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

     Pulmonary- RDS bronchopulmonary dysplasia Cardiovascular: PDA, persistent fetal circulation CNS: IVH, cerebral palsy, seizures, sensory deficits GI: NEC Metabolic: hypoglycemia, hypocalcemia, jaundice

Perinatal morbidity

 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 Abn Cx & Ut Bleeding 2 half Infection Multiple pregnancy Surgery Hydramnios Poor ANC

What are the signs and symptoms of preterm labor

Vaginal discharge Pelvic&Abd pressure Backache Ut contraction Abd cramps 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

Bricanyl • NSAIDS • Corticosteroid • Anti-biotic agent Calcium Chanel blocker • Oxytocin antagonist

Assessment of patients in preterm labor

 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

Diagnosis

 History  “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

• Point of Care test • Cost-up to $50 each • Sensitivity-98.7 98.9% • Specificity-87.5 100% • 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

     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 (3) Tocolysis

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