32- Preterm Labour

8/9/2019 32- Preterm Labour

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Preterm labour( PTL) &premature rupture ofmembranes

Rami Kilani


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Defnition De nition : Labour which occurs

rom the viability o the etus( completed 24 weeks !" until thecompletion o #$ weeks o %estation

Incidence : &'$ white )uropean *+ in ! ricans


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,redisposin% actors orpreterm labour

Epidemiological -./0 *1 Low social class black

unmarried3unsupported 3 smoker oun% a%e5 old a%e6 anemia or polycythemia ,revious preterm labour ( the sin%le most

e7ective predictor " 2+ or one ,8L 4+ or 2,8L

Elective delivery ( iatrogenic !") ,)86 maternal /9 R etal


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,8L ( continued risk actors"

#edical R;. *3# .ultiple pre%nancy ,olyhydramnios .edical disorders uired abnormalities o the

uterus(=ervical incompetence bicornuate uterus

fbroids" ?a%inal in ection ( e'%' bacterial va%inosis" !,@ /ntra abdominal sur%ery


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Diagnosis $istory : R;. -ackache crampin% abdominal pain

,elvic pressure increased va%inal dischar%e

E%amination : !bdominal eAam : uterine tenderness abruptio chorioamnionitis'


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Di erential diagnosis 98/ ,lacental abruption

astroenteritis =onstipation Red de%eneration o fbroid


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Investigations 'etal bronectin : %lue like protein bindin%

the choriodecidual membranes' !ny disruption othe choriodecidual inter ace results in release oCC 5 detection in cervico va%inal section ' 8hisdisruption precedes preterm labor

% lengt : measurement by transvaginalultraso und( normal cA len%thE #'& cm" c%s ortening* dilatation* 5 unneling o themembranes down the cA canal

+epeat vaginal e%am ( in * 4 hours" inthe absence o specialiFed tests


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#anagement -ed rest @ydration

.aternal steroids 8ocolytics !ntibiotics Cetal assessment


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,8L ( mana%ement" ,ed rest & ydration : /ncrease uterine blood Bow 5 >uietin% the

uterus' De ydration increased levels o-D$ ' !D@ may cross react with oAytocinreceptors 5lead to contraction so hydrationdecrease !D@ 5 contractions'

Lyin% on her side 5 /? Buid


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#aternal steroids :


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Tocolysis

*' -eta mimetics2' .a%nesium sul ate

#' =alcium channel inhibitors4' ,rosta%landin inhibitors&' ;Aytocin anta%onist


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,eta mimetics : 8wo beta mimetics commonly used or preterm

labor ritodrine ( utopar"5 terbutaline '

2ide e ects : tachycardia headacheshyper%lycemia hypokalemia'

8he most serious is pulmonary edema 5 in rare

cases maternal death Contraindicated : symptomatic cardiac disease

uncontrolled diabetes hyperthyroidism'


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#agnesium sulfate : 2ide e ects : Bushin% headache ati%ue diplopia' !t 8oAic level o .% ( G *+m%3dl" respiratory

depression hypoAia 5cardiac arrest'

Deep tendon reBeAes depressed5 lost at0 *+ m%3dlso rule out .% toAicity with serial reBeA checks

,ulmonary edema may occur


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a3 c annel bloc1ers : ni edipine


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Prostaglandin in ibitors : /ndomethacin

4%ytocin antagonists : atosiban


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-ntibiotics

Routine use o antibiotics in uncomplicatedpreterm labour did not con er benefts

*+ day course o eryt romycin lead toimproved neonatal outcome after P+4#


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'etal assessment 9ltrasound: etal presentation estimated etal

wei%ht !C/'


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.ode o delivery 8he case should be evaluated


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Premature rupture of membranes

( P+4# ) & preterm +4#

Preterm +4# : R;. occurrin%be ore #$ wk'

Premature +4#(P+4# ":R;.be ore the onset o labour'

/ t0o occur to%ether PP+4# Prolonged P+4# : R;. 6 ./ rs

be ore delivery(or 78 rs "


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Preterm +4# =ommon cause o preterm labour 5

chorioamnionitis 9!" %o into labour within ./ rs :9"0it in /8 rs 8hese correlate inversely with ! at

R;. Prolonged PP+4# associated with

increased risk o chorioamnionitisabruption 5 cord prolapse


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linical features $istory : gus o Buid per va%ina ollowed by

continuous dribblin%' Cetal movement may reduced in stren%th or re>uency

E%amination : PR, temp, appearance Abdominal exam : may oli%ohydramnios

uterine tenderness i chorioamnionitis Speculum exam (defnitive DH": pool o amniotic

Buid post va%ina is dA positive cou%h si%n ?isualiFe the cA or dilatation Di%ital eAam should be avoided


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Di erential diagnosis ;rine loss : /ncontinence 5 98/ are common in

pre%nancy


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Investigations

7> ?itra@ine test amniotic Buid is alkalinebut va%inal secretions are acidic' !lkaline ,@ black stick' Calse positive blood semen 5urine

.> 5enital tract s0abs @?< 5 or - #aternal 0ellbeing vital si%ns I-=

=R, early markers o in ection

/> 'etal 0ellbeing serial


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&';ltrasound !C/ oli%ohydramniossupport ,R;.

J' -mniocentesis =5< %ram stain


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#anagement

Preterm +4# : depends on ! -alance risk o prematurity 5 risk o in ection

-etween #2 #4 weeks


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8he use o antibiotics leads to longer latencyperiod prior to onset o labour so ampicillin withor without eryt romycin is recommended in,,R;.

Tocolysis contraindicated

2teroids are recommended

!ny patient who shows si%ns o infection or fetaldistress needs to be delivered


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#aternal & fetal complicationsassociated 0it P+4#

*' =horioamnionitis2' @yaline membrane disease ( @.D"#' ,ulmonary hypoplasia re>uent when ,R;.

occurs be ore 2J wk5 latent period G & wk4' !bruptio placenta&' Cetal distress the most common is variable

deceleration reBectin% umbilical cord

compression caused by oligo ydramniosJ' Cetal de ormities acial 5 skeletal de ormities inprolon%ed ,R;.

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32- Preterm Labour