Department of Obst.

& Gynae
G.R. MEDICAL COLLEGE, GWALIOR

SEMINAR PRESENTATION

MANAGEMENT OF
PRETERM LABOUR
Chairperson Guide
Prof. Dr. (Mrs.) V. Agrawal Prof . & Dr J Bindal
Prof. & HOD of Obst. & Gynae Department of Obst. & Gynae
G.R. Medical College Gwalior G.R. Medical College Gwalior

Presented by
Dr. Divya Kakrani
IIIrd Year R.S.O. Obst. & Gynae
MANAGEMENT OF PRETERM
LABOUR
 DEFINITION
 PREERM BIRTH-

CAUSES &
OUTCOME
 PREDICTION
 ANTECEDENT

FACTORS
 PREVENTION
 TREATMENT
 DEFINITION

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
 ACOG CRITERIA
to document PRETERM LABOUR
 Contraction of four in 20 min, or 8in 60 min
plus progressive change in cervix
 Cervical dialatation greater than 1cm
 Cervical effacement of 80% or greater

@Such explicit criteria do not appear in more

recent guidelines (ACOG 2008)
MORBIDITY IN PRETERM INFANTS

LATE PRETERM INFANTS SMALL PRETERM INFANTS

34-36 WKS <34WKS
(71.2% of all preterm births) LONG TERM SEQUELAE
PRESENT
THRESHOLD OF VIABLITY
 26 WKS OR 750GM –current threshold
 Not appropriate to initiate resusitation in

MGA <23 wks

CAUSES OF PRETERM DELIVERY
 Induced labour or prelabour caesarian- for
maternal and foetal indications
 Spontaneous unexplained preterm labour

with intact membranes

 Idiopathic preterm premature rupture of

membranes(PROM)
 Twins and high order births
 Drugs like cocaine or methamphetamine
 Uterine and cervical causes-fibroid uterus,

abnormal shape of uterus,thin cervix

Causes for preterm birth
MEDICAL AND OBSTRETIC
INDICATIONS
 Large for gestational age
 Preeclampsia
 Fetal distress
 IUGR
 Placental abruption
 Others-chronic hypertension, placenta previa,

unexplained bleeding, diabetes, renal

disease, Rh incompatiblity and congenital
malformations
SPONTANEOUS PRETERM LABOUR
 PROGESTERONE WITHDRAWL-reversal of
estrogen progesterone ratio. Serum
progesterone conc do not fall
 OXYTOCIN INITIATION- serum conc doesn’t

change, so unlikely cause

 INFLAMMATORY DECIDUAL REACTION
 INFECTION-
Microbes involved are-
-ureaplasma urealyticum
-mycoplasma hominis
-nisseria gonorrhoea
-group B streptococci
-trichomonas vaginalis
PROM AND PPROM
Rupture of membranes prior to 37 wks
Can preterm
labor be
predicted?
 Prediction of preterm labor
1. Risk markers
2. Home uterine activity monitoring (HUAM)
3. Salivary estriol
4. Screening for bacterial vaginosis (BV)
5. Screening for fetal fibronectin (fFN)
6. Cervical ultrasonography (cervical length
assessment
Risk markers

 A previous history of preterm labor is the

strongest risk marker
Risk markers
 Other risk markers include multiple pregnancy
 Cigarette smoking, cervical incompetence or uterine
anomalies,
 uterine over-distension (polyhydraminos,
macrosomia, fibroids),
 previous cervical surgery , using smokeless tobacco ,
 bleeding in early pregnancy , bacterial vaginosis,
poor socioeconomic
 or educational status, and young or advanced
maternal age.
 Antiphospholipid syndrome
Home uterine activity monitoring
(HUAM)
 HUAM is based on the principle of
tocodynamometry
 Telemetric recording of uterine contractions

and transmission to a monitoring center and

daily feed back from healthcare practitioner
 Not useful so not recommended in routine

practice (ACOG 1995)

