growing fetus
and remaining quiescent.
2. The cervix remains rigid and closed to retain the
developing fetus within the uterus.
• Throughout pregnancy ‘pro-pregnancy’ factors
inhibit myometrial contractility.
• ‘pro-pregnancy’ factors :
1. progesterone,
2. relaxin,
3. (hCG)
4. prorelaxation prostaglandins (PGs), such as
prostacyclin

13. • The onset of labour involves the synchronization of myometrial
activity through greater expression of gap junctions that
connect myometrial cells.
• Increased myometrial activity results from the activation of a
‘cassette of contraction-associated proteins’ (CAPs), which
convert the myometrium from a quiescent to a contractile state
• CAPs include:
1. gap junction proteins,
2. oxytocin and prostanoid receptors,
3. enzymes for PG synthesis
4. cell signalling proteins.
• CAPs
1. Activate fetal membrane PG and cytokine production
2. Cervical remodelling and ripening.

14. • Progesterone maintains uterine quiescence
• Labour as an inflammatory process
• The roles of oxytocin and prostaglandins

15. Causes of preterm labour
1. Cervical weakness ↔Ascending Infection
2. Ascending Infection ↔Cervical weakness
3. Ascending Infection→ Decidual Haemorrhage
4. Placental abruption → Decidual Haemorrhage
5. Multiple pregnancy → Uterine distension
6. Multiple pregnancy→ Fetal stress and Maternal stress
7. Uterine müllerian anomalies
8. Haematogenous infection
9. Iatrogenic infection
10. Idiopathic

17. Infection
• Infection of the fetal membranes, chorioamnionitis, is a major cause of
preterm birth particularly in deliveries before <32 weeks’ gestation.
• It is associated with a threefold increased risk of PTD with intact
membranes, and a fourfold increased risk with ruptured membranes.
• In most cases, infection ascends from the vagina, or transplacental or
introduced during invasive procedures.
• Overall, 33% of all pregnancies delivered after PPROM are
complicated by infection.
• The uterine cavity is normally sterile but the vagina contains
commensal bacteria.
• Depending on the bacterial load and cervical resistance, the
bacteria may ascend through the cervix and reach the fetal
membranes. This:
1. may activate the decidua, increase prostaglandin release and
trigger contractions.
2. Alternatively, it may weaken the membranes, leading to rupture.

18. • Abnormal vaginal flora, for example bacterial
vaginosis (BV), affects 16% of pregnant women and is
associated with PPROM and PTL, with a greater risk the
earlier in gestation <16 weeks is identified.
• Chorioamnionitis is associated with :
1. drives PTL,
2. fetal brain damage (periventricular leukomalacia (PVL)
and intraventricular haemorrhage (IVH)) ,
3. since intrauterine infection drives a fetal inflammatory
response, involving:
I. a proinflammatory cytokinaemia
II. morphologically, a vasculitis of the umbilical cord and/or the
vessels of the chorionic plate.

19. TYVU

21. Multiple pregnancy and uterine distension
• Overall, 56% of multiple births deliver before 37 weeks and
10–15% before 32 weeks.
• The risk of PTD rises with fetal number, with triplets
delivering on average at 32 weeks and quadruplets delivering
at 28 weeks.
• Multiple pregnancies have an increased risk of pre-eclampsia,
FGR and other medical complications of pregnancy.
• Twins have a six to sevenfold increased risk of cerebral palsy.
• Polyhydramnios, the presence of too much amniotic fluid.
Severe polyhydramnios can be managed with amnio-drainage,
alternatively, indomethacin (NSAID), used as it reduces fetal
urine production.

22. Uterine müllerian anomalies
• Unrecognized but are estimated to occur in up to 4% of
women of reproductive age.
• Occur as a consequence of abnormal embryologic fusion and
canalization of the müllerian ducts and result in an
abnormally formed uterine cavity, range from an arcuate
uterus, results in minimal fundal cavity indentation, to
complete failure of fusion resulting in uterine didelphys.
• Associated with adverse pregnancy outcome in up to 25% of
women, including first and second trimester miscarriage,
PPROM, preterm birth, FGR, breech presentation and
caesarean section.

