PRETERM LABOUR & PREMATURE RUPTURE OF MEMBRANE DR. MASHAEL SHEBAILI DR. MASHAEL SHEBAILI CONSULTANT OB/GYN CONSULTANT OB/GYN ASSISTANT PROFESSOR ASSISTANT.

PRETERM LABOUR & PRETERM LABOUR & PREMATURE RUPTURE OF PREMATURE RUPTURE OF

MEMBRANEMEMBRANE

DR. MASHAEL SHEBAILIDR. MASHAEL SHEBAILI

CONSULTANT OB/GYNCONSULTANT OB/GYN

ASSISTANT PROFESSOR ASSISTANT PROFESSOR

Labour that occurs after 24 weeks Labour that occurs after 24 weeks but before 37 completed weeks,but before 37 completed weeks,

Although it has an incidence of Although it has an incidence of 10%,its contribution to neonatal 10%,its contribution to neonatal morbidity and mortality is high morbidity and mortality is high ranges from 50 – 70%.ranges from 50 – 70%.

Aetiology and Risk factorsAetiology and Risk factors

A] IdiopathicA] Idiopathic:: is the commonest one. is the commonest one.

Low socioeconomic class.Low socioeconomic class. Previous preterm labour. With one Previous preterm labour. With one

PTL the relative risk in the next PTL the relative risk in the next pregnancy is 3.9,it increases to pregnancy is 3.9,it increases to 6.5with two .6.5with two .

Repeated spontaneous abortions . Repeated spontaneous abortions .

B] Obstetrics causesB] Obstetrics causes::

1- Multiple pregnancy.1- Multiple pregnancy.

2- Premature preterm rupture of 2- Premature preterm rupture of membrane.membrane.

3- Genital tract infection as bacteria 3- Genital tract infection as bacteria vaginosis and B streptococcus.vaginosis and B streptococcus.

4- Cervical incompetence .4- Cervical incompetence .

5- Uterine anomalies.5- Uterine anomalies.

C] Iatrogenic causesC] Iatrogenic causes::

Induction of labour or CS.for Induction of labour or CS.for obstetrics causes as PET,PLACENTA obstetrics causes as PET,PLACENTA PREVIA and ABRUPTIO.PREVIA and ABRUPTIO.

DIAGNOSIS DIAGNOSIS

Documented uterine contractions.Documented uterine contractions.

Documented cervical changes as cervical Documented cervical changes as cervical effacement of 80% , or cervical dilatation effacement of 80% , or cervical dilatation of 2 cm or more.of 2 cm or more.

MANAGEMENTMANAGEMENT

Put the patient on CTG to confirm Put the patient on CTG to confirm uterine activityuterine activity

Assess cervical status, progress of Assess cervical status, progress of labour and presenting part.labour and presenting part.

Vaginal swab for bacteria vaginosis Vaginal swab for bacteria vaginosis and B streptococcus and give and B streptococcus and give antibioticantibiotic

Hydrate the patientHydrate the patient

TOCOLYTIC THERAPYTOCOLYTIC THERAPY

A] B-Adrenergic agonist (B-A] B-Adrenergic agonist (B-sympathomimetic agentsympathomimetic agent))

Mechanism:Mechanism: Convert ATP into cAMP in the cell Convert ATP into cAMP in the cell

causing decrease of the free calcium ioncausing decrease of the free calcium ion..

B-Adrenergic agonistB-Adrenergic agonist

Side effects :Side effects : Mainly cardiovascular as increased heart Mainly cardiovascular as increased heart

rate and hypotensionrate and hypotension Chest pain in 1-2% from myocardial Chest pain in 1-2% from myocardial

ischemia.ischemia. Rarely pul. Oedema particularly with Rarely pul. Oedema particularly with

concurrent corticosteroid therapy.concurrent corticosteroid therapy. Increased liver and muscle glycogenolysis Increased liver and muscle glycogenolysis

causing hyperglycaemia. 2nd increase in causing hyperglycaemia. 2nd increase in insulin cause hypokalaemia.insulin cause hypokalaemia.

Ritodrin hydrochloride (Yutopar)Ritodrin hydrochloride (Yutopar)

Magnesium sulphateMagnesium sulphate

Mechanism:Mechanism: Compete with calcium Compete with calcium for entry into the cell at the time of for entry into the cell at the time of depolarization so there is decrease of depolarization so there is decrease of intracellular calcium.intracellular calcium.

Side effect:Side effect: Warm and flushingWarm and flushing Respiratory arrestRespiratory arrest Fetal hypotonia due to decrease Fetal hypotonia due to decrease

calciumcalcium

Prostaglandin synthetase Prostaglandin synthetase inhibitorsinhibitors

Side effects:Side effects: Decrease fetal renal blood flow and cause Decrease fetal renal blood flow and cause

oligohydraminose.oligohydraminose. Premature closure of ductus arteriosus Premature closure of ductus arteriosus

which lead to pul. Hypertension.which lead to pul. Hypertension. Necrotizing enterocolitis.Necrotizing enterocolitis. Fetal intracranial hag. Fetal intracranial hag. Indomethacin is the most commonly used.Indomethacin is the most commonly used.

Calcium channel blockersCalcium channel blockers

Nifedipine:Nifedipine: Inhibits the inward Inhibits the inward current of calcium iron during the current of calcium iron during the 2nd phase of the action potential of 2nd phase of the action potential of uterine muscle uterine muscle

Side effectsSide effects::

1- Headache 2- Hypotension1- Headache 2- Hypotension

3-Flushing 4- Tachycardia3-Flushing 4- Tachycardia

Oxytocin AntagonistOxytocin Antagonist

Side effects:Side effects:

Nausea, dizziness, headache, and Nausea, dizziness, headache, and flushing.flushing.