Salivary estriol
 Premature activation of HPA axis in preterm
labor may increase the serum and salivary
levels of estriol in the mother.
 Very poor sensitivity and specificity and has a

very high false positive rate

 Diurnal variation of the maternal salivary

estriol level
 Administration of betamethasone to effect

surfactant production may suppress maternal

salivary estriol levels
 BACTERIAL VAGINOSIS

- Normal hydrogen peroxide producing ,

lactobacilli predominant vaginal flora is
replaced by anaerobes –Gardenella vaginalis
, mobiluncus sp , mycoplasma hominis.
- Chronic stress n frequent douching
predispose
- antibiotics not helpful in preventing PTL

#NUGENT SCORE- relative concentrations of

above mentioned phenotypes are studied in
a gram stained smear
Screening for bacterial vaginosis (BV)
 Fishy odour when mixed with 10% KOH
AMINE TEST / WHIP TEST.
 pH of vaginal discharge more than 4.5
 Presence of clue cells on smear.
 Treatment does not alter preterm birth
 Screening routinely not recommended (ACOG

2001)
Screening for fetal fibronectin (fFN)
 Basement membrane protein produced by the
hepatocytes , fibroblasts , endothelial cells , fetal
amnion and functions as an ‘adhesion binder’.
 attachment of the placenta and membranes to the

uterine decidua
 Present in maternal blood and amniotic fluid
 Normally detectable in cervical secretions until 16-

20 weeks of gestation.
 After 24 weeks (>50 ng/ml ) of gestation may

indicate disruption of the normal adhesion

between chorioamnion and the underlying decidua.
 CERVICAL CHANGES
 Mean cervical length at 24 wks is approx
35mm
 Women with progressively shorter cervix

predisposed to PTL.
 Funneling of cervix if present increases risk
ANTECEDANTS AND CONTRIBUTING
FACTORS
 THREATENED ABORTIONS
 LIFESTYLE FACTORS-smoking , inadequate maternal
wt gain , illicit drug usage
 WORK DURING PREGNANCY- only long and hard
physical labour are associated
 GENETIC FACTORS
 PERIODONTAL DISEASE-chronic anaerobic inflammation of
gums,
 BIRTH DEFECTS
 INTERVAL BETWEEN PREGNANCIES- smaller intervals more
associated
 PRIOR PRETERM BIRTHS
PREVENTION OF PRETERM BIRTH
 PROGESTERONE
 Weekly im injections reduce PTL.
 Daily 100mg progesterone suppositories

reduce PTL in women with prior PTL or

circlage or uterine malformation.
 Vaginal progesterone gel not useful in women

with prior PTL

 Efficacy in nulliparous with short cervix is

under way.
17 Hydroxy -Progesterone Caproate

Prophylactic use of 17 hydroxy

progesterone caproate to prevent
preterm labor revealed a
significant decrease in preterm
birth .
However, it has not successfully
inhibited active preterm labor.
PREVENTION
 PRECONCEPTIONAL n DURING PREGNANCY-
decreasing work hours’standing <6hr per day
 Vitamin supplementation-calcium supp

decreases PTL
 Smoking cessation
 Self monitoring of vaginal pH and yoghurt

treatment
Cervical circlage
 For cervical insufficiency which complicates
0.1-2% of all pregnancies and is responsible
for 20% of late 2nd trimester losses

 Prophylactic circlage – 12-14wks. Not much

fruitful.

