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.

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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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