Preterm Labour or PPROM

 

Preterm labour is cervical change, with contractions, in under 37 weeks.

Preterm premature rupture of membranes (PROM).

6-7% of all singleton births. Rates are holding. Major cause of morbidity and mortality.

Rates increasing in multiple births.

 

 

Causes and Risk Factors

 

 

 

Risk factors for preterm labour

 

Associated factors

 

 

 

Signs, Symptoms, and Diagnosis

 

  • history
  • physical exam
  • lab investigations
  • diagnostic imaging

History

Gravity, parity

Gestational age (LMP, US)

pregnancy history

  • complications: TPTL, PROM, US, lab work
  • admissions to hospital

past obstetrical history

  • previous PTB, PROM

PMH: previous history

Physical Exam

Vitals of mother and baby

  • fever
  • baby NST

Leopolds maneuvers for presentation

Contractions should be palpated or by tocometer.

sterile speculum: for fetal fibronectin and ferning first

PV exam: only if ruptured membranes are ruled out

Lab Investigations

Rupture of membranea and amniotic fluid

nitrazine swabs: high NPV; positives with semen

 

Fetal fibronectin: should not be present 24-34 weeks.

Sterile speculum exam. place in the posterior fornix for 10 seconds. 30-120 minutes for result

Predictor of preterm deliver in 7-14 days.

  • high NPV
  • low PPV

Contraindications:

  • anything in the vagina within 24 hours (do this first, before PV)
  • GA above 34 weeks
  • bleeding
  • cervix dilated greater than 3 cm

Easy to do. not as expensive.

 

 

Ferning

 

 

 

 

 

 

Diagnostic Imaging

 

Transvaginal US: measures effacement

<2.5 cm under 28 weeks suggests increased risk of PTB

advantages

  • quite noninvasive
  • quick and easy
  • good inter-rater reliability

disadvantages

  • not available everywhere
  • need training to do

 

 

 

 

 

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Pathophysiology

 

 

 

 

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Treatments

 

Prevention

Prevention of preterm birth is very difficult. We need to educate about symptoms.

 

Management goals

Transfer to a tertiary care centre ( if delivery is imminent, the delivery team often flies to the outlying site)

Delay infection

Encourage lung maturity (beta methasone; useful between 24-34 weeks)

Stop contractions/cervical change

 

With PPROM, labour does not necessarily need to follow; avoid infection, but otherwise you can watchfully wait.

 

 

 

 

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Consequences and Course

 

Risks of Preterm Delivery

Hard to generalize

If <24 weeks, viability is in question

If >24 weeks, risks depend on gestational age, but include RDS, IVH, NEC, feeding, developmental delay

 

Risk of recurrence in tufute pregnancy is 15-20%, though depends on history and circumstances.

Future pregnancy

 

 

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The Patient

 

 

 

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Health Care Team

 

 

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Community Involvement

 

 

 

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Resources and References