 Rescue circlage – when cvx changes already

detected
 Efficacy seen in women with prior PTL
Treatment
Inhibition of labor
 Corticosteroid
 Antibiotics
Others.
Inhibition Of Labor
Bed rest :DVT
Hydration

&sedation
 Tocolytics
Hydration
 Intravenous hydration does not
seem to be beneficial, even during
the period of evaluation soon after
admission,
 Women with evidence of

dehydration may, however, benefit

from the intervention.
Is Tocolysis Better Than No Tocolysis
For Preterm Labour?
 It is reasonable not to use tocolytic drugs,
as there is no clear evidence that they
improve outcome. However, tocolysis
should be considered if the few days gained
would be put to good use, such as
completing a course of corticosteroids, or in
utero transfer
Choice Of Tocolytic Drug
B –Sympathomimetic
(Ritodrine)
Magnesium sulphate
Indomethacin
Nifedipine
atosiban
Most authorities do not
recommend use of tocolytics
at or after 34 weeks' .
There is no consensus on a
lower gestational age limit for
the use of tocolytic agents.
Choice Of Tocolytic Drug
If a tocolytic drug is used, ritodrine no
longer seems the best choice.
Atosiban or nifedipine appear
preferable as they have fewer adverse
effects and seem to have comparable
effectiveness.
 MgSO4 Terbutaline Indocin Nifedipine

Class Β-agonist Cox inhibitors CCB

Action Competes for ↑ cAMP ↓ PGD Block Ca

Ca ↓ intracellular production influx
Ca
Side Effect Pulm edema, Tachy, ↓BP, N/V, gastritis, ↓BP, reflex
? ↑ ped M&M palp, ↓K, narrowing of tachy, ? ↓ of
pulm edema DA, oligo blood flow
Efficacy Not very No ↓ of PTB Appears to ↓ # of women
good! @ 7 days, sx be more giving birth at
relief effective than 7 days
placebo
 Magnesium Sulfate
Magnesium sulphate is ineffective at
delaying birth or preventing preterm
birth, and its use is associated with
an increased mortality for the infant.
@ Neuroprotective for foetus-
decreses chances of cerebral palsy
Nitric Oxide Donors
There is insufficient evidence to
support the routine
administration of nitric oxide
donors (nitroglycerin )in the
treatment of preterm labor.
Side effect- Maternal hypotension
Indomethacin
Indomethacin can be
used as a second-line
tocolytic agent in early
gestational age
preterm labors.
Indomethacin
Indomethacin therapy for
< 48 hours
< 30-32 weeks' gestation)
Not > 200mg/day.

appears to be a relatively safe

and effective tocolytic agent
Indomethacin
Indomethacin may be a
first-line tocolytic in:
Associated

polyhydramnios :
( to have renal effects
of indomethacin)
Indomethacin
Capsule 25mg oral
Amp 50mg
Rectal Supp 100 mg

50 mg Loading dose
Then 25-50mg /6hs
Indomethacin
Fetal risk:
Premature closure of the ductus.
Renal and cerebral

vasoconstriction.
Necrotising enterocolitis

Common with high dose and

prolonged exposure.
Atosiban: Tractocil
Atosiban, a synthetic
peptide, is a
competitive antagonist
of oxytocin at uterine
oxytocin receptors.
Atosiban: Tractocil
Atosiban - compared with beta-
agonists- has:
Little difference in the effect of these agents on
delayed delivery
Fewer maternal adverse effects than beta-
agonists, such as chest pain, palpitations ,
tachycardia , hypotension , dyspnoea ,vomiting ,
and headache.
Nifedipine
Nifedipine- compared with ritodrine -
has:
Higher delaying of delivery for >48 H.
Lower risk of RDS &Neonatal jundice.
Lower admission to NN ICU
Fewer maternal adverse effects
Nifedipine
20mg initial
10-20 mg /4-6 h
Epilate capsule :10mg

Epilate retard Tablet: 20 mg

Nifedipine
When tocolysis is indicated for women in
preterm labor, calcium channel blockers are
preferable to other tocolytic agents
compared, mainly betamimetics.
Further research should address the effects of
different dosage regimens and formulations
Contraindications to Tocolysis for
Treatment of Preterm Labor

