CH11

SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS
CHAPTER 11
PRETERM LABOR and
PRELABOR RUPTURE OF MEMBRANES (PROM)
11.1 PRETERM LABOR
Learning Objectives:
Recognize the clinical criteria for the diagnosis of preterm labor
Apply preventive strategies for preterm labor
Review the proper management of preterm labor
List the diagnostic criteria for preterm labor.
____________________________________________________________________________________________
List the 2 most important objectives of tocolytic therapy.
____________________________________________________________________________________________
____________________________________________________________________________________________
11.1.1 Definition and Etiology
1) Definition
Regular uterine contractions accompanied by progressive cervical dilation and/or effacement at less than 37 weeks
gestation.
Incidence and Significance
reterm delivery occurs in 7! of pregnancies.
"any and various attempts have been made to prevent the onset of preterm labor. #espite improved standards of
living and healthcare$ intensive educational programs and improved diagnostic and therapeutic technologies$ there
has been little change in the rate.
reterm %abor &'%( and delivery accounts for 7)! of neonatal mortality. 'he long*term se+uelae of prematurity
include,
-./ complications such as cerebral palsy
.eurodevelopmental delay
Respiratory complications such as bronchopulmonary dysplasia
0lindness and deafness
2) Etiology
1diopathic
Antepartum hemorrhage
reterm pre*labor rupture of membranes
elvic infection
ALARM INTERNATIONAL 2 Chapter 11 - Preterm Labor/Prelabor Rupture of Membrane (PROM) 2 120
-horioamnionitis and pel
"ultiple pregnancy / polyhydramnios
1ncompetent cervi3 / uterine anomaly
"aternal disease such as malaria$ tuberculosis
4etal anomaly
11.1.2 Diagnosis
Dilemma
1nterventions to stop preterm labor are not particularly effective * especially when not instituted early.
Solution
'he solution to this dilemma has been to make the diagnosis based on a degree of uterine activity combined with a
single cervical e3am suggestive of early dilation and/or effacement. 'his approach facilitates early institution of
therapy however$ results in a significant over diagnosis of preterm labor. 4or this reason$ up to )5! of those given
the diagnosis of preterm labor$ actually are not e3periencing labor.
6stablish dates
* 63amine the prenatal record$ for clinical growth$ review of menstrual history and a dating if available.
6valuate the identified risk factors
6valuate contractions
* history
* abdominal e3amination for uterine activity
#igital cervical e3am
* sterile speculum e3am alone should be done in R7"
* defer digital e3am if there is undiagnosed antepartum bleeding until localization of placenta known
11.1.3 Management of Preterm Labor
b!ecti"es
8. 6arly diagnosis of preterm labor
9. 1dentify the cause of preterm labor
* treat the underlying cause when possible
3. Attempt to arrest labor when appropriate
:. 1ntervene to minimize neonatal morbidity and mortality
Prolongation of Pregnancy
Less than 40% of patients in preterm labor will be a candidate for tocolysis.
6vidence suggests that beta*sympathomimetics &ritrodine( and ; synthetase inhibitors &indomethacin( are the
most effective at delaying delivery for :< hours in order to institute glucocorticoids and nifedepine &adalal(.
.o tocolytic alone improves the outcome of pregnancy. rolongation of pregnancy allows administration of
glucocorticoids and transportation of the mother to a tertiary centre.
#$L%#I$S
&o 'ro"en efficacy
4luid bolus
* small trial &n=:<($ no effect$ concern re, fluid overload particularly if a betamimetic is used subse+uently
6thanol
* small trials$ no benefit over placebo$ concerns re, adverse effects
* less effective than ritodrine in comparative trials
/edation
* no evidence$ concerns re, adverse effects
