PPROM and preterm

1. PRETERM LABOR
DR. RUKSAR GOLANDAZ
ASSISTANT PROFESSOR
DEPT. OF OBS AND GYNAE

2. DEFINITION
• Preterm labor (PTL) is defined as one where the labor starts before the 37th completed week (< 259
days), counting from the first day of the last menstrual period
• Lower limit of gestation 
 developed countries -20 weeks
 developing countries - 28 weeks
• Preterm birth is the significant cause of perinatal morbidity and mortality
• INCIDENCE: The prevalence widely varies and ranges between 5% and 10%

3. ETIOLOGY
HISTORY
•Previous history of induced or
spontaneous abortion or preterm
delivery
• Pregnancy following assisted
reproductive
techniques (ART)
•Asymptomatic bacteriuria or recurrent
urinary tract infection
•Smoking habits
• Low socioeconomic and nutritional
status and
•Maternal stress.
Complications in present pregnancy
•Pregnancy complications: Preeclampsia,
APH, PROM, polyhydramnios
•Uterine anomalies: Cervical
incompetence, malformation of uterus
•Medical and surgical illness: Acute fever,
acute pyelonephritis, diarrhea, acute
appendicitis
•Chronic diseases:Hypertension,
nephritis, diabetes, decompensated
heart lesion, severe anemia
Complications in present pregnancy
• Genital tract infection: Bacterial
vaginosis, beta-hemolytic
Streptococcus,
bacteroides, chlamydia and
mycoplasma.
Fetal: Multiple pregnancy,
congenital malformations and
intrauterine death.
Placental: Infarction,
thrombosis, placenta previa or
abruption.

4. ETIOLOGY
Iatrogenic
•Indicated preterm delivery due to medical or
obstetric complications
Idiopathic
•Premature effacement of the cervix with
irritable uterus and early engagement of the
head are often associated

7. DIAGNOSIS
(1) Regular uterine contractions with or without pain (at least one in every 10 minutes)
(2) Dilatation (> 2 cm) and effacement (80%) of the cervix
(3) Length of the cervix (measured by TVS) < 2.5 cm and funneling of the internal os
(4) Pelvic pressure, backache and/or vaginal discharge or bleeding
It is better to overdiagnose preterm labor than to ignore the possibility of its presence
Preterm labor is very unlikely when cervical length is > 30 mm, irrespective of uterine contractions

8. MANAGEMENT OF PRETERM LABOR
(1) To prevent preterm onset of labor, if possible
(2) To arrest preterm labor, if not contraindicated
(3) Appropriate management of labor
(4) Effective neonatal care

9. Predictors of preterm labor
•
CLINICAL
PREDICTORS
• History of prior
preterm birth
• Multiple
pregnancy
• Presence of
genital tract
infection
• Symptoms of
PTL
BIOPHYSICAL
PREDICTORS
• Uterine
contractions
(UC) > 4/hr
• Bishop score >
4
• Cervical length
(TVS) < 25 mm
BIOCHEMICAL
PREDICTORS
• Fetal
fibronectin
(fFN) in
cervicovaginal
discharge
• Others IL-6, IL-
8, TNF-α

10. • Fibronectin is a glycoprotein that binds the fetal membranes to the decidua
• Normally it is found in the cervicovaginal discharge before 22 weeks and again after 37 weeks of
pregnancy
• Presence of fibronectin in the cervicovaginal discharge between 24 weeks and 34 weeks is a
predictor of preterm labor
• When the test is negative it reassures that delivery will not occur within next 7 days

12. PREVENTION OF PRETERM LABOR
The following guidelines are adopted:
 Primary care is aimed to reduce the incidence of preterm labor by reducing the high-risk factors (e.g.
infection, etc.)
 Secondary care includes screening tests for early detection and prophylactic treatment (e.g. tocolytics)
 Tertiary care is aimed to reduce the perinatal morbidity and mortality after the diagnosis (e.g. use of
corticosteroids)

13. INVESTIGATIONS
(1) Full blood count
(2) Urine for routine analysis, culture and sensitivity
(3) Cervicovaginal swab for culture and fibronectin
(4) Ultrasonography for fetal well being, cervical length and placental localization
(5) Serum electrolytes and glucose levels when tocolytic agents are to be used

14. MEASURES To ARREST PRETERM LABOR
• The scope to arrest preterm labor is limited early expulsion of the fetus may be beneficial
• about 10–20%, where the fetus is not compromised, the maternal condition remains good and membranes
are intact, the following regime may be instituted in an attempt to arrest premature labor

15.  Bed rest- left lateral position
 Adequate hydration is maintained
 Prophylactic antibiotic -not routinely given.( YES- if infection is evident or culture report suggests)
 Prophylactic cervical cerclage for women with prior preterm birth and short cervix
 Tocolytic agents: nifedipine, atosiban, progesterone (micronized) , short-term (1–3 days)
 Dose schedule of MgSO4 and monitoring are same as used for seizure prophylaxis of preeclampsia
(4 g IV over 3–5 minutes followed by an infusion of 1 g/hr)

17. Short-term therapy: objectives
(1) To delay delivery for at least 48 hours for glucocorticoid therapy to the mother to enhance fetal
lung maturation and
(2) In utero transfer of the patient to a unit with an advanced neonatal intensive care unit (NICU)

18. CONTRAINDICATIONS
A. Maternal: Uncontrolled diabetes, thyrotoxicosis, severe hypertension,
cardiac disease, hemorrhage in pregnancy, e.g. placenta previa or abruption
B. Fetal: Fetal distress, fetal death, congenital malformation and pregnancy beyond 34 weeks
C. Others: Rupture of membranes, chorioamnionitis and cervical dilatation more than 4 cm

