preterm and prom
DESCRIPTION
breif presentationTRANSCRIPT
Preterm Labor
Introdution
24 37
Survival by gestational age among live-born resuscitated infants
In: Creasy, Resnik . Maternal – Fetal Medicine, 2009
Pathophysiology
Ascending intrauterine infections stage I changing flora vagina/cervix, II Microorganism alocated between the amnion and chorion, III intra amniotic infection, IV fetal invation
Infection
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
Infections associated with preterm delivery
In:Jane Norman.Preterm labor 2005
Over distension
Multiple
GestationPolyhydramnios
Vascular ( uteroplacental disturbance )
Surgical procedures and intercurrent illness
Pyelonephritis Appendicitis Pneumonia
Cholestasis 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/contactions–onset – frequency-duration-severity.
Vaginal loss : SROM or PV bleeding Obstetric History
Examination
Maternal pulse – tempreture – respiratory rate.
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
assay )>> 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
improvement in perinatal mortality and morbidity
Liason with senior obstetricians & neonatologists is essential .( 23-26 wks ): Mode, monitoring,intervention during Labor.
Start IV antibiotics if labour confirmed
Prevention
Rx of bacterial Vaginosis Progesterone Cervical cerclage Cervical pessary Reduction of selective number of
pregnancy
Premature of membrane
Definition
Premature rupture of the membranes (PROM) is defined as amniorrhexis (spontaneous rupture of membranes) prior to the onset of labor at any stage of gestation
Incidence
PROM occurs in about 1/3 of preterm deliveries.
1/3 caused with other infections
Cause of PROM(1)
The cause of PROM is not clearly understood, perhaps associated with the follow factors:TraumaSexual intercourse (particularly in the late
gestational weeks) lax of internal os of uterine
Cause of PROM(2)
Vaginal infection due to bacteria, virus, TOXO, CMV, HPV, HSV, et al STDs sexually transmitted diseases play an important role in the cause of PROM, because such infections are more commonly found in women with PROM than in those without PROM
Increased of intra-uterine pressure (such as multiple pregnancy 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 increased 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 from urine and vaginal secretions, the paper turns dark blue in response to the amniotic fluid
Amniotic fluid is quite alkaline having a pH above 7.0, but vaginal secretions in pregnancy usually have pH values of less 6.0
Experimental Test(2)
The “fern” test : placing a sample on a microscopic slide, air drying, and examining for ferningThe amniotic fluid does fernThe other fluid does not fern
Risk of PROM
Preterm labor: 75% Intrauterine infection(chorioamnionitis, 30-
50% 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 measurement)
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)