PRETERM

LABOR GROUP 2
Interns: Dr. Nikki Jill N. Bearis and Dr. Rosangela de Leon

Clerks
Cariño, Shaira; Carpio, Gabrielle; Celso, Karren;
Corral Bernadette Fatima, Descalzo, Regine Bernadette
Conde, Ma. Thelma Precy; Cosa, Michael Angelo; Karan Thakkar;
Kumar, Suraj; Mandaliya, Ajaybhai; Suruchi Dhillon; Singh, Priya;
Punadiya, Arati
IDENTIFYING
DATA

S.P. 15 y/o
CHIEF
COMPLAINT
● G1P0 labor pain
● 26 4/7 wks AOG
● Single
● Roman Catholic
● Marigondon,
Pio Duran
HISTORY OF
PRESENT
PREGNANCY

PRE NATAL CHECK UP:

2 times Barangay Health Center
LMP: OCT. 10, 2020 SUPPLEMENTS/MEDICATIONS:
AOG: 26 4/7 WEEKS FESO4 + Folic Acid (Nov - March)
EDD: JULY 29, 2021 Multivitamins (Nov - Dec)
IMMUNIZATION: TETANUS TOXOID (1 DOSE)
ULTRASOUND: none
Few hours
5 months PTA, 2 months PTA, PTA,
1st prenatal checkup at 2nd prenatal checkup at BHC. 4 days PTA, (+) labor
the barangay health Reported dysuria and was Few weeks PTA, half a spoon of pains lasting
center. Prescribed with diagnosed with UTI. Prescribed went to a “hilot” greenish discharge, for few
FeSO4 and Folic Acid with unrecalled antibiotics taken (“para maitaas si non-foul smelling seconds
(4 months), and for 10 days with relief of baby”). No other and vulvar itching. every 30
multivitamins symptoms. No fever, no complaints No consult done. No mins; hence,
(1 month). abdominal, flank or back pain. thereafter. meds taken. admission.
 OBSTETRIC
HISTORY

G1P0

# of Year T/P/A Delivery Live/Aborted/Still Complicati Gender

pregnancy birth ons

1 Present Preterm NSD Live - Male

(expired after ≅ 3 h)

4
PAST MEDICAL
HISTORY:

(-) asthma
(-) hypertension
(-) blood dyscrasia
(-) rheumatic heart disease
(-) history of drug allergy
(-) previous surgery

(+) UTI - February

took unrecalled antibiotics for 10 days

5
FAMILY HISTORY:

● (+) Hypertension - Mother

● (+) Asthma - Brothers

6
PERSONAL AND SOCIAL
HISTORY:

EDUCATIONAL ATTAINMENT: HIGH SCHOOL

OCCUPATION: STUDENT
NON ALCOHOLIC BEVERAGE DRINKER, NON
SMOKER,
(+) SECONDHAND SMOKING exposure because of
her partner
(-) ILLICIT DRUG USE

Lives with her 23-year old partner who works as a

fisherman in a well-ventilated concrete house in a
7
slightly congested area. Source of drinking water is
SEXUAL HISTORY:

● COITARCHE: 15 years old

● # of SEXUAL PARTNERS: 2

● CONTRACEPTIVE: None

● HISTORY OF SEXUALLY TRANSMITTED

INFECTIONS: None
8
MENSTRUAL
HISTORY:

● MENARCHE: 12 YEARS OLD

● INTERVAL: Regular (28-30 days)
● DURATION: 4-7 days
● AMOUNT: 8 pads, moderately soaked
● SYMPTOMS: dysmenorrhea

9
 REVIEW
OF
SYSTEMS

GENERAL: HEENT: RESPIRATORY:

(-) fever (-) hearing loss (+) cough (-)
(-) weight loss (-) eye discharge
(+) Itching inner
difficulty of
(-) nasal discharge breathing
thigh (-) loss of smell
 REVIEW
OF
SYSTEMS