"agnesium sulfate
* small$ poor +uality placebo and comparative trials$ no benefit
* trials may not have used high enough dosage to demonstrate effect
Pro"en efficacy
0eta*sympathomimetics &ritodrine(
* highly effective for delaying delivery in the short term
* no evidence of beneficial effect on fetus/neonate
* allow use of corticosteroids$ transfer$ e3pectant care
; synthetase inhibitors &indomethacin(
- more effective than placebo in delaying delivery >:< hours and beyond
- no effect by itself on R#/ or mortality
- small trials$ concern re, adverse effects
- should not be used after 3: weeks gestation
-alcium channel blockers &nifedipine(
- ?ighly effective for delaying delivery in the short term
- .o evidence of beneficial effects on fetus neonate
- Allow use of corticosteroids$ transfer$ e3pectant care
- %ess side effects than ritodrine
$ontraindications to #ocolysis
-ontraindications to continuing the pregnancy
-ontraindications to specific tocolytic agents
$ontraindication to 'rolongation of 'regnancy
/evere pregnancy induced hypertension
-horioamnionitis
"ature fetus
1mminent delivery
1ntra uterine fetal death &1@4#( or lethal fetal abnormality
$ontraindications to (eta)mimetics
"aternal cardiac disease * structural$ ischemic$ rhythm
/ignificant antepartum hemorrhage
oorly controlled medical condition
diabetes mellitus
hyperthyroidism
11.1.* Minimi+ing &eonatal Morbidity and Mortality
Respiratory distress syndrome &R#/( is a maAor concern with preterm delivery. 1ntraventricular hemorrhage &1B?($
necrotising enterocolitis &.6-($ persistent pulmonary hypertension and other respiratory conditions are also
associated with preterm birth and are more likely to occur in newborns with R#/. 'en years ago$ R#/ accounted
for more than one*fifth of all neonatal deaths. 'he increased use of antenatal steroids and innovations in neonatal
care has reduced this occurrence.
1) ,ntenatal -lucocorticoid #.era'y
'he benefits of antenatal glucocorticoid therapy are now definitively established. 0etamethasone and
de3amethasone cross the placenta and induce enzymes that accelerate fetal pulmonary maturity. 1t takes :< hours
for the full benefit to be achieved. An incomplete course of steroid therapy may still offer worthwhile benefits.
/ecommendations
E"eryone who is at increased risk of a preterm delivery is a candidate for antenatal steroid therapy.
0.en S.ould Steroid #.era'y be -i"en1
'he graph shows the meta*analysis of steroids in preterm labor.
Effects of $orticosteroids on &eonatal utcomes
R#/
1B?
.6-
erinatal 1nfection
.eonatal #eath
5.8 8 85
7dds Ratio &C)! -onfidence 1nterval(
7utcome &subAects(
-ephalohematoma &n = 839C(
7ther scalp/face inAury &n = 89C3(
@se of phototherapy &n = 859C(
Retinal hemorrhage &n = :)<(
Apgar D 7 at 8 min &n = :99(
Apgar D 7 at ) min &n = 8)))(
5.8 8 85
7dds Ratio &C)! -onfidence 1nterval(
%ower gestation limit 99 * 9: weeks
@pper gestation limit 3: weeks
rophylactic administration depends on diagnosis and risk$ e.g. preterm previa and bleeding
Repeated administration not determined
Steroid 'tions
0etamethasone l9mg 1" + 9:h 3 9 doses &or + 89h(
#e3amethasone Emg 1B/1" + 89h 3 : doses &or + Eh(
#e3amethasone is less e3pensive and has no mineralocorticoid activity$ which may be beneficial in situations
where fluid overload is a concern.
$aution
/teroids should not be use in the presence of chorioamnionitis
/teroids should be used with caution in combination with tocolytics especially in multiple gestation or
diabetes
$oncerns
otential 1ndication -onsiderations /hould steroids be givenF
reterm labor cause G6/
reterm R7" infection G6/
?ypertension urgency G6/
#iabetes type$ control G6/
1@;R urgency G6/
"ultiple gestation pulmonary edema G6/
2) Maternal #rans'ort
1n making the decision to transfer a patient in premature labor$ the following factors should be considered,

