21. Pre-term labour and Pre-labour rupture of membranes(PPROM)

Question 1

Define Pre-Term labor and PPROM.

Answer 1

Onset of labour before 37 weeks of gestation.
2nd commonest cause of perinatal deaths in SA.

Question 2

What is the 2nd commonest cause of perinatal deaths in SA?

Answer 2

Pre-Term labour and PPROM

Question 3

What are the contra-indications of tocolytics?

Answer 3

Maternal Factors:
Chorioamnionities
Antepartum Haemorrhage
Pre-eclampsia

Foetal Factors:
IUFD
IUGR
Foetal Abnormalities
Fetal distress

Question 3

What are the complications of Pre-term labour and PPROM at >34 weeks?

Answer 3

Hyaline Membrane Disease
Infections
Necrotizing enterocolitis
Intracranial haemorrhage

Question 4

What are the causes of PTL and PPROM?

Answer 4

1. Maternal Factors: Infection (chorioamnionitis, GTI), maternal pyrexial illness(sepsis>pyelonephritis and RTI), Uterine abnormalities (Uterine fibroids, bicornuate Uterus) and cervical incompetence.
2. Foetal Factors:
   Multiple pregnancy, Polyhydramnios
3. Placental Factors:
   Placenta Previa, Abruptio Placentae, IUGR.

Question 4

Risk factors for PTL and PPROM

Answer 4

Smoking and Alcohol
Prev Hx
Malnutrition and Poor SES (Good nutrition for placental integrity)

Question 4

How many hours apart is a vaginal exam done?

Answer 4

4hrs

Question 5

Management of PTL

Answer 5

Find cause and decide in tocolyses.
Assess gestation : if fetal weight >2kg no tocolyses

Question 5

How to assess growth restriction clinically?

Answer 5

1.SFH < gestational age
2. Small hard head
3. Oligohydramnios
4. Irritable uterus (Linked to placental disorders such as: Placental insufficiency, ischemia, placenta previa)

Question 5

When to give patient tocolyses?

Answer 5

GA < 34 weeks
EFW < 2kg

Question 6

Define threatened PTL

Answer 6

Onset of contractions without cervical dilations

Question 6

Tocolytic medication to give in PTL of < 34 weeks

Answer 6

Nifedipine (calcium channel blocker) 30mg then 20mg after 90 minutes
Endomethacin (NSAID)

Question 7

How is PTL diagnosed?

Answer 7

Regular painful contractions associated with progressive cervical changes with or without ROM.

Question 7

What is the steroid administered in PTL and its benefits?

Answer 7

Betamethasone
Prevents:
HIN
Hyaline membrane disease
Necrotizing enterocolitis
Intraventricular hemorrhage.

Question 8

What is administered in PTL for neuroprotection?

Answer 8

MgSO4, cerebral palsy

Question 9

Define PPROM

Answer 9

Leakage of amniotic fluid through the cervix before 37 weeks of gestation.

Question 10

How can one diagnose PPROM?

Answer 10

Litmus testing: Liquor is alkaline and turns red litmus paper blue.
Ferning can be observed when liquor is placed under microscope.
Highly sensitive: Amnisure > detection of PAMG-1.
Fetal fat cells stain orange with 1% Nile blue sulphate (after 30 weeks)

Question 11

How to manage PPROM

Answer 11

If not in labour after 24 hours induce labour using misopristol or oxytocin. If HIV positive after 4hrs.
Administer penicillin intravenously.
>34 weeks:
1. Admit the patient and counsel about risks of preterm labour.
2. Avoid vaginal examination unless prolapsed cord suspected because of
abnormal fetal heart rate.
3. Administer antibiotics Azithromycin 500mg daily for 3 days
4. Administer Betamethasone 12mg IMI 12 hourly x 2 doses
5. Midstream urine to exclude urinary tract infection
6. Twice weekly white cell counts
7. Use of sterile pads
8. Growth ultrasound
9. If labour supervenes, consider tocolysis for 48 hours to administer steroids
10. If there are signs of infection such as maternal pyrexia, uterine tenderness
or fetal tachycardia or rising white cell count, induce labour urgently
regardless of the gestational age.