GIT: GUT:
CARDIOVASCULAR: (-) diarrhea (+) frequent
(-) easy fatigability (-) constipation urination
(-) palpitations (+) Abdominal pain (-) no bloody urine
 REVIEW
OF
SYSTEMS

MUSKULOSKELETAL: CNS: HEMATOLOGY:

(-) no joint pains (-) LOC (-) easy bruising
(-) leg cramps (-) numbness
 PHYSICAL
EXAMINATION
 PHYSICAL
EXAMINATION GENERAL SURVEY

Alert, awake,
not in cardiorespiratory distress

VITALS
BP: 100/60 mmHg HR: 114 bpm RR: 22cpm

T: 36.4℃ O2: 98%

HEIGHT / WEIGHT

133.5cm / 44 kg
BMI: 24.6
(NORMAL)
PHYSICAL EXAMINATION

HEENT
Anicteric sclerae, Pink palpebral conjunctiva, no eye discharge, pink nasal mucosa,
septum midline, no discharge, pinna complete, no bleeding nor discharge, no
cervical lymphadenopathy

CHEST AND LUNGS

Symmetrical chest expansion, no retractions, Breast engorged, lung sound

clear, no wheezes nor crackles

HEART
Adynamic precordium, tachycardia, no murmur. no heaves nor thrills, PMI at 5th
ICS MCL
 PHYSICAL
EXAMINATION

ABDOMEN
No scars, lesions.
Normoactive bowel sounds,
soft non tender
FH: 19cm FHT: 130s bpm
 PHYSICAL
EXAMINATION

NEURO EXAM
Mental Status: Alert, relaxed, cooperative
Cranial Nerves: Intact

5/5 5/5 100 100

5/5 5/5 100 100

 PHYSICAL
EXAMINATION

PELVIC EXAM
Normal external genitalia, parous
Cervix 3cm dilated; 80% effaced
Intact bag of water
Breech
Station -3
LABORATORY AND
DIAGNOSTICS CBC

PARAMETERS RESULT REFERENCE RANGES

WBC 16.66 4 - 10
RBC 4.54 4 - 5.4
Hemoglobin 134 120 - 160
Hematocrit 0.41 0/37 - 0.43
MCV 91.3 80 - 96
MCH 30 28 - 33
MCHC 32 33- 36
Platelet 245 150 - 400
Neutrophil 88 50 - 70
Lymphocytes 6 20 - 40
Monocytes 5 3 - 12
Eosinophil 1 0.5 -5
Basophils 0 0-1
RDW 11 10 - 35
MPV 8.60 6.1 - 8.9
LABORATORY AND
DIAGNOSTICS

URINALYSIS

Color pH Pus Cells Epithelial Cells

Light Yellow 6.5 12 - 22/hpf Moderate
Slightly Turbid 1.025 3-6/hpf Few
Transparency Specific Gravity RBC Bacteria

Negative Protein
Negative Glucose
LABORATORY AND
DIAGNOSTICS

Blood Type: O Positive

HBsAg: Non-reactive

RPR: Non-reactive
SALIENT
FEATURES

● 15 y/o ● (+) UTI, February 2021, treated with unrecalled

● Senior high school antibiotics for 10 days
● G1P0 ● Medications:
● (+) labor pain ○ Fe SO4 + Folic Acid (4 months)
● 4 days PTA, non-foul smelling, greenish ○ Multivitamins (1 month)
discharge ● IE:
○ Normal external genitalia, parous
● LMP: Oct. 10, 2020 ○ Cervix 3cm dilated
● AOG: 26 4/7 weeks ○ 80% effaced
● EDD: July 29, 2021 ○ Intact bag of water
● 2 PNCU at a barangay health center ○ Breech
● (+) 2nd hand smoking exposure ○ Station -3
● (+) History of external manipulation
 Differential
Diagnosis
Preterm Labor with Intact
Membrane
Preterm Premature Rupture of
Membrane (PPROM)
Abruptio placenta
Rule in Rule out
26 4/7 weeks AOG Cannot be totally ruled
Painful regular uterine contraction out
Cervical change (3 cm dilated, 80%
effaced)
History of UTI
(+) external manipulation
Intact BOW
24 4/7 weeks AOG Intact BOW
Labor pain (-) smoking
Regular uterine contraction
Cervical change
Abdominal Pain, Back pain (-) vaginal bleeding
History of manipulation (-) uterine tenderness
Admitting
Diagnosis