 General contraindications
 Acute fetal distress (except intrauterine

resuscitation)
 Chorioamnionitis
 Eclampsia or severe preeclampsia
 Fetal demise (singleton)
 Fetal maturity
 Maternal hemodynamic instability 
Contraindications for specific tocolytic
agents
Beta-mimetic agents
 Maternal cardiac rhythm disturbance or other cardiac
disease

 Poorly controlled diabetes, thyrotoxicosis or
hypertension

Magnesium sulfate

 Hypocalcemia

 Myasthenia gravis

 Renal failure
Indomethacin (Indocin)
 Asthma
 Coronary artery disease
 Gastrointestinal bleeding (active or past history)
 Oligohydramnios

 Renal failure
 Suspected fetal cardiac or renal anomaly

Nifedipine (Adalat, Procardia)

 Maternal liver disease
Potential Complications of Tocolytic
Agents

 Beta-adrenergic agents 
Hyperglycemia 
Hypokalemia 
Hypotension 
Pulmonary edema 
Cardiac insufficiency 
Arrhythmias 
Myocardial ischemia 
Maternal death

 Magnesium sulfate 
Pulmonary edema 
Respiratory depression
Cardiac arrest
Maternal tetany 
Profound muscular paralysis 
Profound hypotension
 Indomethacin (Indocin) 


Hepatitis
Renal failure 
Gastrointestinal bleeding
 Nifedipine (Adalat, Procardia) 


Transient hypotension
B -Sympathomimetic Agents.
 Maternal: pulmonary edema,
myocardial ischemia, arrhythmia, and
even maternal death.
 Fetal : arrhythmia, cardiac septal

hypertrophy , hydrops, pulmonary

edema, and cardiac failure.
hypoglycemia, periventricular-
intraventricular hemorrhage, and fetal
and neonatal death. .
 Maintenance Tocolysis Is Not
Recommended For Routine
Practice in threatened PTL.
Corticosteroids
The optimal treatment-delivery
interval for administration of
antenatal corticosteroids is after
24 hours but < 7 days after the
start of treatment.
Decreses RDS , IVH.
Corticosteroids
Two 12 mg doses of betamethasone given IM
24 hours apart, Or
Four 6 mg doses of dexamethasone given IM
12 hours apart (I-A).
There is no proof of efficacy for any other
regimen.
Antibiotics
There is no evidence of
clear overall benefit from
prophylactic antibiotics for
preterm labour with intact
membranes on neonatal
outcomes.
Screening for GB Strep.
ACOG Advises
Screening All
Pregnant Women
for Group B Strep.
Group B Streptococci (GBS) Prophylaxis

All patients in preterm labor

are considered at high risk
for neonatal GBS sepsis and
should receive prophylactic
antibiotics regardless of
culture status.
Group B Streptococci (GBS) Prophylaxis

The goal of this

strategy is to prevent
neonatal sepsis, and
not to prevent preterm
birth.
 Prophylactic Vitamin K Or
Phenobarbital
Have not been shown to
significantly prevent
periventricular
haemorrhages in preterm
infants.
Conclusions
Various strategies that have been
used to prevent or treat preterm
labor, haven't proven effective.

Tocolysis should be considered only for

2 days- if needed - for corticosteroids
thereby , or in utero transfer to a
tertiary center .
Conclusions
If a tocolytic drug is used,
ritodrine no longer seems
the best choice.
Conclusions
Other drugs with fewer adverse effects and
comparable effectiveness are now
recommended
Atosiban or nifedipine have been
recommended by RCOG
Indomethacin may be used as a 2nd line
tocolytic or if there is polyhydramnous
Conclusions
Maintenance tocolytic
therapy has no proven
effect.
It cannot be recommended
for routine practice.
PSCHYCOSOCIALSUPPORT
AND COUNCILLING FOR
NEXT PREGNANCY
NEWER DEVELOPMENTS

 CARBON MONOOXIDE
 HUMAN GONADOTROPIN
Thank You