Preterm Labor

International

Preterm Labor

Preterm Labor
International

Objectives
Definition and Incidence
Etiology
Diagnosis
Management
- Delaying delivery
- Promoting fetal maturity
- When to transfer
- Delivery

Preterm Labor
International

Definition
regular uterine contractions accompanied by
progressive cervical dilatation and/or
effacement at less than 37 weeks gestation
20 to 50% of PTL diagnosis is incorrect

Preterm Labor
International

Dilemma
interventions to stop preterm labor are not
particularly effective - especially when not
instituted early

'Solution'
diagnosis based on some degree of uterine activity
combined with a single cervical exam suggesting
early dilatation or effacement

Preterm Labor
International

Diagnosis
establish dates
history of contractions, risk factors
abdominal exam for uterine activity
cervical exam - serial if reasonable
sterile speculum exam alone should be done in PPROM
defer digital exam if there is undiagnosed vaginal
bleeding until _______ of placenta is known

Preterm Labor
International

Establishing the EDD - LMP

Naegele's Rule can be used in conjunction with the
LMP if:
- first day of last menses is known
- period was 'normal'
- cycle is regular and between 24 and 35 days
- no recent hormonal contraception, lactation or
pregnancy (3 subsequent spontaneous periods)

Preterm Labor
International

Establishing the EDD - When

ultrasound is available
Ultrasound should be used when the LMP is unknown
or criteria are not fulfilled for its use in calculating the
EDD
U/S dating accuracy decreases as gestational age
increases
- 7 - 12 weeks GA
5 days
- 13 - 20 weeks GA
1 week
- 21 - 30 weeks GA
2 weeks
- > 30 weeks GA
3 weeks

Preterm Labor
International

Establishing the EDD

please tell someone the EDD!
- inform woman of EDD from LMP if appropriate and
reinforce at time of dating and/or 18 week ultrasound
- document EDD on antenatal forms
- document dates and findings of each ultrasound on
antenatal (include placental location)
good dating is useless if no one but you knows the
EDD and you are not available

Preterm Labor
International

Incidence
preterm delivery occurs in about 7% of pregnancies
there has been little change in this rate despite new
technologies

Preterm Labor
International

Significance
preterm birth accounts for 75% of perinatal mortality
significant longterm neonatal/pediatric sequelae
- CNS and neurodevelopmental
- respiratory
- blindness and deafness

Preterm Labor
International

Etiology
Idiopathic
Antepartum haemorrhage
Preterm prelabor rupture of membranes
Chorioamnionitis
Multiple pregnancy / Polyhydramnios
Incompetent cervix / Uterine Anomaly
Maternal disease
Fetal anomaly

Preterm Labor
International

Management of Preterm Labor

Four Objectives:
1. Early diagnosis of preterm labor
2. Identify and treat the underlying cause of preterm
labor if possible
3. Attempt to stop labor when appropriate
4. Minimize neonatal morbidity and mortality

Preterm Labor
International

Management - Prolongation of
Pregnancy

less than 40% of patients in preterm labor will be

candidates for tocolysis

Goal of Tocolytic Therapy

Delay delivery when appropriate

- gain 48 hours for corticosteroids
- transport
- optimize personnel

Preterm Labor
International

Management - Tocolysis Contraindicated

contraindication to continuing pregnancy
e.g.
severe pregnancy induced
hypertension, chonoamnionitis intrauterine fetal death
contraindication to specific tocolytic agents

Preterm Labor
International

Tocolytics - No strong evidence for efficacy

Fluid bolus - small trial (n=48), no detected effect
Ethanol
- small trials, no benefit over placebo
- ritodrine more effective in comparative trials
- concerns re: adverse effects
Sedation - no evidence, concern re: adverse effects

Preterm Labor
International

Tocolytics - No strong evidence for

efficacy
Magnesium sulfate
- small, poor quality trials; placebo and comparative
- no benefit shown

Preterm Labor
International

Tocolytics - Good evidence for efficacy

-sympathomimetics (ritodrine)
- highly effective for delaying delivery in the short term
- no demonstrated effect on neonatal outcome
PG synthetase inhibitors (indomethacin)
- more effective than placebo in delaying delivery
>48 hours and beyond
- no demonstrated positive effect on neonatal outcome
- small trials, concern re: adverse effects
Calcium channel blockers (e.g. nifedipine)

Preterm Labor
International

Side Effects of -mimetics

tachycardia - maternal and/or fetal

headache and nasal congestion
hyperglycemia / hypokalemia
hypotension
pulmonary edema
- multiple gestation
- other interventions
- infection
myocardial ischemia

Preterm Labor
International

Contraindications to -mimetics
Maternal cardiac disease - structural, ischemic, rhythm
Significant antepartum haemorrhage
Poorly controlled medical condition
- type I diabetes mellitus
- hyperthyroidism
Contraindication to prolongation of pregnancy
- preeclampsia or other medical indication
- chorioamnionitis, suspected fetal compromise
- mature fetus / imminent delivery / IUFD or anomaly

Preterm Labor
International

Minimizing Neonatal Adverse Outcomes

Respiratory distress syndrome (RDS) is a major concern
with preterm delivery
Incidence of RDS has improved due to newer therapies
RDS plays a role in several other conditions
- intraventricular haemorrhage (IVH)
- necrotising enterocolitis (NEC)
- persistent pulmonary hypertension (PPHN)
- other respiratory conditions

Preterm Labor
International

Meta-analysis of Antepartum Steroids

15 trials evaluating antenatal glucocorticoids for the
reduction of RDS in preterm infants (>24 weeks and
< 34 weeks)
an incomplete course of steroids may still be beneficial