Expensive drug.Expensive drug. Atosipan ( tractocil )Atosipan ( tractocil )

CONTRAINDICATIONS TO CONTRAINDICATIONS TO TOCOLYTIC THERAPYTOCOLYTIC THERAPY

1.Severe PET1.Severe PET 2.IUGR 2.IUGR

3.Severe APH3.Severe APH 4.Fetal anomalies 4.Fetal anomalies

5.Chorioamnionitis 6.Maternal heart 5.Chorioamnionitis 6.Maternal heart diseasedisease

CORTICOSTEROID THERAPYCORTICOSTEROID THERAPY

reduces mortality, incidence of RDS, and reduces mortality, incidence of RDS, and intracranial hage.intracranial hage.

stimulate pnemocyte 2 cell to produce stimulate pnemocyte 2 cell to produce surfactantsurfactant

statistically sig.effect up to 34 weeks.statistically sig.effect up to 34 weeks.

betamithasone IM 12 mg given twice 24 h. betamithasone IM 12 mg given twice 24 h. apart.apart.

optimal benefit is from 24h – 7 days.optimal benefit is from 24h – 7 days.

LABOUR AND DELIVERYLABOUR AND DELIVERY

should be in a well equipped center should be in a well equipped center with good SCBUwith good SCBU

continuous fetal monitoringcontinuous fetal monitoring

forceps and episiotomy for cephalic forceps and episiotomy for cephalic presentationpresentation

?? C.S. for breeches if wt. is less C.S. for breeches if wt. is less than 1500 gms.than 1500 gms.

Premature Rupture of Premature Rupture of MembraneMembrane

Rupture of the membrane before the Rupture of the membrane before the onset of labour at any stage of onset of labour at any stage of gestation.gestation.

CAUSESCAUSES

In majority of cases no clear cause In majority of cases no clear cause can be found.can be found.

Vaginal infection ,bacteria vaginosis Vaginal infection ,bacteria vaginosis and group B streptococcus.and group B streptococcus.

Cervical incompetence.Cervical incompetence. Abnormal membrane.Abnormal membrane.

DIAGNOSISDIAGNOSIS History of fluid loss per vagina.History of fluid loss per vagina. Visualization of amniotic fluid in the vagina Visualization of amniotic fluid in the vagina

by by sterilesterile speculum. speculum. +Ve NITRAZIN test .Alkaline amniotic fluid +Ve NITRAZIN test .Alkaline amniotic fluid

turns yellow nitrazin reagent to blue turns yellow nitrazin reagent to blue colour. Blood, cervical mucus and alkaline colour. Blood, cervical mucus and alkaline urine give false +ve results.urine give false +ve results.

+ve fern test.+ve fern test.

USS : Marked decrease or absent USS : Marked decrease or absent liquor .liquor .

USS : Confirm gestation age and USS : Confirm gestation age and exclude fetal anomalies.exclude fetal anomalies.

COMPLICATIONSCOMPLICATIONS

1- 1- Premature labourPremature labour: Amniotic fluid : Amniotic fluid contains prostaglandins.contains prostaglandins.

2-2- Chorioamnionitis Chorioamnionitis :The amniotic fluid :The amniotic fluid has bacteriostatic properties and acts as a has bacteriostatic properties and acts as a mechanical barrier against infection.mechanical barrier against infection.

3- 3- Fetal sepsisFetal sepsis..4- 4- Lung hypoplasiaLung hypoplasia if occurs before 24 if occurs before 24

weeks.weeks.

MANAGEMENTMANAGEMENT

The management depends mainly on The management depends mainly on the gestation age:the gestation age:

A] 36 weeks or more A] 36 weeks or more IOL. IOL.

B] < 36 weeks expectant B] < 36 weeks expectant management, unless there management, unless there evidence of chorioamnionitis.evidence of chorioamnionitis.

CHORIOAMNIONITISCHORIOAMNIONITIS

1.1. Maternal pyrexia >38 C.Maternal pyrexia >38 C.

2.2. Tender irritable uterus.Tender irritable uterus.

3.3. Foul smelling vginal discharge.Foul smelling vginal discharge.

4.4. Fetal tachycardia.Fetal tachycardia.

EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT

Rest in hospital.Rest in hospital. Early detection of Chorioamnionitis Early detection of Chorioamnionitis

(immediate delivery) by twice weekly (immediate delivery) by twice weekly WBCS.and C reactive protein.WBCS.and C reactive protein.

High vaginal swab for culture.High vaginal swab for culture. Prophylactic antibiotics for 10 days.Prophylactic antibiotics for 10 days.

Rule of tocolytics:Rule of tocolytics:1- Allow time for corticosteroids to work.1- Allow time for corticosteroids to work.

2- Contraindicated in the presence of 2- Contraindicated in the presence of infection.infection.

Rule of corticosteroids:Rule of corticosteroids:1- Significant value for pregnancy less than 1- Significant value for pregnancy less than

34weeks.34weeks.

SURFACTANTSURFACTANT

Produced by pnemocyte type 2 cells.Produced by pnemocyte type 2 cells. Consists mainly of phospholipids, Consists mainly of phospholipids,

neutral lipids, proteins and neutral lipids, proteins and carbohydrates.carbohydrates.

Measured as a ratio (lecithin / Measured as a ratio (lecithin / sphyngomyelin) mature lung >2.sphyngomyelin) mature lung >2.

Decreases alveolar surface tension, Decreases alveolar surface tension, maintains alveoli open at a low maintains alveoli open at a low internal alveolar diameter and internal alveolar diameter and decrease intra alveolar fluid.decrease intra alveolar fluid.

THANK YOUTHANK YOU