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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Preterm Labor and Preterm Premature Rupture of Membranes
Sponsored by The Indian Health Service Clinical Support Center
GUIDELINES FOR THE MANAGEMENT OF PRETERM LABOR
Definitions:
- Preterm Labor - regular uterine contraction after 20 weeks or before 37 weeks GA, which occur regularly, leading to progressive cervical change.
Associations with preterm birth:
- Preterm premature rupture of membranes (see below)
- Chorioamnionitis
- Fetal anomalies
- History of prior preterm labor
- Multiple gestation
- Polyhydraminos
- Intrauterine fetal demise
- Cervical insufficiency
- Uterine anomalies
- Placenta previa or abruptio placentae
- Retained IUD
- Serious maternal disease (e.g., preeclampsia )
- Cervical conization or L.E.E.P.
- Idiopathic
Preterm birth due to:
- PROM 35% of the time
- Maternal fetal complications 35%
- Idiopathic preterm labor 30%
Risks of reccurent preterm birth
- First Birth Second Birth Next Birth Preterm
term --------------- 5%
preterm --------------- 15%
term preterm 24%
preterm preterm 32%
Management:
- History of Preterm Labor with preterm delivery
- preconceptual counseling to eliminate risk factors, e.g., stop tabacco , alcohol , drugs, space pregnancies, good nutrition, normalize hypertension, stabilize maternal medical conditions, anticipate need for increased pregnancy surveillance and possibly prophylactic rest.
- early pregnancy care
- excellent dating by exam and early ultrasound
- urine culture x1
- identify and treat cervical or vaginal infection
- preterm labor education by qualified personnel by 20 to 23 weeks GA.
- intensive monitoring for signs and symptoms of recurrent preterm labor and/or asymptomatic cervical change
signs & symptons :
*increased vaginal discharge ;
*blood tinged mucus
*low backache
*pelvic pressure
*menstrual - like cramps
*intestinal cramping, with or without diarrhea
*”not feeling right”
*precocious cervical dilations (1 cm or more) - 1) lives in town: cervical exam 24-26 weeks
- lives outside of town: travel to town at 26 weeks GA, obtain cervico -vaginal swab for fetal fibronectin ( fFN ) (no lubricant, no coitus, no bleeding) (excellent negative predictive value-95%, poor positive predictive value-15%), perform cervical exam, transvaginal ultrasound for cervical length, and ultrasound for dating if not yet done.
- Cervix no change , in combination with negative fFN , and transvaginal ultrasound cervical length>2.5 cm- return to village, weekly radio monitoring for early signs and symptoms, transfer to town as needed
- Cervix changed, or transvaginal ultrasound cervical length <2.5 cm, or fFN positive- to remain in town for routine prenatal care, refer to Anchorage as needed
- If local resources do not permit, consider counseling the patient to remain in town regardless of cervical findings. Time of patient remaining in town should be based on prior time of preterm birth.
- History of preterm labor with Term Delivery- Same as 1.
- History of preterm labor due to prior maternal or fetal complications
- Reassess risk of recurrence -if prior preterm birth associated with nonrecurring condition, i.e. twins, preterm
birth risk probably same as “normal” singleton pregnancy. - Liberally consult ANMC OB-GYN to determine risk of recurrent preterm labor and management.
- Current preterm labor
- Obtain cervico -vaginal swab for fFN
- Review pregnancy dating
- Rule out maternal fetal complications before initiating tocolytic therapy
- obtain NST
- repeat U/S as needed to check fetal anatomy, size, amniotic fluid volume , and placentation ; obtain transvaginal ultrasound for cervical length
- monitor maternal status for infections, hypertensive disease, bleeding, etc.
- administer betamethasone 12 mg IM x2 doses 24 hrs apart
- if GA <32 weeks and true preterm labor ( cx change) and no oligohydramnios (AFI <8.0 or no pocket >2.0 cm) initiate tocolysis with indomethacin 100 mg po initially, followed by 50 mg po q6h to a maximum of 400 mg total.
- If GA 32-34 weeks, bolus with 500 mL lactated Ringer's and then initiate tocolysis with terbutaline 0.25 mg SQ and repeat q4h prn not to exceed 4 doses
- initiate group B strep prophylaxis: penicillin G 5 mullion units IV load, then 2.5 million units IV q4h until delivery. Because of concerns about the emergence of bacterial resistance, penicillin is the preferred drug, but as an alternative, ampicillin 2g IV initially, followed by 1g IV q4h until delivery is also acceptable (if not allergic to penicillin)
- Liberally consult ANMC OB - GYN consultant re: management or transfer
- Although preterm labor is defined as labor prior to 37 weeks, it has been the current practice to tocolyze and transfer patients only for true preterm labor at <35 weeks GA. This has been based on nursery care, facilities and neonatal outcomes.
- ANMC Practice Guidelines
- Current preterm labor
- Management same as above
- Preterm labour education while hospitalized
- Outpatient management if medical compliance assured. Social Service Mental Health, and Home Health Care consults may be appropriate.
- If discharged, the patient should be seen in clinic on a weekly basis. Symptoms and compliance are re-assessed at each visit and cervical exam is considered at each encounter. Preterm labor recommendations are maintained until 35 weeks GA.
- Patients referred in from outside the Anchorage Service Unit remain in town until preterm labor is resolved. They should not transfer back to their Service Unit until their delivery could be safely managed by their Level 1 Nursery, eg ., after 36 weeks. The patient should return to the Service Unit Hospital and not to their village. Notify referring provider prior to patients return to Service Unit.
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