P. Crowley CCPC Review No. 02955

Preterm Labor
International

Effect of Corticosteroids on Neonatal Outcomes

RDS
IVH
NEC
Perinatal Infection
Neonatal Death
0.1
P. Crowley CCPC Review No. 02955

1
10
Odds Ratio (95% Confidence Interval)

Preterm Labor
International

Recommendations
Which steroid ?
betamethasone 12 mg IM q 24h x 2 doses (or q 12h)
dexamethasone 6 mg IV q 12h x 4 doses (or q 6h)
Beware
steroids in the presence of infection
steroids in combination with tocolytics in multiple
gestation or diabetes

Preterm Labor
International

Recommendations
When should steroid therapy be instituted?
lower gestation limit

22 - 24 weeks

upper gestation limit

34 - 36 weeks

prophylactic administration

depends on
diagnosis and risk

repeated administration

unknown

Preterm Labor
International

Recommendations
Who is a candidate for antenatal steroid therapy?
preterm labour
preterm PROM
hypertensives
diabetics
IUGR
multiple gestation

YES
YES
YES
YES
YES
YES

Considerations
cause
infection
urgency
type, sugars
urgency
pulmonary edema

Preterm Labor
International

Decision to Transport
Available level of neonatal or obstetrical care
Available transport and skilled personnel
Travel time
Risk of journey - maternal and fetal/neonatal well-being
Risk of delivery en route
- Parity, length of previous labour
- State of cervix
- Contractions
- Response to tocolytics

Preterm Labor
International

Transport Plan
Copies of antenatal forms, lab results, ultrasounds
Communication
- with patient and family
- with receiving physician re: indication, stabilization,
optimization, mode of transport, E.T.A.
Appropriate attendant
IV access, indicated medications, appropriate equipment
Assess patient immediately prior to transport

Preterm Labor
International

Preterm Delivery
caesarean not indicated on basis of prematurity
recommendation for C/S of breech < 31 weeks not
based on good evidence
prophylactic outlet forceps not indicated
routine episiotomy not indicated
personnel skilled in neonatal resuscitation present

Preterm Labor
International

Conclusion
Prompt and accurate diagnosis
Identify and treat underlying cause if possible
Attempt to prolong pregnancy if appropriate
Intervene to minimize neonatal mortality and morbidity
- antenatal steroid therapy
- maternal transport
- optimize local resources if unable to transport

Preterm Labor
International

Prelabor Rupture of the

Membranes (PROM)

Preterm Labor
International

Objectives
Definition
Diagnosis
Management - Preterm and Term

Preterm Labor
International

Definition
rupture of the membranes before the onset of labor
preterm - < 37 weeks gestation (PPROM)
term
- 37 weeks gestation (TPROM)

Preterm Labor
International

Latent Period
time from rupture until onset of labor
earlier the gestation the longer the latent period
At term - 90% go into labor within 24 hours
At 28 - 34 weeks
50% go into labor within 24 hours
80 - 90% go into labor within 1 week

Preterm Labor
International

Etiology of PROM
idiopathic
infection (e.g. bacterial vaginosis)
polyhydramnios
cervical incompetence
uterine abnormality
following cervical cerclage or amniocentesis
trauma

Preterm Labor
International

Diagnosis of PROM
history
sterile speculum exam ( avoid digital exam)
glistening, washed out vagina
fluid pooling in posterior fornix
free flow from cervix
pH testing of fluid (nitrazine paper) - non specific
ferning
ultrasound - PROM less likely if normal fluid volume

Preterm Labor
International

Complications of PROM - Term

fetal / neonatal infection
maternal infection
umbilical cord compression / prolapse
failed induction resulting in cesarean section

Preterm Labor
International

Complications of PROM - Preterm

preterm labor and delivery
fetal / neonatal infection
maternal infection
umbilical cord compression / prolapse
failed induction resulting in cesarean section
pulmonary hypoplasia (early, severe oligohydramnios)
fetal deformation

Preterm Labor
International

Management - General
assess maternal and fetal well-being
confirm diagnosis
assess cervical status by speculum exam (sterile)
avoid digital cervical exam
assess for conditions requiring concurrent management
e.g.

presence of temperature or maternal or

fetal tachycardia
assess for indications for immediate delivery

Preterm Labor
International

Management - Term (> 37 weeks)

avoid digital cervical exam
assess for infection
consider need for antibiotics if prolonged
PROM
expectant or active management depending on
circumstances and patient preference

Preterm Labor
International

Management - Preterm (34-37 weeks)

avoid digital cervical exam
consider antenatal steroids
intrapartum antibiotic prophylaxis
surveillance for infection - clinical (monitor maternal
temperature and pulse, fetal heart rate)
appropriate antibiotics for chorioamnionitis if develops

Preterm Labor
International

Management - Preterm (< 34weeks)

avoid digital cervical exam
steroids
antepartum and intrapartum antibiotics to mother
surveillance for infection - clinical (monitor maternal pulse and
temperature, fetal heart rate, presence of uterine irritability)
appropriate antibiotics for chorioamnionitis if develops
consider transfer to higher level of care center if appropriate
expectant management (possibly outpatient)

Preterm Labor
International

Antibiotic options are:

Iv Penicillin G 5 million units q 4-6h preferred
or
Iv Ampiullin 2g followed by 1 g q 4h
or
IV Clindamyin 600 ng q 8h
Women with suspected chorioamnitonitis require broader
range spectrum antibiotic coverage