Preterm labor resident survival guide

Preterm labor Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Dos
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords:Preterm delivery, Premature labour, Early delivery, Premature birth, Premature labor, Pre term birth

Causes

Intra-amniotic infection so far has only been shown to cause preterm delivery. The other factors are being associated based on reports by clinical, epidemiologic, placental pathologic, or experimental studies.Intra-amniotic infections can be subclinical. One in four preterm infants are born due to this cause.

• Infection:
  • The most frequent route is the ascending pathway, but hematogenous dissemination can occur.
  • Microorganisms are recognized by pattern recognition receptors, such as toll-like receptors (TLRs)
  • TLRs stimulate the production of chemokines (IL-8, C-C motif ligand 2 (CCL2), etc.), cytokines (IL-1b, TNF-a, etc), prostaglandins and proteases which activate the quiescent myometrium and stimulates parturition.
  • In 30% of cases of intra-amniotic infection, bacteria can be found in the fetal circulation which causes fetal systemic inflammatory response. These fetuses are at risk for long-term complications, such as cerebral palsy and chronic lung disease, which emphasizes that these complications may not only occur due to immaturity but also inflammatory response.
• Uterine over distension
• Decidual senescence
• Vascular disorders
• Stress
• Cervical disease
• Decline in progesterone action
• Breakdown in maternal-fetal tolerance.
• Placental abruption, Placenta previa
• Smoking
• Maternal age <18 or >40
• Poor nutrition, low body mass index
• Fetal anomaly
• Fetal growth restriction, oligohydramnios, polyhydramnios
• Vaginal bleeding
• Premature preterm rupture of membranes (PPROM)
• Environmental factors

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Preterm labor:

Abbreviations: BP: Blood pressure; RR=Respiratory rate; HR=Heart Rate, PROM= Premature rupture of membranes; AFV= Amniotic fluid volume

Pregnant woman comes with Preterm labor

Take complete history

Record the vitals: ❑ Blood pressure ❑ Temperature ❑ Respiratory rate ❑ Heart rate

Take obstetric history : ❑ Date of last menstrual period? ❑ Estimated date of delivery. ❑ Confirm the gestational age, gravidity and parity. ❑ Check if this is a single or multiple gestation.

Ask about previous obstetric history if she was previously pregnant : ❑ Ask about previous pregnancies including miscarriages and terminations. ❑ Length of gestation. ❑ Ask about mode of delivery. ❑ Ask if there was similar complaints during previous pregnancy? ❑ Was there any complications throughout the pregnancy or during delivery such as shoulder dystocia, postpartum haemorrhage ?

Ask the following questions about menstrual history : ❑ Age of menarche ❑ Last menstrual period ❑ Is the menstrual flow normal? How many pads she has to use in a day? ❑ Is there any foul smell or colour change? ❑ How many days does the menstruation stay? ❑ Contraceptive history for example oral contraceptives, intrauterine device

Perform physical examination : ❑ A physical exam is done to assess firmness, abdominal tenderness, fetal size, and position. ❑ Perform cervical exam to identify asymptomatic cervical dilatation and effacement. ❑ Regular contractions before term gestational age associated with cervical change, pelvic pressure, menstrual like cramps, watery vaginal discharge, and lower back pain. ❑ Lower back pain is present in normal pregnancy but if it occurs before term, it might be associated with impending preterm labor. ❑ If cervical dilatation is at least 2 or 3 cm at less than 34 weeks, then the patient is highly likely to deliver preterm. ❑ Transvaginal ultrasound may show short cervix( cervical length <25mm at 16-24 weeks of gestation).It can help to distinguish cervical effacement due to cervical insufficiency versus due to active labor.

Do the following tests: ❑ If there is any suspicion about PROM: perform speculum examination to visualize amniotic fluid passing from the cervical canal and pooling in the vagina. Fern and pH testing of the pooled vaginal secretions can indicate rupture of membranes. The PH of amniotic fluid is 7.1 to 7.3. ❑ Fetal fibronectin test: Due to the breakdown of the cervical extracellular matrix, fetal fibronectin in released. It is specific but not a sensitive test. If the result is negative, it is strongly indicates that of an intact membrane, but if positive, it does not necessarily indicative of premature rupture of membranes. ❑ Rectovaginal group B streptococcal culture should be done. ❑ Urine drug screen if mother has history of drug abuse. ❑ A urine culture because asymptomatic bacteriuria increases the risk of preterm labor. ❑ Tests for sexually transmitted infections

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Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Dos

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

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