G1P0 26 4/7 WEEKS AOG PU BIPTL, TEENAGE PREGNANCY

Management

Plan

4/26/21 Diet: DAT

2:25 pm IVF: D5LR 1L 30 gtts/min
Diagnostics:
CBC w/ BT
Urinalysis
HBsAg, RPR
Medications:
1. Dexamethasone 6 mg IM, q12h x 4 doses
2. Nifedipine 10 mg/cap, 3 caps now then 1 cap q8h w/
BP <90/60 mmHg
Hook to fetal monitor
Monitor VS, FHT, progress of labor
 Plan

4/26/21 MgSO4 Loading

5:00 pm D5W 90 cc + 4g MgSO4 to run for 20 mins via soluset followed by
MgSO4 Drip
1. D5W 400 + 4 g MgSO4 to run at 100 cc/hr via soluset x 4 hrs
2. D5W IL + 10 g MgSO4 to run at 100 cc/hr via soluset x 10 hrs
3. D5W IL + 10 g MgSO4 to run at 100 cc/hr via soluset x 10 hrs

WOF:
DTR <2+
UO <30cc/hr
RR <12 cpm
 Plan

4/26/21 Cefuroxime 500 mg/ cap, 1 cap every 12 hrs x 7 days

6:35 pm Ferrous sulfate tab OD at night
Calcium carbonate tab, 1 tab OD in the morning

4/26/21 DAT w/ SAP once fully awake

8:41 pm D5LR 1L + 10 u oxytocin 30 gtts/min
Medications:
1. Amoxicillin 500 mg/cap, 1 cap q5h x 7 days
2. Mefenamic acid 500 mg/tab, 1 tab TID for pain
3. Ferrous sulfate tab, 1 tab ODHS
Keep uterus well contracted
Apply uterine massage
Final Diagnosis

Gravida 1 Para 1 (0101) Pregnancy Uterine delivered

Preterm live baby boy AS 8,9 BW 0.980g BL 34cm
BS 26 weeks by partial breech extraction
PRETERM BIRTH
William’s 25th edition
PRETERM NEONATE
● neonate born before 37 completed weeks (<36 6/7
weeks)

DEFINITION OF PRETERM BIRTH

Before 33 6/7 weeks - early preterm
Between 34 to 36 completed weeks - late preterm
With respect to size, a newborn may be normally grown and appropriate
or gestational age
● Small for gestational age: newborns whose birthweight is <10th
percentile for gestational age.
● Large for gestational age: newborns whose birthweight is > 90th
percentile for gestational age.
● Appropriate for gesta­tional age: newborns whose weight is
between the 10th and 90th percentile
BY BIRTH WEIGHT

● Low birthweight - to neonates weighing 1500 to 2500 g

● Very low birth­weight - those between 1000 and 1 500 g
● Extremely low birth weight - those between 500 and 1 000 g
PRETERM BIRTH RATE

● In the United States, the preterm birth rate rose slightly

from 9.57 percent in 2014 to 9.63 percent for 2015. This
marks the first rise in this percentage since 2007.

● 2015 obstetrical estimate-based preterm birth rate was

9.6 per­cent compared with the last menstrual period-
based rate of 11.3 percent
PRETERM BIRTH RATE
 PRETERM NEWBORN MORBIDITY

Largely due to organ system immaturity

● birth weight of ≥1000 g;

● gestational age of 28 weeks for females,
● 30 weeks for males;
● survival rates reach 95 percent.