19. Glucocorticoid therapy:
Maternal administration of glucocorticoids pregnancy is less than 34 weeks
helps in fetal lung maturation
delivery is delayed beyond 48 hours of the first dose
Benefit persists as long as 18 days
betamethasone (Betnesol) 12 mg IM 24 hours apart for two doses (steroid of choice)
 dexamethasone 6 mg IM every 12 hours for 4 doses

20. • Risks of antenatal corticosteroid use:
(a) Premature rupture of the membranes especially with evidence of infection as the infection may
flare-up
(b) Insulin-dependent diabetes mellitus where patients need insulin dose readjustment
(c) Transient reduction of fetal breathing and body movements

21. MANAGEMENT IN LABOR
• The principles in management of preterm labor are:
(1) To prevent birth asphyxia and development of RDS
(2) To prevent birth trauma
Duration of labor is usually short

23. • Routine cesarean delivery is not recommended
• Lower segment vertical or “J”-shaped incision may have to be made to minimize trauma during
delivery poor formation of the lower uterine segment
• Immediate management of the preterm baby
PROGNOSIS: high perinatal mortality and morbidity
Late preterm labor—Birth of infants between 34 weeks and 36 weeks gestation. These infants do
better than those infants born before 34 weeks.

24. PRELABOR RUPTURE OF THE
MEMBRANES (PROM)

25. DEFINITION
• Spontaneous rupture of the membranes any time beyond 28th week of pregnancy but before the
onset of labor is called prelabor rupture of the membranes (PROM)
• When rupture of membranes occur beyond 37th week but before the onset of labor, it is called
term PROM and when it occurs before 37 completed weeks, it is called preterm PROM
• Rupture of membranes for > 24 hours before delivery is called prolonged rupture of
membranes
• Incidence : 10% of all pregnancies

26. CAUSES
(1) Increased friability of the membranes
(2) Decreased tensile strength of the
membranes
(3) Polyhydramnios
(4) Cervical incompetence
(5) Multiple pregnancy
(6) Infection—Chorioamnionitis, urinary tract
infection and lower genital tract infection
(7) Cervical length < 2.5 cm
(8) Prior preterm labor
(9) Low BMI (< 19 kg/m2)

27. DIAGNOSIS
• The only subjective symptom is escape of watery discharge per vaginum either in the form of a
gush or slow leak
• This is often confused with :
(a) Hydrorrhea gravidarum—a state where periodic watery discharge occurs probably due to
excessive decidual glandular secretion
(b) Incontinence of urine especially in later months

28. CONFIRMATION OF DIAGNOSIS
(1) Speculum examination
(2) To examine the collected fluid from the posterior fornix (vaginal pool) for:
(a) Detection of pH by litmus or Nitrazine paper. The pH becomes 6–6.2 (Normal vaginal pH
during pregnancy is 4.5–5.5 whereas that of liquor amnii is 7–7.5). Nitrazine paper turns from
yellow to blue at pH > 6
(b) To note the characteristic ferning pattern when a smeared slide is examined under
microscope
•

29. (c) Centrifuged cells stained with 0.1% Nile blue sulfate showing orange blue coloration of the
cells (exfoliated fat containing cells from sebaceous glands of the fetus)
(3) AmniSure—A rapid immunoassay is accurate
(4) Ultrasonography is to be done not only to support the diagnosis but also to assess the fetal well
being. Digital vaginal examination should be avoided

30. INVESTIGATIONS
(1) Full blood count
(2) C-reactive protein (CRP)
(3) Urine for routine analysis and culture
(4) High vaginal swab for culture (specially for Gr. B Streptococcus)
(5) Vaginal pool for estimation of phosphatidyl glycerol and L: S ratio
(6) Ultrasonography for fetal biophysical profile
(7) Cardiotocography for nonstress test

31. DANGERS
• The implications are less serious when the rupture occurs near term than earlier in pregnancy.
(1) In term PROM labor starts in 80–90% of cases within 24 hours. PROM is one of the important causes of
preterm
labor and prematurity
(2) Chance of ascending infection is more if labor fails to start within 24 hours. Liquor gets infected
(chorioamnionitis) and fetal infection supervenes
(3) Cord prolapse, especially when associated with malpresentation
(4) Continuous escape of liquor for long duration may lead to dry labor

32. DANGERS
(5) Placental abruption
(6) Fetal pulmonary hypoplasia, especially in preterm PROM is a real threat when associated with
oligohydramnios
(7) Neonatal sepsis, RDS, IVH and NEC in preterm PROM
(8) Perinatal morbidities (cerebral palsy) are high
Maternal complications of PROM: Chorioamnionitis, placental abruption, retained placenta, endometritis,
maternal sepsis and even death

33. MANAGEMENT
• PRELIMINARIES:
(1) Aseptic examination with a sterile speculum is done not only to confirm the diagnosis but also to note the state of the cervix
and to detect any cord prolapse
(2) Vaginal digital examination is generally avoided
(3) Patient is put to bed rest and sterile vulval pad is applied to observe any further leakage
Once the diagnosis is confirmed, management depends on
(i) Gestational age of the fetus (ii) Whether the patient is in labor or not
(iii) Any evidence of sepsis and (iv) Prospect of fetal survival in that institution, if delivery occurs
Maternal pulse, temperature and fetal heart rate are monitored 4 hourly

35. THANK YOU