26. Haemorrhage
• The presence of a subchorionic haematoma in early pregnancy
increases the risk of later PPROM, either through an effect of
thrombin on membrane strength or through the occurrence of
infection in the haematoma.
• Acute bleeding leads to the release thrombin that directly
stimulates myometrial contractions.
• Risk factors include pre-eclampsia and hypertension,
previous abruption, trauma, smoking, cocaine use,
multiple pregnancy, polyhydramnios, thrombophilias,
advanced maternal age and PPROM.
• When an abruption involves 50% or more of the placenta it is
frequently associated with fetal death.

27. Problems of preterm baby
1. Cerebral palsy:
2. Neurological deficit
3. Learning difficulty
4. Retinopathy
5. Hearing aid
6. RDS
7. Hyperbilirubinaemia

28. Neonatal care unit

29. Clinical features of preterm labour

30. History
- Dating of pregnancy / LMP
, early US
- Clinical presentation / risk factors:
1. Pain /uterine contraction
2. Vaginal loss
3. Pelvic pressure
4. low backache
5. Generally unwell, may be fever or urinary
symptoms

31. Examination
1. General examination:
• pulse, BP, temperature and state of hydration.
2. Abdominal examination:
• the presence of uterine tenderness, suggesting abruption or
chorioamnionitis.
3. Sterile Speculum examination:
• pooling of amniotic fluid,
• blood and/or abnormal discharge.
• Ask patient to cough/press over the fundus  leaking liquor.
• A visual assessment of cervical dilatation
4. Vaginal examination:
• Digital exams should be limited, as they are known to stimulate
prostaglandin production and may introduce organisms into the
cervical canal.
• Repeat vaginal examination in 1–4 hours should be considered
essential in the absence of specialized tests. The interval between
assessments should be guided by the severity of the symptoms.

32. • Nevertheless, the diagnosis of preterm
labour remains notoriously difficult unless
contractions are accompanied by advanced
dilatation (>3 cm), ruptured membranes or
significant vaginal bleeding.
• Differential diagnosis of PTL:
1. Urinary tract infection
2. Gastroenteritis
3. Constipation
4. Red degeneration of fibroid
5. Placental abruption

33. Investigations
❖ Blood group & Rh
❖ Full Blood Count
❖ MSU / culture & sensitivity
❖ Cervicovaginal swab / microbiology
❖ Fetal fibronectin (fFN)
❖ TA/ TV US :
o Gestational age,
o cervical length
 Cervical length measurement by TVU has been shown to improve
diagnostic accuracy.
 A normal cervix measures approximately 35 mm in length .
 Significant cervical shortening is often accompanied by dilatation and
funnelling of the membranes down the cervical canal .
o Amniotic fluid volume
o placental site

34. Fetal fibronectin (fFN)
• Testing the cervicovaginal fluid levels of fetal fibronectin
(fFN), a glycoprotein found in cervicovaginal fluid, amniotic
fluid, placental tissue and in the interface between the
chorion and decidua.
• It acts like ‘glue’ at the maternal–fetal interface and its
presence in cervicovaginal fluid between 22 and 36 weeks’
gestation has been shown to be a predictor of PTD.
 Negative fFN test to be sent home.
 Those with a positive fFN test can be admitted for tocolysis
and steroids for fetal lung maturation.

35. How you manage women with
symptomatic PTL ?

38. Treatment in symptomatic patient
o if cervix not dilated  support
o if membrane ruptured  contraction
wait & monitor
terminate
no contraction

39. Management of symptomatic PTL women
At tertiary center or intrauterine transfer
1. Communication and support:
• Ensure: Sympathy , pain relief, reassurance
2. Maternal corticosteroids:
• The most beneficial treatment in preterm labour is a course of
maternal steroids.
• a single course of maternal steroids (two injections 12–24 hours apart)
given between 28 and 34 weeks gestation and received within 7 days
of delivery.
• Maximum benefit from the injection is seen after 48 hours.
• Courses received less than 48 hours or more than 7 days before
delivery still lead to benefit, as may courses given between 24 and 28
weeks.
• They are not indicated below 24 weeks.
• Effects within 7 days of delivery: ↓RDS, ↓IVH, ↓necrotizing
enterocolitis, improve neonatal outcomes and lung function.