Available level of neonatal and obstetrical care
Available transport and skilled personnel
'ravel time
"aternal and fetal health stable
Risk of delivery en route
* parity$ length of previous labor
* state of cervi3
* contractions
* response to tocolytics
#rans'ort Plan
6very instit uti on shoul d have a trans port prot ocol that includes,
-ommunication
* with patient and family
* with receiving physician re, indication$ stabilisation$ mode of transport
ALARM INTERNATIONAL 2 Chapter 11 - Preterm Labor/Prelabor Rupture of Membrane (PROM) 2 12!
Appropriate attendant for transport
1B access$ indicated medication$ appropriate e+uipment
Assessment of patient immediately prior to transport
-opies of her obstetrical history
Met.od for 'reterm deli"ery
-esarean section is not indicated on basis of prematurity
Recommendation for -// of breech D38 weeks is not based on good evidence
rophylactic outlet forceps are not indicated and vacuum e3traction is relatively contraindicated
Routine episiotomy is not indicated
ersonnel skilled in neonatal resuscitation should be present
1t is rarely recommended to intervene operatively in a pre*term delivery
11.1.2 Summary
rompt and accurate diagnosis
1dentify and treat underlying cause if possible
Attempt to prolong pregnancy if appropriate
1ntervene to minimize neonatal morbidity and mortality
Antenatal steroid therapy
"aternal transport
/eferences:
8. #u+uette "$ #esrosiers "$ -ho+uette H$ #ubois /. rogram sponsored by the Iuebec ;overnment to assess the
effectiveness of nutriotional intervention of the "ontreal #iet #ispensary. Report presented before the ministry of ?ealth,
neonatal cost considerations. 8CC8, EE*7:
9. Jramer$ " 8C<7. Determinants of Low Birth eight! "ethodological #ssessment #nd "eta$#nalysis. 0ull K?7 E),EE3*
737
3. /7;- Hournal )78$ Hune 8CCE$ %reterm Birth %revention! &ffectiveness of '(rrent )trategies
11.2 PRELABOR RUPTURE OF MEMBRANES (PROM)
ALARM INTERNATIONAL 2 Chapter 11 - Preterm Labor/Prelabor Rupture of Membrane (PROM) 2 12"
Learning Objectives
#efine remature Rupture of "embranes
%ist the clinical criteria for the diagnosis of R7"
/tate the proper management for 'erm and reterm Rupture of "embranes
# **$year$old +2%, woman at *- .wee/s gestation presents to yo(r maternity (nit with a two$day history of
vaginal lea/ing. )he is e0periencing some irreg(lar contractions similar to those she has felt for the past two
wee/s. 1ow wo(ld yo( confirm %23"4
____________________________________________________________________________________________
____________________________________________________________________________________________
3n confirmation of %23"5 what wo(ld be yo(r management plan4
____________________________________________________________________________________________
____________________________________________________________________________________________
11.2.1 Definition and Etiology
1) Definition:
R7" is prelabor rupture of the membranes. 1t may occur at any time in the pregnancy. 'he risk to the pregnancy
is increased after the occurrence of R7" whether at or before term.
'he latent 'eriod is the interval between the rupture of the membranes and the onset of labor. 'he duration of the
latent period varies inversely with the gestational age. Almost C5! of women at term will be in spontaneous labor
within 9: hours of membrane rupture. 4or the woman who is remote from term the latent period will be longer.
4or e3ample at 9< to 39 weeks only )5! will enter labor within 9: hours and <5 ! will go into labor within one
week.
Incidence
'erm R7" 9 to 85 ! of pregnancies
reterm R7" 9 to 3 ! of pregnancies * but accounts for 8/3 of the cases of preterm delivery
2) Etiology of P/M
1diopathic
1nfection
olyhydramnios
-ervical incompetence
@terine abnormality
4ollowing cervical cerclage or amniocentesis
'rauma
0acterial vaginosis &0B( is one condition associated with preterm R7" and subse+uent preterm birth. 0B is a
multi*agent infection by ;ardnerella vaginalis$ mycoplasma hominis$ anaerobes and coliforms.
1t may present$ as a foul smelling discharge. 1t should be treated with oral or vaginal metronidazole or
clindamycin. 'reatment has been shown to reduce the incidence of preterm birth in those at risk.
11.2.2 Diagnosis of P/M
#igital e3amination should be avoided as it increases the risk of ascending infection. /terile speculum e3am
ALARM INTERNATIONAL 2 Chapter 11 - Preterm Labor/Prelabor Rupture of Membrane (PROM) 2 12#
allows for confirmation of R7" and determination of cervical status in most instances.
?istory
appro3imately 35! of women with history of vaginal fluid leakage will not have R7"
/peculum e3am,
;listening$ washed out vagina
4luid pooling in posterior forni3
4ree flow of fluid from cervi3
4erning
p? testing of fluid &nitrazine paper( * non specific
$om'lications of #erm P/M
