1. Audace NIYIGENA
Intern in Gynecology & Obstetrics
In Butare University Teaching Hospital
Supervised by
Dr Ntwali NDIZEYE

2. Objectives
 Define preterm labor
 Discuss epidemiology
 Review risk factors
 Diagnosis
 Review complication
 Discuss Management

3. Case study
 M.E 19y
 Admitted on 19th Jan. 2013
 Transferred from Nyanza DH
 Nifedipine 20mg bid
 Dexametasone 12mg 2times
 Symptoms
 Periodic pelvic pain and back pain for 2 days
 No bleeding, no fluid gush
 G.O
 G1P0
 Lmp 12th Jull. 2012 GA 27W2D

4. Case study cnt
 Mhx:
 No hx of STI
 No diseases on pregnancy
 No asthmatic
 HIV neg
 No alcohol
 No tobacco
 No trauma
 Low socio economic status

5. Case study cnt
 P/E
 HEENT: no pallor, no oedema, no jaundice
 Chest: good symmetric chest expansion, lung clear, S1 &
S2 well audible without added sound
 Abdomen & pelvic:
 Gravid uterus FH: 24cm
 Bcf: 148b/m
 Cephalic presentation
 2 contractions/10m
 Cervix dilatation 4cm
 Effacement 100%
 Engagement 1/5
 Diagnosis: Preterm labor

6. Case study cnt
 Spontaneous rupture of membrane at 13h15’
 14h45’
 Eutocic delivery of preterm baby
 APGAR 3, weight:900gr
 Transferred in neonatology (but died in the evening)

7. Define preterm labor

8.  Term pregnancy - 37 to 42 weeks gestation
 Preterm pregnancy 24 to 37 weeks gestation
 Preterm labor is occurrence of uterine contractions
between 24 to 37 weeks of gestation( amenorrhea)
 Preterm labor is the presence of contractions of
sufficient strength and frequency to effect progressive
effacement and dilation of the cervix between 20 and
37 weeks' gestation (WHO)
Gynecology and obstetrics clinical protocols & treatment guidelines

9. Epidemiology

10. Preterm Birth
 12 % of deliveries/yr are preterm
 71.2% 34-36 weeks
 13% 32-33 weeks
 10% 28-31 weeks
 6% <28 weeks

11. Preterm Birth
 Spontaneous preterm labor 30-50%
 Multiple gestation 10-30%
 PPROM 5-40%
 Preeclampsia/eclampsia 12%
 Antepartum bleeding 6-9%
 Fetal growth restriction 2-4%
 Other 8-9%

12. Survival in Premature Infants
 23 wks – 17%
 24 wks – 39%
 25 wks – 50%
 26 wks – 80%
 27 wks – 90%
 28-31 wks – 90 to 95%
 32-33 wks – 95%
 34-36 wks – approaches
term survival rates
Sources: march of Dimes, Quint Boenker Preemie Survival Foundation

13. Review risk factors

14. Risk Factors for PTD
 Previous PTB
 Multiple gestation  Maternal age extremes
 Increased uterine size  Anemia
(Polyhydramnios, twins)
 Low BMI < 20
 Uterine abnormalities
 cervical incompetency
 Maternal Infections
 Severe stressors
 Placental pathology
 Short inter-pregnancy
 Maternal trauma interval
 Smoking (Substance abuse)

15. Diagnosis

16. Signs and Symptoms
 Pelvic and Back pain
 Uterine contractions
 Cervix dilatation and effacement

17. Investigations
 FBC
 Vaginal swab for lab analysis
 Urine analysis
 Maternal and fetal screening for infections
 Obstetric Ultrasound

18. Review complication

19. Complications of Prematurity
 RDS
 IVH
 Feeding difficulties/NEC
 Apnea
 PDA
 Infection
 Jaundice
 Hypothermia
 Neurobehavioral
 ROP
 Anemia

20. Management

21. Goals of Treatment of PTL
 Halt contractions temporary by tocolysing
 Allow 48 hr+ for steroids to be given
 Allow for transport to delivery location with
NICU capability

22. Steroids
 Reduce incidence of RDS, IVH, NEC, sepsis, and
mortality by about 50%
 Dexamethasone 6 mg IM 12 hr x 4 (cervix dilatation <
4cm)
 Dexamethasone 12mg IM 12 hr x 2 ( cervix dilatation >
4 cm) (Gynecology and obstetrics clinical protocols &
treatment guidelines)

23. Tocolysis
 Beta agonists ( terbutaline, salbutamol)
 Magnesium sulfate
 Indomethacin
 Atosiban
 Nifedipine

24. Tocolysis
Risk/benefit ratio of various treatments
 Beta agonists (salbutamol, terbutaline)
 Tachycardia, hypotension, tremor, palpitations, chest
discomfort, hypokalemia, hyperglycemia
 Magnesium sulfate
 Nausea, flushing, fatigue, diaphoresis, loss of DTRs, respiratory
depression, cardiac arrest
 Indomethacin
 Maternal GI SE, premature closure of ductus, oligohydramnios
 Atosiban
 Possible increase in fetal/neonatal morbidity/mortality; not available
in US
 CAUTION we should avoid combining tocolytics (Green-top
guideline no:1b feb 2011)

25. Tocolysis
 Nifedipine
 Low cost
 Oral
 Low incidence of side effects
(hypotension, dizziness, flushing)
Often considered first line
Dose:
 20mg start dose and 10-20 mg 3 to 4 times daily
Total ≥ 60mg appears to be associated with increase of 3 to 4
fold the bad event of headache and hypotension
Caution: be careful when use in multiple pregnancy, rupture
of membrane, sepsis, diabet mellitus and cardiac disease.
(Source: the royal Australian and new Zealand college of obstetrics and
gynecology C-obs 15)

26. Management after Tocolysis
 If maternal and fetal conditions are stable, can be
managed at home
 Avoid excessive physical activity; most advocate pelvic
rest
 Continued tocolytics have not shown definite benefit

27. Prevention of PTB
 Reduce/eliminate risk factors, if possible
 Not proven to be effective: bedrest, home uterine
monitoring, prophylactic tocolytics, prophylactic
antibiotics, abstinence

28. To retain
 Preterm labor is the presence of sufficient uterine
contractions to effect progressive cervix changes between
20 and 37 weeks' of gestation
 Various strategies that have been used to prevent or treat
preterm labor, haven't proven effective.
 Tocolysis should be considered only for 2 days-
 for corticosteroids action,
 gain time for transfer to a tertiary center .

29. References
 UpToDate19.3 2009 offline
 march of Dimes, Quint Boenker Preemie Survival
Foundation
 Gynecology and obstetrics clinical protocols &
treatment guidelines Sept.2012
 the royal Australian and new Zealand college of
obstetrics and gynecology C-obs 15
 Green-top guideline no:1b Feb.2011

30. Thanks