40. 3. Tocolytics:
• The sole reason for using tocolytics is to delay delivery
for 48-hour window to allow :
 a course of steroids for fetal lung maturation to be
completed
 to facilitate transfer of the undelivered mother to a unit
able to provide appropriate neonatal care.
 In utero transfer.
• Tocolytics are only used for short pregnancy prolongation
(delay delivery) for about 48-hour.
• The first choice → CCB (nifedipine) or an OTR
antagonist (atosiban).
• However, recently PG inhibitors and CCB are most likely
the best therapy for PTD on the basis of delaying
delivery by 48 hours, neonatal mortality, neonatal (RDS)
and maternal side-effects.

41. Types of Tocolysis
1. Beta-sympathomimetics Beta-agonists (ritodrine, salbutamol and
terbutaline) are predominantly β2 adreno-receptor agonists),
which mediate myometrial relaxation by stimulating cyclic
adenyl monophospate (AMP) production.
2. Magnesium sulphate (muscle relaxant)
3. Non-steroidal anti-inflammatory drugs (Indomethacin for short
term use < 30 wks gestation)
4. Calcium channel blockers (Nifedipine)
5. Oxytocin receptor antagonists (OTR-A atosiban)

43. 4. Antibiotics
- Given in case of :
1. Suspected or proved vaginal infection
2. ROM or established chorioamnionitis
 10 days Erythromycin +/- Clindamycin or Metronidazole.
- The use of prophylactic antibiotics in uncomplicated
preterm labour before 37 weeks with intact membranes
did not confer any short-term neonatal benefit.
5. Pain killers
- Risk of placental retention / manual removal under anesthesia
6. Continuous (EFM).
• Because preterm infants have less reserve to tolerate the
stress of labour
7. Low threshold for CS (abnormal FHR Pattern, preterm
breech)

44. 8. Augment contractions
• After 24 weeks, if there is no evidence of acute maternal or
fetal compromise induction with milder prostaglandins +/-
conventional-dose oxytocin (precaution if history of uterine
surgery) can be considered as an alternative to a planned CS.
• If there is already clinical evidence of chorioamnionitis:
o Great care must be exercised.
o In these cases, delay in ending the pregnancy may lead to worsening
infection and consequent morbidity for both mother and baby.
o Augmenting labour may be the most appropriate management.
9. Emergency cervical cerclage
-Difficult if cervical dilatation >3 cm & effacement.
-Contraindicated:
1. Bleeding
2. Contractions
3. Infection
10. In utero transfer

46. How you manage
asymptomatic women with
known risk factors for preterm
birth ?

47. 1. Early dating scan / accurate
2. Genital tract infection: Bacterial vaginosis
• early treatment of BV prior to 20 weeks gestation may lower the risk of late miscarriage
and early birth.
3. Asymptomatic bacteriuria:
• It carries an increased risk of preterm birth.
• Short courses of antibiotics based on culture sensitivities reduce the risk of
pyelonephritis and early delivery.
4. GBS genital colonization:
• Preterm infants are more susceptible to early-onset GBS infection, acquired during
passage through the birth canal.
• In women known to be at increased risk of early delivery, testing for GBS antenatally with
a combined low vaginal/rectal swab allows consideration of intrapartum prophylaxis.
• Attempts at antenatal eradication has repeatedly been shown to be of no benefit.
5. Fetal fibronectin : (at ≥ 22 weeks)
• Can only be undertaken after 23 weeks, as high levels may be physiological before then.
• In high-risk asymptomatic women:
o + test at 24 weeks gestation  nearly half will deliver before 30 weeks gestation.
o - test  the chance of such an early birth is less than 1 per cent with.
• This negative predictive value may be its main use, as interventions based upon positive
test results have not been shown to be helpful.
6. Tocolytics: no evidence of benefit from prophylactic or maintenance therapy with
conventional oral or intravenous tocolytics.
Management of high-risk asymptomatic women