4etal/neonatal infection
"aternal infection
@mbilical cord compression/prolapse
4ailed induction of labor resulting in cesarean section
$om'lications of Preterm P/M
reterm labor and delivery
4etal/neonatal infection
"aternal infection
@mbilical cord compression/prolapse
4ailed induction of labor resulting in cesarean section
ulmonary hypoplasia &with early$ severe oligohydramnios(
4etal deformation
7f the several complications of R7"$ the most significant is preterm birth and its conse+uences. 'he
management strategy is$ therefore$ appropriately directed to minimizing this adverse outcome.
11.2.3 Management of P/M
#.e management of P/M at any gestational age re3uires:
-onfirmation of the diagnosis
Assessment of maternal and fetal well*being
#etermination of the presence of any associated condition which re+uires concurrent management or may
indicate that delivery is desirable at once
Assessment of cervical statusL however$ digital e3amination should be avoided whenever possible. 'his is
especially true in the preterm setting or when e3pectant management of term R7" is to be undertaken.
ALARM INTERNATIONAL 2 Chapter 11 - Preterm Labor/Prelabor Rupture of Membrane (PROM) 2 12$
4ltrasound :P/M is less li5ely if fluid "olume is normal
'he presence of temperature &3<.)( or maternal or fetal tachycardia
Management of #E/M P/M 6738 9ee5s)
4or women with R7" at term determining the management strategy has been greatly aided by the information
now available from the 'erm R7" 'rial. 'his trial showed no difference in any maAor outcome measure whether
the chosen management was immediate induction$ using o3ytocin or vaginal prostaglandin$ or e3pectant
management. 'herefore the preference and needs of each individual woman should be determined and respected.
Avoid digital cervical e3am
1nstitute antibiotics or prophyla3is if prolonged R7"
63pectant or active management depending on circumstances and patient preference
Management of P/M 63*)38 9ee5s)
1n this gestational age range$ induction or e3pectant management are acceptable management options depending
on local resources.
-onsider antenatal steroids
1ntrapartum antibiotic prophyla3is
/urveillance for infection M clinical &monitoring maternal pulse and temperature$ fetal heart rate$ presence of
uterine tenderness or irritability(
Appropriate antibiotics for chorioamnionitis if it develops
Management of P/M 6:3* 9ee5s)
4or women who have R7" D3: weeks$ e3pectant management is usually preferred and attempts should be made
to prolong the latent period. Steroids to accelerate fetal lung maturity are indicated Aust as for other cases of
anticipated preterm delivery unless there is evidence of chorioamnionitis. 1f chorioamnionitis is suspected$ delivery
is recommended and e3pectant management is contraindicated.
/teroids as in preterm labor
1ntrapartum antibiotics prophyla3is
-onsider transfer to a higher care center
/urveillance for infection M clinical &monitoring maternal pulse and temperature$ fetal heart rate$ presence of
uterine tenderness or irritability$ K0- changes(
Appropriate antibiotics for chorioamnionitis if it develops
63pectant management &possibly outpatient(
,ntibiotics o'tions for c.emo'ro'.yla;is are:
1B enicillin ; ) million @nits +:*Eh &preferred(
7R
1B Ampicillin 9 g and followed by 8 g +:h
7R
ALARM INTERNATIONAL 2 Chapter 11 - Preterm Labor/Prelabor Rupture of Membrane (PROM) 2 12%
,mniotic fluid may be collected from "agina to assess fetal lung maturity
4ltrasound assessment of cer"ical status and fluid "olume
1B -lindamycin E55 mg +<h
Komen with suspected chorioamnionitis re+uire broader spectrum antibiotic coverage.
"anagement of asymptomatic infants of mothers who received intrapartum chemoprophyla3is should be based on
the infantNs gestational age$ results of investigations for sepsis$ the ade+uacy of the maternal intrapartum
chemophyla3is and the clinical presentation. All infants who are symptomatic re+uire antibiotic therapy and
appropriate septic work*ups.
/eferences,
8. arry /$ /trauss H4. %remat(re r(pt(re of the fetal membranes. . 6ngl H "ed 8CC<L 33<, EE3*75.
9. ?annah "6$ 7hlsson A$ 4arine #$ ?ewson /$ ?odnett 6#.$ "yhr '%$ Kang 66%$ Keston HA$ Killan AR$ for the
'ermR7" /tudy ;roup. 6nd(ction of labor compared with e0pectant management for prelabor r(pt(re of the
membranes at term. . 6ngl H "ed 8CCEL 33:, 855)*85.
3. "ercer 0"$ %ewis R. %reterm labor and preterm premat(re r(pt(re of the membranes. 1nfectious #isease -linics of
.orth America 8CC7L 88, 877*958.
ALARM INTERNATIONAL 2 Chapter 11 - Preterm Labor/Prelabor Rupture of Membrane (PROM) 2 12&

CH11

Diunggah oleh

Informasi Dokumen

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

CH11

Diunggah oleh

Hak Cipta:

Format Tersedia

SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS

Anda mungkin juga menyukai