1. Preterm Labor & PROM

2. 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
WHO- 22wks and 500gm
United kingdom- 24wks
India- 28wks

3. 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.

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

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

6. 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

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

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

9. Management of Advanced PTL
Allow delivery if
-Cx is >4cm dilated
-Signs of chorioamnionitis
-Baby malformed
-Severe placental insufficiency
But if Cx is <4cm 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

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

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

12. 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

13. Threatened PTL When there are regular uterine contractions,
Cervix is <1cm dilated , length of cervix
<2.5cm 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 wks , so if it is present it is predictor of PTL

14. 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.

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

16. Tocolytic Drugs Various tocolytic drugs which can be used are :-
* Nefedipine
* Betamimetics –Isoxsuprine
-Terbutaline
- Retrodine
* Indomethacin
* Mgso4
* Nitroglycerine

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

18. Bitamimetic Tocolytics
Turbutaline
It can be given IV or subcutaneous
For IV- Dissolve 5mg of terbutaline in 500ml
of RL, each ml contains 10ug
-Start with 5ug (o.5ml)/min. & increase
the dose of 5ug every 10-20min.till
uterine contraction stops.
-Maximum dose 30ug/min.
Subcutaneous dose-o.25mg every 3-4 hours for 12hrs
A maintenance dose-2.5-5mg orally 4-6 times/day

19. Ritodrine
Beta mimetic drug causes smooth muscle relaxation by B2 receptor stimulation
Doses- given by IV infusion
- Start with 100ug/min. & increase the
dose by 50ug every min. till
the uterine contraction stops or
maximum dose of 350ug
- Continue infusion for 12hrs after the
contractions stop.

20. Isoxsuprine Doses- 0.2-0.5mg/min I V infusion for 12hrs
followed by 10mg IMI every 6-8 hour for
24hours
Side effects of Beta mimetics
Headache
Palpitation , Tachycardia
Hypotension , Hypokalemia
Pulmonary oedema & Cardiac failure

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

22. Mgso4 Dose – 4-6 gm (20% solution) i.v. slow in 20-30
min. followed by an infusion of 1-2gm/hr
& continue for 12 hrs after the contraction
have stopped
Side effects- Headache , flushing
- Muscular weakness
- Rarely pulmonary oedema

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

24. (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%

25. 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

26. 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

27. 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 but PH of liquor is 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

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

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

30. Management ofPROM
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

31. 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

32. 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 24-48hrs-induction
of labor

33. 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.

34. Signs of chorioamnionitis
Temperature > 100.4*F and 2 or more of:
-Maternal tachycardia pulse >100/min.
-Uterine Tenderness
- Foul smelling vaginal discharge
- Leukocytosis15000cmm
- C-reactive protein >2.5mg%
- Fetal tachycardia >160 min
if there is no other site of infection