4. DEFINITION
Deliveries between 24+0 and 36+6 w.
Documented regular UC ≥6/h
AND
At least one of the following:
Rupture of membranes
Cervical change
(Cervix 2 cm dilated or 80% effaced)
Aboubakr Elnashar
9. Morbidity
1. Neuro developmental impairment, disability and
handicap: especially within the 24-26-w
50% of the survivors at 23-25 w were impaired, half
with severe disability.
2. Educational difficulties.
3. Social behaviour and criminality, as well as
subsequent influences on adult health.
Aboubakr Elnashar
10. AETIOLOGY
I. Infection
Subclinical infection of the choriodecidual space
and amniotic fluid
II. Vascular
1. Spontaneous prematurity has been associated
with an increase in membrane haemosiderin
deposits, thought to reflect decidual haemorrhages.
2. The link between placental abruption and either
uterine activity or PPROM is well recognized.
Aboubakr Elnashar
11. III. Uterine overdistension
1. Multiple pregnancy
Median gestation at delivery
for twins: 35 w
for triplets 33 w.
ART responsible for
35% of twin
77% of triplets
2. Polyhydramnios
Fetal anomalies
Atresias of the GIT, are the most common cause of
polyhydramnios: PTL.
Aboubakr Elnashar
12. IV. Cervical incompetence
Difficult diagnosis
Even a careful review of the clinical events: PTL
does not necessarily show correlation with the
aetiology.
Aboubakr Elnashar
13. V. Intercurrent illness
1. Serious infection:
Pyelonephritis, appendicitis and pneumonia
{direct blood-borne spread of infection to the uterine
cavity or
indirectly to chemical triggers, such as endotoxins
or cytokines}.
2. Other medical complications
cholestasis of pregnancy
3. Any surgical procedures
{mechanisms remain obscure.}
Aboubakr Elnashar
14. Often multifactorial
No risk factors in 50%
PTL is a “syndrome”
•Inflammation/Infection (40%)
•Maternal/fetal stress (25%)
•Uteroplacental ischemia (25%)
•Thrombophilia, decidual hemorrhage, abruption
•Abnormal uterine distension (10%)
Aboubakr Elnashar
15. RISK GROUPS
I. Major risk factors
1. Previous PTL.
After 1 PTL: risk 20%.
After 2 PTL: risk 40%
2· Uterine overdistension.
Multiple pregnancies
Polyhydramnios
Aboubakr Elnashar
16. 3. Uterine abnormalities.
Cone biopsy
LLETZ.
Surgical cervical dilatation
4. Malformed uterus
{cervical weakness},
although recent evidence suggests that
abnormalities of uterine vascularity may also playa
role.
Aboubakr Elnashar
17. 5. Fibroids
Controversial
considering their frequency, their influence is
probably minimal in the absence of cervical
involvement.
6. Factors in current pregnancy.
intercurrent illness
Surgery
recurrent vaginal bleeding.
Aboubakr Elnashar
18. II. Minor risk factors
A. Modifiable.
Smoking
low BMI
interpregnancy interval <1y.
B. Not modified
Maternal age (teenage)
Parity (nulliparous or grandmultiparous)
Ethnicity (black women)
Socioeconomic deprivation
Unemployment
low levels of education.
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20. I. Before pregnancy
1. Assessment and the events leading to their PTL
reviewed.
2. Management Plan for any subsequent
pregnancy
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21. II. During pregnancy
A. Prediction
1. Assessment of risk factors
2. Early dating scan
3. TVS: cervical length & dilatation
4. Foetal fibronectin in cervicovaginal secretions
5. Salivary oestriol, home uterine-activity monitoring and measurement of
plasma metabolites: not effective in routine clinical practice
Aboubakr Elnashar
22. 1. Assessment of risk factors:
Scoring systems e.g. Creasy score
Based on risk factors e.g.
PreviousPTD
Bleedingin pregnancy,
UTI
Higherorderpregnancies
BMI<20 kg/m2,
Stress(family illness,mortality,disruption,violence,or financial)
Do not identify the majority of women Limited
clinical use. have not proved helpful.
Aboubakr Elnashar
23. 2. Early dating scan
{To time subsequent investigations.
Ensures precise gestational age}
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24. 3. Cervical ultrasound
The risk of PTL is inversely related to cervical length
[C}
Not TAS:
{full bladder: false lengthening and can obliterate
gross funneling}.