48. 7. Progestational agents:
• Progesterone:
1. support of pregnancy through uterine quiescence.
2. it affects cervical ripening and mucous production.
3. have anti-inflammatory properties.
• It has a good safety profile when used in pregnancy.
• Using IM or intravaginal progesterone have shown some reductions in the incidence of
preterm birth.
8. Life style modification: may be helpful
• smoking cessation// sexual abstinence and/or psychological support: are no clearer.
9. Cervical length (TV/US):
• Cervical length can be accurately and repeatedly measured by TVUSS.
• In asymptomatic women with a short cervix, the risk of preterm delivery rises
dramatically with further decreases in length.
 In the presence of a normal cervical length  intervention can usually be deferred.
 Short cervix at < 24 weeks  can be managed by cervical cerclage.
 When significant cervical shortening is found at or beyond 24 weeks:
1. women should be educated as to the signs and symptoms that should provoke
hospital attendance.
2. Prophylactic steroids should be considered.
3. vaginal progesterone reduces the risk of preterm delivery in cases where the cervix
is short.
10. Cerclage
Management of high-risk asymptomatic women, cont..

49. Elective cervical cerclage
• The procedure is usually performed at 12-14 wks
1. Elective cerclage may be advised solely based on a woman’s past
obstetric history.
• if history of 3 or more late miscarriage or very preterm deliveries.
2. In selective cerclage, surgery is based upon serial transvaginal ultrasound
measurements of cervical length.
• Cervical cerclage can be done under general or regional anaesthesia.
• Removed at:
1. 37 wks
2. if labour started at any time
3. If membrane ruptured
• McDonald’s technique , simple & quick (mersilene suture)

52. ROM

53. Case scenario
Manal is 34 years old lady, 29 weeks
twin gestation presented with history of
generalized mild abdominal pain & no
vaginal bleeding, , recurrent dampness,
decreased fetal movement, temperature =
37.2 0C

54. Differential diagnosis of watery vaginal discharge (gush of fluid)
1. ROM
2. Urine loss: incontinence and UTIs are both more common
in pregnancy
3. Vaginal infection
4. Leukorrhoea: the cervical glands often become overactive
during pregnancy

55. History of gush of
fluid
Dysuria,
frequency,
urgency &
incontinence
UTI
Whitish,
yellowish or
greenish
vaginal
discharge
± offensive
± itching
Vaginal
Infection
Colorless,
odourless
vaginal
discharge of
variable
amount &
not
associated
with pruritus
Leukorrhoea
Severe abd. Pain
, Fever,
tachycardia
Fetal
tachycardia
Offensive vag.
Discharge
Abdominal
tenderness
↑WBC & CRP
Chorioamnionitis
Recurrent dampness,
decreased fetal
movement
± pain
+
Sterile speculum
exam.
+
Investigation
ROM

56. Definitions
# PROM: It is the leakage of amniotic fluid beyond 37
weeks gestation, prior to the onset of labour (in
the absence of uterine contraction)
- Incidence: (8 %)
# PPROM: It is the leakage of amniotic fluid in the
absence of uterine activity in preterm pregnancy
(prior to 37 weeks)
- Incidence: (2 %)

57. • Latency Period: it is the time from membrane rupture until delivery
• from the onset of PPROM:
• 50% of women deliver within 1 week of PPROM.
• 75% within 2 weeks of PPROM.
• The earlier in pregnancy that PPROM occurs the shorter the
interval to delivery.
• Pregnancies complicated by PPROM prior to 23 weeks,
pulmonary hypoplasia may develop leading to an increased risk
of neonatal death.
• The presence of amniotic fluid greater than 2 cm on
ultrasound is associated with a lower incidence of
pulmonary hypoplasia.

58. Pathophysiology of PROM:
it is physiological condition:
- Apoptosis & Braxton Hicks contraction
- → ↑ stretching of the membranes
- → thinning focally & biochemical changes
- → membrane prolapse & rupture

59. Significant perinatal morbidity
- Preterm delivery
- RDS (respiratory distress syndrome)
- Risk of chorioamnionitis, neonatal sepsis
- Cord prolapse, compression
- Abruptio placentae
- Operative delivery
Fetal death