Singh,Priya
Threshold of Viability

newborns
Births once delivered before
considered to be Currently, the
33 weeks’
“abortuses” because threshold of viability
gestation,
the fetus weighed lies between 20 and
<500 g are now perinatal and
26 weeks’ gestation.
classified as live neonatal care has
births. advanced
tremendously.
Periviable Neonatal Survival

periviable period Delivery before 23

have been described weeks typically
as fragile and results in death, and Among those that
vulnerable because survival rates live, morbidity is
of their immature approximate only 5 nearly universal.
organ systems percent
CAUSES OF PRETERM BIRTH

• spontaneous unexplained preterm labor with intact membranes

• idiopathic preterm premature rupture of membranes
• delivery for maternal or fetal indications
• twins and higher-order multifetal births
SPONTANEOUS PRETERM LABOR -
ASSOCIATED FINDINGS
CONTRIBUTING FACTOR

Pregnancy factor
genetic and environmental factor
Light and heavy bleeding
Birth defect
Lifestyle factor
Smoking , drugs and in adequate maternal weight gain
Poverty , short suture and vitamin deficiency
Genetic factor
❖ Periodontal disease –
associated with preterm birth
Treatment during pregnancy improved the disease but does not significantly
improve the preterm labour

Interval between pregnancy - <18 and >59 months is associated with

preterm birth and low for gestational age
❖ Prior preterm birth – greater risk of recurrence
3 factor---- frequency of preterm birth , severity measured by AOG ,
order of prior preterm occurred
Infection like bacterial vaginosis is associated with spontaneous abortion
,PPROM, chorioamnionitis
DIAGNOSIS

SYMPTOMS:
Contractions
pelvic pressure, menstrual-like cramps, watery vaginal
discharge, and lower back pain
DIAGNOSIS

CERVICAL CHANGE:
Asymptomatic cervical dilation after midpregnancy
DIAGNOSIS

Ambulatory Uterine Monitoring

DIAGNOSIS

FETAL FIBRONECTIN:
fFN detection in cervicovaginal secretions before
membrane rupture
(+) values exceeding 50 ng/Ml
DIAGNOSIS

CERVICAL LENGTH MEASUREMENT:

transvaginal cervical length screening
PRETERM BIRTH PREVENTION

● Cervical Cerclage
● Prophylaxis with Progestogen Compounds
● Prior Preterm Birth and Progestogen Compounds
● Progesterone Use without Prior Preterm Birth
● Geographic-Based Public Health-Care Programs

Reference: Williams Obstetrics, 25th Edition

PROPHYLAXIS WITH PROGESTOGEN COMPOUNDS

● Administration of progesterone may block

the preterm labor
● progesterone therapies are limited to
singleton pregnancy

PRIOR PRETERM BIRTH AND PROGESTOGEN COMPOUNDS

● 17- OPH- C is synthetic progestogen
● FDA approved
 Progesterone Use without Prior Preterm Birth

● Spontaneous
delivery was
significantly
reduced
● FDA rejected
● Did not reduce
the frequency of
preterm birth
before 37 weeks

From all these studies, the American College of Obstetricians and Gynecologists concluded
that universal cervical length screening in women without prior preterm birth is not
mandatory. However, screening strategy could be considered in the context of treatment with
vaginal progesterone
 Geographic-Based Public-Health Care Programs

● A well-organized prenatal system lowers the preterm birth rate in high-risk

indigent population.
● declining preterm birth rate coincide with a substantial rise in prenatal care
attendance
● Referral to hospital-based central clinic system of women with high-risk
pregnancy complications
 MANAGEMENT OF
PRETERM PREMATURE
RUPTURE OF
MEMBRANES
 CLINICAL CHORIOAMNIONITIS

● Fever is the only reliable indicator for the diagnosis of chorioamnionitis

- The diagnosis of suspected intraamniotic infection is made when the maternal temperature is
≥39.0°C OR when the maternal temperature is 38.0 to 38.9°C and one additional clinical risk factor
is present. (ACOG)