TVS: more accurate than digital measurements
In asymptomatic women
11-20 mm: 4% risk
10 mm: 15% risk
<10 mm: dramatic increase in risk
Recommended
high risk asymptomatic at 22-24 w
Not for routine screening
Aboubakr Elnashar
25. 4. Cervlcovaginal fibronectin testing
Done after 23 w {high prior to this gestation, rarely present in vaginal
secretions between 23 and 34 w}.
fFN: glue-like ‘ protein binding the choriodecidual membranes.
Any disruption at the choriodecidual interface: fFN release
positive/ negative result.
Aboubakr Elnashar
26. Steps:
No Digital examination or lubricating jelly or Endocervical swabbing
The swab should be rotated in the posterior fornix for 15-20 secs
The test result should be read within 15 min
False-positive results
Sexual intercourse within 24 h.
Vaginal bleeding.
Aboubakr Elnashar
27. Interpretation
Positive at 24 w: 46% will deliver before 30 w: no proven treatment: several
groups are studying the potential role of antibiotics.
Negative: risk of PTL 1%: High negative predictive value to either withhold
treatments or optimize their timing.
Aboubakr Elnashar
28. B. Prevention
Before pregnancy:
1. Smoking cessation.
2. Dietician referral for women with a low BM.
4. Prevent multiple pregnancy
5. Leaving 12 months between pregnancies
During pregnancy
1. Detection and tt of vaginal and intrauterine
infection
2. Cervical cerclage
3. Progesterone
4. Life style modification
Aboubakr Elnashar
29. 1. Diagnosis and treatment of vaginal and
intrauterine infection
a. Bacterial vaginosis
{associated with an increased risk of PTL}
Diagnosis:
A vaginal swab is rolled on to a glass slide
Gram staining and microscopy: Nugent scoring.
Treatment:
Oral metronidazole: 5-7 days at standard doses
lowers the risk of PTL, by 60% [A}
{BV may reflect chronic intrauterine infection}
Vaginal clindamycin cream in BV-positive women :
an increase in PTL
{topical therapy adequately treats vaginosis, but fails
to affect pre-existing intrauterine infection}Aboubakr Elnashar
30. b. Asymptomatic bacteriuria
{increased risk of pyelonephritis in women
presenting with asymptomatic bacteriuria.}
Screening
Antibiotic treatment [A].
Aboubakr Elnashar
31. c. Group B streptococcal colonization (GBS)
{Preterm infants are more susceptible to early-onset
GBS infection, acquired during passage through the
birth canal}.
evidence that it is one of the major causal organisms
behind spontaneous prematurity: weak}
Screening
High risk group
combined low vaginal/rectal swab
Intrapartum prophylaxis
{1. antenatal antibiotics have not been shown to lower perinatal
transmission.
2. prophylactic treatment of GBS: increase in neonatal infections with
penicillin-resistant Escherichia coli.
3. antibiotics have the potential for harm}.
Aboubakr Elnashar
32. d. Other organisms
Chlamydia trachomatis,
Neisseria gonococcus and
Trichomonas vaginalis have been associated with
preterm delivery: a causal link has not been
established.
Treatment of chlamydia:
No decrease PTL
prevent perinatal transmission.
Treatment of chlamydia and gonococcus
include contact tracing and treatment of the partner.
Aboubakr Elnashar
33. 2. Cervical cerclage
Indication
1. 3 or more previous PTL and/or 2nd T losses.
2. History of one or more spontaneous mid-trimester
losses or preterm births +TVS: cervix is 25 mm or
less
Aboubakr Elnashar
34. 3. Progesterone supplementation
Indications: (ACOG 2008)
1. Singleton (not multiple) pregnancy and a history of
PTL < 37 w
2. Asymptomatic women with an incidentally
identified very short cervical length (< 15 mm)
Effect
reduce the incidence of PTL by 50%
Aboubakr Elnashar
35. Forms and Dose
I. Vaginally:
•Gel (Crinone 8%, 90 mg/day),
•Capsules (Uterogestan 200 mg twice daily)
•Suppositories (cyclogest 200 mg daily,
prontogest 200 mg daily)
from 22 - 34 w
II. IM:
•17-alpha-hydroxyprogesterone caproate weekly of
250-1000 mg, from 16-37 w
•Prontogest100 mg= Gestone
Aboubakr Elnashar
36. 4. Lifestyle modification
1. Stop smoking [C].
Hospitalization for bed rest: an increase in PTL
[A].