60. What are the clinical features
of PROM / PPROM?

61. History
• The most reliable diagnostic feature of PPROM from the history is the report of a
‘gush of fluid’ vaginally, usually followed by a more-or-less continuous dribble.
• The presence of any vaginal discharge should be ascertained.
• Fetal movements may be ↓ in strength or frequency after PPROM.
• occasionally uterine irritability or contractions may be reported.
Examiantion
1. General examination:
• Infection may lead to an increased pulse and temperature and a flushed appearance. .
2. Abdominal examination:
• may reveal a clinical suspicion of oligohydramnios
• uterine tenderness if chorioamnionitis is present.
3. Sterile Speculum examination:
• For definitive diagnosis of PPROM.
• It is done preferably after the patient has been resting supine for 20–30 minutes.
• A pool of amniotic fluid in the posterior vagina is diagnostic.
• Cough or fundal pressure  leakage of liquor.
• It is also important at this point to visualize the cervix.
• Fluid may be seen trickling through the external os and dilatation can be assessed.
4. Vaginal examination:
• Digital vaginal examinations should be avoided if possible in PPROM,
as they are associated with a significant reduction in the latent interval before labour.
This reduction is most dramatic at the earliest gestations.
• Frequent vaginal examination should be avoided

62. • If a pregnant woman provides a clinical history highly
suspicious for PPROM, but diagnosis is not confirmed by initial
speculum exam, the woman can be placed in a semi-upright
position and reexamined after 1 hour to allow for vaginal
poring.
• As a last resort, if results are still equivocal, amniocentesis
with injection of indigo carmine dye may be performed.
• A tampon is placed and if any dye leaked from the cervix, a
blue staining would be noted on the tampon, confirming the
diagnosis of PPROM.

63. What investigations would be most helpful
and why?
1.Bed side tests:
* Nitrazine test:
o Amniotic fluid is alkaline, whereas the vaginal secretions are usually
acidic.
o An elevated pH turns a nitrazine stick black.
o Some units use nitrazine sticks to define the presence of amniotic
fluid.
o false positives occur with: blood, semen urine.
o However, the predictive value of a negative test is very high.
* Ferning test: microscopic dry smear of liquor
False positive: Cervical mucus
2.Genital tract swabs (specialized tests)
- HVS (high vaginal swab)
- Screening for GBS ( group B streptococcus)
Lower genital tract swabs are routinely taken, but cultures do not correlate
well with the risk of chorioamnionitis.

64. 3. Maternal well-being:
Conservative management includes intensive clinical surveillance for signs of
chorioamnionitis:
1. Regular recording of maternal temperature, heart rate or PR, blood pressure
2. serial white cell counts and C-reactive proteins as early markers of infection
4. Fetal well- being:
• Serial antepartum CTG is important after PPROM, as a gradually increasing
baseline heart rate or fetal tachycardia can be the first sign of intrauterine
infection.
5. US:
• Amniotic fluid volume, placental location, presentation & congenital
abnormality of the fetus, estimated fetal weight.
o Oligohydramnios offers supporting evidence for PPROM having occurred
butis not gold standard for the diagnosis.
o Normal or increased volume does not preclude the diagnosis.
• Unlike preterm labour, cervical length measurements do not have predictive
ability in PPROM.
6. Amniocentesis:
• A sample of amniotic fluid can be sent for Gram stain, microscopy and culture,
to establish whether there is an intrauterine infection (chorioamnionitis).
• There is, however, a risk of stimulating preterm labour by performing an
invasive test, and amniocentesis can be technically very difficult when there is
little amniotic fluid.

65. Nitrazine test

66. Ferning

67. How you manage women with
PPROM ?

68. Treatment of PPROM
- It balances the risk of prematurity (if delivery is
encouraged) versus the risk of maternal and fetal
infection (if delivery is delayed) .
- Clinical management of PPROM is based on the
gestational age and mother-fetal condition :
1.Viability to 34 wks gestational age
2. 34 to 37 wks gestational age

69. PPROM before 34 weeks’ gestation 
 Conservative management in hospital is followed unless it is
contraindicated.
 Conservative management include:
1. Hospital admission.
2. Close Fetal and maternal surveillance for Chorioamnionitis
/abruption/PTL/prolapse/non-reassuring fetal status ( either
with a nonstress test or biophysical profile).
3. Antenatal steroids –
 i.m. betamethasone , 12 mg / 24 hours → 2 days Or
 i.m. dexamethasone , 6 mg / 12 hours → 2 days
• There appears to be no increased risk of maternal infectious morbidity
from steroids administration.
• leukocytosis occurs after administration of steroid and may not be
representative of infection.
1. Viability to 34 wks gestational age

