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Preterm Labour and Prom Lecture

Preterm Labour and premature rupture of membranes

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Victor Tayo
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14 views

Preterm Labour and Prom Lecture

Preterm Labour and premature rupture of membranes

Uploaded by

Victor Tayo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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PRETERM LABOUR AND

PROM
Dr Zubairu, U.D.
Dept of Obstetrics and Gynaecology,
A. B. U. Zaria
Objectives
• Define preterm labour and PROM

• Outline risk factors

• Make diagnosis

• Treatment plan

• Prognosis
PRETERM LABOUR
DEFINITION/INTRO
• Onset of uterine contractions with cervical changes before 37
completed weeks of gestation

• Different from preterm contractions: no cervical changes

• Preterm delivery
• Spontaneous preterm labour; 50%
• PROM; 30%
• Medically necessary delivery; 20%
CAUSES
• Unknown in 50% cases

• Usually multifactorial

• Risk factors rather than aetiology


Risk factors
• Previous history; preterm labour, spontaneous or induced abortion

• Asymptomatic bacteruria/UTI

• Smoking

• Low socioeconomic status/Nutritional deficiency


• Vitamin C deficiency
Aetiology
• Maternal
• Congenital; Cx incompetence, uterine anomalies

• Genital tract infections; Bacterial vaginosis, Trichomonas, Chlamydia

• Pregnancy complications; APH, PROM, Preeclampsia, polyhydramnios

• Medical/Surgical conditions; High grade fever, acute appendicitis


Aetiology; Contd
• Fetal
• Multifetal pregnancies

• Congenital malformations

• IUFD

• Placental; Abruption, infarction, thrombosis

• Idiopathic; about 50% of cases


Pathophysiology
• Unclear

• Possible mechanisms
• Abnormal uterine enlargement

• Infection+inflammation

• Decidual haemorrhage

• Physical/emotional/physiological stress

• Uteroplacental vasculopathy
DIAGNOSIS
• History
• Onset of persistent/progressive uterine contractions

• Drainage of liquor

• Passage of show

• Presence of risk factors


• Examination findings
• General and systemic

• Sterile speculum examination


• May show features of PROM

• Cervical os may be open/bulging membranes

• Vaginal discharge suggestive of genital infection

• If no PROM digital examination


• Cervix ≥ 3cm dilated/≥ 80% effaced is CONFIRMATORY

• 2 – 3cm, < 80% effaced; Suggestive but not established

• < 2cm, < 80% effaced; Diagnosis uncertain

• Confirm with transvaginal USS for cervical length


• Cervical length < 2cm with adequate contractions; CONFIRMATORY

• Length 2 – 3cm with adequate contractions; PROBABLE/Uncertain

• > 3cm; very unlikely regardless of contractions


TREATMENT
• GOAL; Minimize risks/complications of prematurity

• Corticosteroids for fetal lung maturation

• Tocolysis to buy some time for corticosteroid effects

• Antibiotic prophylaxis; especially with PROM

• Bed rest/adequate hydration


Tocolysis
• Prostaglandin synthase inhibitors .E.g. Indomethacin

• B adrenergic blockers; ritodrine, terbutaline, salbutamol

• Calcium channel blockers; Nifedipine

• Magnesium sulphate
Labour and delivery
• Close fetal montoring; electronic if available

• Labour usually shorter

• Delivery; prevent fetal distress and birth trauma

• ??Episiotomy ??Forceps to shorten 2nd stage

• NOT AN INDICATION FOR CSECTION!!!


FETAL COMPLICATIONS
• RDS
• Birth trauma
• Hypothermia
• NEC
• IVH
• Metabolic complications; hypoglycemia, hypocalcemia
• NNJ
• NNS
PROGNOSIS
• Increased perinatal morbidity and mortality

• Good/efficient NICU care improves neonatal survival

• Surfactant for < 28 weekers improves survival up to 75%


PROM (PREMATURE RUPTURE OF MEMBRANES)
DEFINITION/INTRO
• Spontaneous Rupture of membranes (ROM) occurring after 28 weeks
gestation (age of viability) before onset of labour

• ROM before age of viability; inevitable abortion

• PROM could occur at term, or before term


Definition of terms
• Term PROM; ROM at 37 completed weeks and above

• Preterm PROM; ROM before 37 completed weeks

• Prolonged PROM; ROM for longer than 24 hours

• Latency period; time between the ROM and onset of labour


INCIDENCE
• 5 – 10 % of all deliveries (term or preterm)

• 30% of preterm deliveries

• 70% of PROM cases occur at term

• Is the precipitating factor in about 1/3 preterm deliveries


Risk factors/aetiology
• Intrinsic membrane weakness
• Congenital; Collagen disorders, Cx incompetence

• Smoking

• ?Malnutrition
Risk factors/Aetiology (contd)
• Genital tract infections; Bacterial vaginosis

• Mechanical stress
• Multifetal pregnancy

• Polyhydramnios

• Foetal anomalies

• Idiopathic
DIAGNOSIS
• History
• Leakage of fluid per vaginam; sudden gush, slow leak, persistent/intermittent

• Presence of risk factors/aetiology

• Examination
• General and systemic

• STERILE SPECULUM EXAMINATION!!!


Sterile speculum exam
• Use Graves/Cuscos

• Pooling of liquor in posterior fornix

• Spurt of liquor from cervical os on vasalva manouvre

• Appearance of liquor; Contains vermix casseosa, meconium stain


• Nitrazine test; turns nitrazine paper blue
• FALSE +VE: Blood, semen, alkaline urine, BV, Trichomonas

• Ferning pattern

• Indigo carmine instillation


Investigations
• SUPPORTIVE NOT DIAGNOSTIC; DIAGNOSIS IS CLINICAL!!!

• FBC + Differentials

• Urine, HVS m/c/s

• Biophysical profile (USS + CTG)


TREATMENT
• Depends on GA

• Conservative management or IOL

• Conservative mgt if < 34weeks GA


• Bed rest
• Avoid digital VE
• IVF infusions
• Antibiotics
• Fetomaternal surveillance for chorioamnionitis
• Tocolysis
• Indications for IOL
• Term PROM

• Labour onset

• Presence of infection; particularly chorioamnionitis

• IUFD

• Congenital anomalies not compatible with life

• Fetal distress
• Fetomaternal surveillance for preterm PROM
• Maternal PR, temperature, FHR every 4hours

• BPP + CTG

• FBC + Diff, ESR/CRP


• Corticosteroids for fetal lung maturation
• Dexamethasone/bethamethasone

• Antibiotics; usually started at 6 – 12hours after onset of PROM


• Oral erythromycin for prophylaxis
• IV Broad spectrum given if prolonged PROM, risk of/confirmed
chorioamnionitis

• Tocolysis if contractions present


Chorioamnionitis
• Maternal temperature 38 degrees

• Uterine tenderness

• Maternal tachycardia

• FHR abnormalities

• Offensive liquor/PV discharge


COMPLICATIONS
• Preterm labour
• Ascending infection
• Cord prolapse
• Abruptio placenta
• Precipitate labour
• Problems of prematurity
Prognosis
• Term PROM; latency period < 24 hours in about 90%

• Preterm PROM; latency up to 5 – 7 days in 70 – 80%

• Prognosis usually good with uncomplicated PROM

• Risk of disseminated sepsis with prolonged PROM and


choriomanionitis
• Route of delivery in PROM preferably vaginal

• C/Section only with obstetric indications.


THANK YOU

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