Preterm labor and
PROM
Dr. Wisit Woranitat
Preterm labor
• What is preterm labor
• How dose labor start
• What can happen if my baby
is born too early
• What factors increase the
risk of preterm labor
• What are the signs and
symptoms of preterm labor
• How can preterm labor be
diagnosed
Preterm labor
• If I am at risk of preterm
labor, what can I do to
decrease the risk
• How do I monitor myself for
contraction
• What medications are used
to slow or stop per term
• What are the special needs
of preterm babies
What is preterm labor
• The labor begin start before 37 weeks
• About 1 in 10 babies born in USA
• 75% of neonatal mortality
•
50% of the long term neurologic impairment in
children
How does labor start
• Regular uterine contraction
• Progression of cervix
• Effacement
• Dilatation
• Hormones produced by uterus and placenta
What can happen if
my baby is born too
early
• Newborn death
• Eyes
• Ears
• Breathing
• Nervous system
Perinatal Morbidity
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Pulmonary- RDS bronchopulmonary dysplasia
Cardiovascular: PDA, persistent fetal
circulation
CNS: IVH, cerebral palsy, seizures, sensory
deficits
GI: NEC
Metabolic: hypoglycemia, hypocalcemia,
jaundice
Perinatal morbidity
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Infections: GBS, E. Coli
SIDS
Psychosocial:> prevalence of child abuse
• 50% Preterm labor
Pathogenesis
• 30% Preterm premature
rupture of the membranes
• Pathogenic processes
• Activation of the maternal
or fetal hypothalamic
pituitary axis
• Infection
What factors increase the risk of preterm labor
Previous History
Smoking
Cocaine use & DES
Multiple pregnancy
Abn Cx & Ut
Surgery
Bleeding 2 half
Hydramnios
Infection
Poor ANC
What are the signs
and symptoms of
preterm labor
Vaginal discharge
Pelvic&Abd pressure
Backache
Abd cramps
Ut contraction
PROM
How can preterm labor be
diagnosed
• Cervical change
• Regular contraction
• Ultrasonography. ( Cx length )
• Fetal fibronectin
• Fetal mornitoring
Biologic markers for
predicting preterm birth
• Cervical length measurement- many studies
have confirmed an association with cervical
shortening and preterm delivery. When
combined with positive fetal fibronectin and
length less than 2.5 cm, this is a strong
predictor of preterm delivery
Biologic markers for
predicting preterm birth
• Fetal fibronectin- need intact membranes, less
than 3 cm dilated, not useful before 24 weeks
or after 34 weeks 6 days
• Negative fetal fibronectin gives about a 95%
chance of the pregnancy continuing 14 days
or more. A positive test is not as predictive.
What can I do to
decrease the risk of
preterm labor
• Early ANC
• Test or investigation
• Progesterone
• Limited and control the risk
How do I monitor
myself for contraction
• Monitor for sign of uterine activity
• 4 times in 20 minutes
• 8 times in 60 minute
• Vaginal discharge
• PROM
What medications are
used to slow or stop
• Tocolysis agents
preterm
Bricanyl
• NSAIDS
• Corticosteroid
• Anti-biotic agent
Calcium Chanel blocker
• Oxytocin
antagonist
Assessment of patients in
preterm labor
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Labs-CBC, UA +/- culture, electrolytes
Sterile speculum exam obtaining cultures for
group B strep, BV, GC, Chlamydia, obtain
fetal fibronectin
Cervical length measurement
The last thing is the cervical digital exam
What are the special needs of
preterm babies
• NICU
• Breathe
• Eat
• Keep warm
• Other health
problem
Premature rupture of
membrane
• Definition
• Incidence
• Diagnosis
• Risk factors
• Management
Definition
Premature rupture of membranes (PROM)
Rupture of the chorioamnionic membrane
prior to the onset of labor at any stage of
gestation
Preterm premature rupture of membranes
(PPROM)
PROM prior to 37-wk. gestation
Incidence
PROM – 12% of all pregnancies
PROM – 8% term pregnancies
PPROM – 30% of preterm deliveries
History
Diagnosis
“Gush” of fluid
Steady leakage of small amounts of fluid
Physical
Sterile vaginal speculum exam
Minimize digital examination of cervix,
regardless of gestational age, to avoid risk of
ascending infection/amnionitis
Assess cervical dilation and length
Obtain cervical cultures (Gonorrhea,
Chlamydia)
Obtain amniotic fluid samples
Findings
Pooling of amniotic fluid in posterior vaginal
fornix
Fluid per cervical os
Diagnosis
• Test or investigation
• Nitrazine test
• Fern test
• Nine blue test
• Ultrasound
• Indigo-carmine Amnioinfusion
Nitrazine test
Fluid from vaginal exam
placed on strip of
nitrazine paper
Paper turns blue in
presence of alkaline (pH
> 7.1) amniotic fluid
Fern test
Fluid from vaginal
exam placed on slide
and allowed to dry
Amniotic fluid narrow
fern vs. cervical
mucus broad fern
Nile blue tests
• >32 wks. Fetal fat cell can
discover in amniotic fluid
• Strained with Nile blue
sulphate. Become to red
color
•
Fetal
Fibronectin
(AmniSure)
Newer test
• Point of Care test
• Cost-up to $50 each
• Sensitivity-98.798.9%
• Specificity-87.5100%
• Awaiting further
testing prior to
recommendations
Ultrasound
Assess amniotic fluid level and compatibility
with PROM
Indigo-carmine Amnioinfusion
Ultrasound guided indigo carmine dye
amnioinfusion (“Blue tap”)
Observe for passage of blue fluid from vagina
Risk factor of PROM
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Prior PROM or PPROM
Prior preterm delivery
Multiple gestation
Polyhydramnios
Incompetent cervix
Vaginal/Cervical Infection
 Gonorrhea, Chlamydia, GBS, S. Aureus
 Antepartum bleeding (threatened abortion)
 Smoking
 Poor nutrition
Effect to mother and fetus
• Feto-maternal infection
• Placenta abruptio
• Premature infant: 30% - 40% of premature
labour is associated with premature rupture of
membrane
• Cord prolapse, cord compression
• Poor fetal lung development and fetal
compression syndrome
Management
PROM at term:
(1) Awaiting the onset of spontaneous labor
for 12-24h
(2) Termination of pregnancy after 24 hours
PROM before term
Termination of pregnancy
(1) Evidence of fetal pulmonary maturation
(2) Evidence of intrauterine infection
Expectant therapy
Indication :
(1) Evidence of fetal pulmonary
immaturation
(2) Without evidence of intrauterine infection
Management:
(1)To enhance fetal pulmonary maturation
(2) Antibiotic
Management: Rationale
Antibiotics
Prolong latency period
Prophylaxis of GBS in neonate
Prevention of maternal chorioamnionitis and neonatal
sepsis
Corticosteroids
Enhance fetal lung maturity
Decrease risk of RDS, IVH, and necrotizing enterocolitis
Tocolytics
Delay delivery to allow administration of corticosteroids
Controversial, randomized trials have shown no
pregnancy prolongation
Management: Surveillance
Maternal: Monitor for signs of infection
Temperature
Maternal heart rate
Fetal heart rate
Uterine tenderness
Contractions
Management: Surveillance
Fetal: Monitor for fetal well-being
Kick counts
Nonstress tests (NST’s)
Biophysical profile (BPP)
Immediate Delivery
Intrauterine infection
Abruptio placenta
Repetitive fetal heart rate decelerations
Cord prolapse.
Thank you
For your attention