70. 1. Viability to 34 wks gestational age, cont..
4. Latency antibiotics.
• Administration of latency antibiotics:
1. improves neonatal outcomes.
2. ↓ RDS, NEC, neonatal sepsis, bronchopulmonary dysplasia, and pneumonia
3. ↑ latency interval.
4. Latency antibiotics along with antepartum steroids likely reduce perinatal
mortality.
• A typical antibiotic regimen includes 48 hours of intravenous ampicillin and
erythromycin, followed by 5 days of oral ampicillin and erythromycin.
• Ampicillin and amoxicillin cover GBS and provide gram-negative and some
anaerobic coverage.
• Erythromycin offers coverage of genital mycoplasma along with some coverage
of gram-positive cocci.
• Azithromycin, which has a better side effect profile than erythromycin, may be
used as an alternate macrolide.
• Amoxicillin-clavulanic acid should be avoided because of a possible increased
risk of NEC.
5. If there is cervical cerclage → removed
• PPROM at less than 23 weeks or greater than or equal to 32 weeks  cerclage
should be removed immediately.
• For patients greater than or equal to 23 to less than 32 weeks cerclage should
either be removed immediately or after a 48-hr course of steroids.

72. 6. Magnesium Administration
• For patients presenting with PPROM prior to 32 weeks, maternal administration
of magnesium sulfate may provide neuroprotective benefits for neonates.
• Pregnant women at risk for preterm delivery between 24 and 31 weeks because
of PPROM or advanced preterm labor who were randomized to magnesium
sulfate had a significantly lower risk of a child born with cerebral palsy.
• While protocols and dosing regimens may vary by center, administration of
magnesium sulfate for 24 hours, in the absence of maternal contraindications,
for patients presenting with PPROM prior to 32 weeks is a reasonable clinical
strategy.
• If a patient with PPROM is not at risk of imminent delivery 24 hours after
presentation, magnesium may be discontinued.
 Induction of labour / at 34 weeks (if possible).
 Immediate induction if ( contraindications for conservative management):
1. Chorioamnionitis.
2. Active labour
3. Non reassuring fetal heart tracing
4. Significant abruption
5. Cord prolapse
1. Viability to 34 wks gestational age, cont..

73. 2. 34 to 37 wks gestational age
 PPROM greater than or equal to 34 weeks  delivery is
recommended, because the fetal and maternal risks of
prolonging pregnancy outweigh fetal benefits of expectant
management.
• However, in remote locations without intensive neonatal care,
expectant management may be warranted up until 36 weeks.
 PROM after 37 weeks’ gestation and labour has not already
begun  Immediate induction of labour is advised by
oxytocin (iv) or PG vaginally or within 12 hours.

74. Chorioamnionitis:
It is an infection of chorion & amnion with an elevation
of temperature ≥ 38 ͦ C (> 100°F) with at least 2 of the
followings:
- Maternal PR ≥ 100 bpm
- FHR ≥ 160 bpm
- ↑CRP, ↑WBC
- Uterine tenderness
- Offensive vaginal discharge

75. - If chorioamnionitis is present, antibiotic (Ampicillin or
Erythromycin as prophylaxis ) & delivery are indicated
- If chorioamnionitis is not present antibiotic therapy
can significantly delay delivery
-Tocolysis is contraindicated due to the increased risk
of maternal and fetal infection in patients with PPROM.
In the majority of cases of PPROM there is time for
administration of corticosteroids and in utero transfer
before the onset of PTL.
- Amnio – infusion

76. Prediction of preterm delivery
• Past obstetric history
• Ultrasound measurement of cervical length
• Prevention of preterm delivery
1. Progesterone uterine quiescence and inhibit the production
of proinflammatory cytokines and PGs within the uterus
2. Cervical cerclage the cervix shortens (usually <25 mm) in
women with a history of cervical surgery or previous preterm
birth (ultrasound indicated cerclage); or when the cervix is
dilating in the absence of contractions (rescue cerclage).