- Suggested factors include low parity, multiple digital examinations, use of internal uterine and
fetal monitors, meconium-stained amnionic fluid, and the presence of certain genital tract
pathogens
 ANTIMICROBIAL THERAPY
● Intravenous ampicillin plus erythromycin every 6 hours for 48 hours, which was followed by
oral amoxicillin plus erythromycin, every 8 hours for 5 days.
○ The women had membrane rupture between 24 and 32 weeks’
○ Antimicrobial-treated women had significantly fewer newborns with RDS, necrotizing
enterocolitis, and composite adverse outcomes

● Three-day treatments compared with 7-day regimens using either ampicillin or ampicillin-
sulbactam appear equally effective in regard to perinatal outcomes

● The amoxicillin-clavulanate regimen was not recommended, however, because of its

association with an increased incidence of neonatal necrotizing enterocolitis
 CORTICOSTEROID TO ACCELERATE
FETAL LUNG MATURITY
● A single course of corticosteroids is now recommended for pregnant women with ruptured
membranes between 24 and 34 weeks’ gestation

● As with periviability, a single course of corticosteroids as early as 23 0/7 weeks in those

who are at risk for preterm delivery within 7 days may be considered
 MANAGEMENT OF
PRETERM LABOR WITH
INTACT MEMBRANE
MANAGEMENT OF PRETERM LABOR WITH INTACT MEMBRANE

1. Amniocentesis to detect infection

2. Corticosteroids
•For fetal lung maturation
•Single course of corticosteroids between 24 and 34 weeks who are at risk of delivery
within 7 days
- Betamethasone: 12mg IM q24 x 2 doses
- Dexamethasone: 6mg IM q12h x 4 doses
•Repeated dose not recommended (risk for cerebral palsy)
•Late-Preterm Delivery:
- Consider giving at 34 0/7 and 36 6/7 weeks
- Risk of hypoglycaemia and subsequent developmental delay
MANAGEMENT OF PRETERM LABOR WITH INTACT MEMBRANE

•Rescue therapy
- Administration of a second corticosteroid dose when delivery becomes
imminent and more than 7 days have elapsed since the initial dose

- <34 weeks AOG:

- Consider single rescue course
- Prior course is at least 7 days ago
 MANAGEMENT OF PRETERM LABOR WITH INTACT MEMBRANE

3. Magnesium Sulfate
•Prophylaxis for neuroprotection
•Reduces risk for cerebral palsy
MANAGEMENT OF PRETERM LABOR WITH INTACT MEMBRANE

4. Antimicrobials:
- Antimicrobial prophylaxis given to women with intact
membranes did not reduce preterm birth rates or affect
other clinically important short-term outcomes (Flenady,
2013).
MANAGEMENT OF PRETERM LABOR WITH INTACT MEMBRANE

5. Bed Rest
- Most often prescribed interventions
- Some studies have shown no benefits:
- Thromboembolic complications
- Significant bone loss
- Increased risk for preterm birth before 34 weeks
- Recommendation: Ambulation
 MANAGEMENT OF PRETERM LABOR WITH INTACT MEMBRANE

6. Cervical Pessaries
- Silicone rings
- Used to support incompetent/short
cervix (≤25 mm)
- Conflicting results from several
studies on its use in preterm birth
prevention.
7. Emergency or Rescue
Cerclage
8. Tocolysis
•Uterine relaxants/ Labor suppressants
•Delay delivery for up to 48 hours
•For short-term use
•Maintenance tocolysis after acute therapy is not recommended.
•Benefits:
-Allow corticosteroids administration and elicit its action
-To permit the transfer of the mother to a center with a NICU
 Labor
- Induced or spontaneous preterm labor necessitates
continuous monitoring of:
a.Fetal heart tone
b.Uterine contractions
- Ruptured membrane followed by fetal tachycardia
suggest sepsis.
- GBS infection common, antimicrobial prophylaxis should
be given.
- Intrapartum acidemia (pH <7.0) may intensify neonatal
complications attributed with preterm delivery.