Sexual abstinence and/or psychological support:
should not be recommended as a universal or
general measure in high-risk women.
Aboubakr Elnashar
37. MANAGEMENT OF
SYMPTOMATIC WOMEN
Assessment:
A. Maternal
B. Foetal
Therapy
1. Corticosteroids
2. Tocolytics
3. Antibiotics
4. Emergency cerclage
5. In Utero transfer
6. Mode of delivery
7. Anathesia
Aboubakr Elnashar
38. I. Assessment
A. Maternal
Objective: chance of delivery within the next 7 d.
1. Low risk: Observation and review.
2. High risk: Treatment
Aboubakr Elnashar
39. History
Risk factors
Current symptoms
•low backache or cramping: often cyclical.
•Vague complaints: pelvic pressure or increased
discharge: common.
•Vaginal bleeding: should be taken seriously.
UC+ closed cx + bleeding
UC+ 2 cm cx dil
Risk of delivery within 7 days
Aboubakr Elnashar
40. Examination
Abdominal examination
uterine tenderness, suggesting abruption or chorioamnionitis.
Speculum examination
Pooling of amniotic fluid, blood and/or abnormal
discharge .
Visual assessment of cervical dilatation:
accurate as digital examination findings.
Aboubakr Elnashar
41. limit digital examinations
speculum assessment is inconclusive
{1. stimulate prostaglandin
2. introduce organisms into the cervical canal
3. Reduce latent interval before labour}.
Repeat vaginal examination
in 1-4 h (guided by the severity of the symptoms)
in the absence of secondary tests.
Aboubakr Elnashar
42. Investigation
1. Cervical length measurement
In symptomatic women:
Accepted safe length is 3 cm
Cx length > 3cm: No risk of PTL
Cx length <2cm: 70% will deliver PT
Aboubakr Elnashar
43. 2. Bedside fibronectin testing
:rapid assessment of risk in symptomatic women who do not have advanced
dilatation.
Igreater predictive value than digital examination.
30% of women with a positive fibronectin test delivered within 7 days, compared
with only 10% of women who were 2-3 cm dilated.
positive fibronectin test carries a risk of delivery within 28 days of up to 70%,
regardless of initial cervical length. Combination testing refines the prediction of
deliveries in the next 7 days.
positive fibronectin test but a normal cervical length, only 5% will deliver within 1
w.
However, if the cervix is also short when tested, the risk of delivery within 7
days climbs to 50%
This is particularly useful, as many interventions (tocolytics, steroids and in-
utero transfer) should be based on this end-point.
Aboubakr Elnashar
44. B. FETAL
1. CTG:
During pregnancy:
Maternal steroid therapy can suppress both fetal activity and heart
rate variability.
Interpretation: difficult
Applying criteria used at term is inappropriate.
Baseline rate is more important than either decelerations or
variability.
During labour:
Moderately PTL: no benefit from continuous as opposed to
intermittent monitoring [B]
Severe PTL: Decisions regarding monitoring must be discussed with
parents.
Intervention on the basis of FHR monitoring may not be justifiable
near the limits of viability.
Aboubakr Elnashar
45. 2. Umbilical artery Doppler
AED or RED: a short-term return of end diastolic flow is
commonly observed.
When labour has started or is thought to be imminent
3. US
a. Presentation
{clinical palpation is unreliable}
b. Fetal weight
Aboubakr Elnashar
46. II. THERAPY
1. Corticosteroids: RCOG,2011
When:
between 24 and 35 W
between 24 and 36 W (SFGA)
between 24 and 39 W (elective CS)
Dose:
Betamethasone: 12 mg given IM in two doses or
Dexamethasone: 6 mg given IM in four doses
Betamethasone Vs Dexamethasone:
No difference
improved neurological outcomes with betamethasone.
Aboubakr Elnashar
48. Single course
Harmful effects of repeated doses:
increased sepsis in PPROM
restricted fetal body and brain growth
adrenal suppression.
increased risk of neonatal death seen when 3 or
more courses of antenatal steroids
Aboubakr Elnashar
49. 2. Tocolytics: RCOG, 2011
Effect:
prolongation of pregnancy for up to 7 days
No significant effect on preterm birth
No clear effect on perinatal or neonatal morbidity.
Indication
1. Completing a course of corticosteroids
2. In utero transfer.
Maintenance therapy is not recommended.
