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Preterm Labor

Introdution

24

37

Survival by gestational age among


live-born resuscitated infants

In: Creasy, Resnik . Maternal Fetal Medicine, 2009

Pathophysiology

Infection

Ascending intrauterine infections


stage I changing flora vagina/cervix,
II Microorganism alocated between
the amnion and chorion, III intra
amniotic infection, IV fetal invation

Infections associated with preterm delivery


Genital

* Bacterial vaginosis (BV)


* Group B streptococcus
* Chlamydia
* Mycoplasmas

Intra-uterine
* Ascending (from genital tract)
* Transplacental (blood-borne)
* Transfallopian (intraperitoneal)
* Iatrogenic (invasive procedures)
Extra-uterine
* Pyelonephritis
* Malaria
* Typhoid fever
* Pneumonia
* Listeria
* Asymptomatic bacteriuria
In:Jane Norman.Preterm labor 2005

Over distension

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Vascular ( uteroplacental
disturbance )

Surgical procedures and intercurrent illness

Pyelonephritis

Appendicitis

Cholestasis

Pneumonia

Amniocentesis

Abnormal uterine cavity

Cervical weakness

Risk Factors

Previous preterm delivery or late miscarriage


Multiple Gestation
Cervical surgery
Uterine anomlies
Medical condition e.g renal disease
Pre-eclampsia & IUGR (spontaneous & iatrogenic)

Diagnosis
History
Examination
Investigations

History
Ask about pain/contactionsonset frequencyduration-severity.
Vaginal loss : SROM or PV bleeding
Obstetric History

Examination
Maternal pulse tempreture respiratory r
ate.
Uterine tenderness ( abruption infections)
Fetal presentation
Speculum : look for blood,discharge,liquor.
Take swaps .
Gentle VE

Investigations
FBC
Swabs
MSU
USS for fetal presentation age
Fetal fibronectin TVS if available

Management
Theartend or real Labour
(TVS cervical >15mm Neg fibronectin a
ssay )>> unlikely to be labour .
Admision if high risk & inform neonatal unit
Arrange in utero transfer
Check fetal presentation by US
Steriods

Tocolytic Therapy ex nifidipine


( still prefer to avoid it , because no improv
ement in perinatal mortality and morbidity
Liason with senior obstetricians & neonato
logists is essential .( 23-26 wks ): Mode, m
onitoring,intervention during Labor.
Start IV antibiotics if labour confirmed

Prevention
Rx of bacterial Vaginosis
Progesterone
Cervical cerclage
Cervical pessary
Reduction of selective number of pregnan
cy

Premature of membrane

Definition

Premature rupture of the membranes (PR


OM) is defined as amniorrhexis (spontane
ous rupture of membranes) prior to the on
set of labor at any stage of gestation

Incidence
PROM occurs in about 1/3 of preterm deliv
eries.
1/3 caused with other infections

Cause of PROM(1)

The cause of PROM is not clearly underst


ood, perhaps associated with the follow fa
ctors:
Trauma
Sexual

intercourse (particularly in the late ges


tational weeks)
lax of internal os of uterine

Cause of PROM(2)

Vaginal infection due to bacteria, virus, TOXO, CMV, HP


V, HSV, et al STDs sexually transmitted diseases play a
n important role in the cause of PROM, because such inf
ections are more commonly found in women with PROM
than in those without PROM
Increased of intra-uterine pressure (such as multiple pre
gnancy and hydraminios)
Abnormalities in presentation and position

Cause of PROM(3)

Smoking the risk of PROM is at lease doubled in women


who smoke during pregnancy
Other factors for PROM include the follow
Prior PROM
A short cervical length
Prior preterm delivery
Bleeding in early pregnancy

Manifestation and Diagnosis


Fluid passing through the vagina suddenly, and then small amounts
of fluid flow through the vagina intermitently, particularly when the in
creased of abdorminal pressure (cough, sneeze, et al)
Intermittent urinary leakage is common during pregnancy, especially
near term
Increased vaginal secretions in pregnancy
Perineal moisture
Increased cervical discharge
Urinary incontinence
Vesicovaginal fistula
May be mistaken for the fluid

Experimental Test(1)
The Nitrazine test uses pH to distinguish amniotic fluid fr
om urine and vaginal secretions, the paper turns dark blu
e in response to the amniotic fluid
Amniotic fluid is quite alkaline having a pH above 7.0, but v
aginal secretions in pregnancy usually have pH values of
less 6.0

Experimental Test(2)

The fern test : placing a sample on a micros


copic slide, air drying, and examining for ferni
ng
The

amniotic fluid does fern


The other fluid does not fern

Risk of PROM
Preterm labor: 75%
Intrauterine infection(chorioamnionitis, 3050% of case)-( maternal fever abdominal pain offensive

discharge tachytracia)

Puerperal infection

Fetal and neonatal complications

Fetal and neonatal pneumonia, sepsis


Neonatal respiratory distress syndrone
Neurologic dysfunction
Intracranial hemorrhage
Prolapse of umbilical cord
Abruptio placenta

Evaluation

The gestational age( LMP, ultrasound and uterus fundal height meas
urement)
The presence of uterine contractions (abdominal examination)
The amount of amniotic fluid (ultrasound)
Fetal heart rate (FHR monitor)
Fetal maturity (L/S or PG)
The likelihood of chorioamnionitis (white blood cell count)
The likelihood of prolapse of umbilical cord

Management

If there is an evidence of chorioamnionitis : steroids


deliver antibiotics
If not : conservation with admission with information
neonatal unit steroids antibiotics (erythromycin)

Thank You