Aboubakr Elnashar
50. Nifedipine Vs atosiban (Tractocil)
comparable effectiveness in delaying birth for up
to 7 days.
Price is 1/10
Nifedipin Vs Beta-agonists or indomethacin
improvement in neonatal outcome
fewer maternal adverse effects
less risk of rare serious adverse events.
Aboubakr Elnashar
51. Dose
Nifedipine:
Initial oral dose: 20 mg followed by 10–20 mg three
to four times daily, adjusted according to uterine
activity for up to 48 hours.
A total dose above 60 mg appears to be
associated with a three- to four-fold increase in
adverse events.
Atosiban
Initial bolus dose of 6.75 mg over 1 minute, followed by an infusion of
18 mg/h for 3 h, then 6 mg/h for up to 45 h (to a maximum of 330 mg).
Aboubakr Elnashar
52. Indomethacin:
orally or rectally.
50 to 100 mg is followed at 8-hour intervals not to
exceed a total 24-hour dose of 200 mg. or
50 mg Loading dose, then 25-50mg /6hs
Serum concentrations usually peak 1 to 2 hours
after oral administration, whereas levels after rectal
administration peak slightly sooner.
limited use to less than 72 h and only below 30 w
{oligohydramnios, it is reversible}
Aboubakr Elnashar
53. 3. Antibiotics
Uncomplicated PTL
no evidence of benefit
significant increase in the incidence of cerebral
palsy.
Preterm PROM
significant advantages
No increase in cerebral palsy in the long term
Erthryomycin
(250 mg qds for 10 d)
Aboubakr Elnashar
55. 4. Emergency cervical cerclage
Indication:
mid-trimester
minor symptoms (pelvic pressure, watery discharge
membranes bulging into the tipper vagina.
Contraindication:
1. symptomatic contractions
2. intrauterine infection: 10%of chorioamnionitis are
clinically obvious
Reassess the cervical dilatation after several hours. This can be precisely
and repeatedly measured using transperineal US.
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56. 5. In-utero transfer
To a unit with adequate neonatal facilities, where
these are not available in the admitting unit
improve outcome for babies.
Aboubakr Elnashar
57. 6. MODE OF DELIVERY
<26 W:
Vaginal delivery
{fetal morbidity and mortality, the difficulty in diagnosing intrapartum
hypoxia/acidosis and the maternal risk} do not justify
CS has not been shown to improve neonatal
outcomes}.
{As gestation advances, both neonatal outcomes and the ability to
diagnose fetal compromise improve, and intervention for fetal reasons
becomes universally appropriate}.
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58. Breech
CS
{an increased mortality and morbidity to the preterm breech born
vaginally. recent similar studies that conclude the opposite}.
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59. Type of CS
Membranes ruptured:
De Lee vertical lower segment
{At the earliest gestations, the lower segment is
poorly formed
does not appear to carry any greater risk than a
conventional transverse incision} [D].
Membranes intact:
Transverse incision
Aboubakr Elnashar
60. 7. ANALGESIA
Epidural
Benefits
1. Avoiding expulsive efforts before full dilatation or
a precipitous delivery, a relaxed pelvic floor and
perineum
2. Ability to proceed quickly to CS.
Narcotics
prolonged effects on a preterm infant with limited
metabolic capacity.
Aboubakr Elnashar
61. SUMMARY
Beneficial antenatal treatments for high-risk
women include
metronidazole for bacterial vaginosis
antibiotics for asymptomatic bacteriuria
cerclage for three or more 2nd T losses or PTL
progesterone supplementation.
Hospitalization for bed rest leads to an increase
in preterm births.
Aboubakr Elnashar
62. Tocolytics have no significant benefit on perinatal
mortality or the prolongation of pregnancy to term,
but do reduce the number of women delivering
within 48 hours by 40%.
There is no evidence of benefit and some
evidence of harm associated with the use of
antibiotics in uncomplicated preterm labour with
intact membranes.
Aboubakr Elnashar
63. In symptomatic women, the following factors are
associated with a high risk of delivery within 7
days:
cervical dilatation >3 cm,
ruptured membranes or
any vaginal bleeding.
A single course of maternal steroids given
between 24 and 35 w and received within 7 days of
delivery results in markedly improved neonatal
outcomes.
Aboubakr Elnashar
64. After the diagnosis of preterm labour
neonatology consultation,
fetal monitoring,
mode of delivery
intrapartum antibiotics if a known GBS carrier.
Aboubakr Elnashar