PRETERM LABOR AND PREMATURE

RUPTURE OF MEMBRANES
LECTURE FOR C1

By; omer mohamed (M.D)

Oct 27 2016 G.C
 PROM/PTL

DEFINITION:
 PROM

 PPROM

 Prolonged PROM

 Latency period

 Preterm labor

 
 INCIDENCE

 The frequencies of term and preterm PROM are 8 & 3%

respectively.

 12.7 percent of births are PTL. It is rising as a result of

multiple pregnany & ART.
 FETAL MEMBRANES

 Made of thin inner layer that covers amniotic cavity called

amnion.
 Outer layer ,thicker that apposes the decidua called chorion.
 Both fuse together at 14weeks
 ETIOPATHOGENESIS
 Risk factors
 Connective tissue disorders

 Urogenital tract infection

 Low socioeconomic status

 Uterine over-distention

 Second- and third-trimester bleeding

 Low body mass index

 Nutritional deficiencies

 Maternal cigarette smoking

 Cervical conization or cerclage,

 ETIOLOGY…

 Risk factors--- an imbalance in the interaction between

MMPs and TIMPs activity---Collagen breakdown--
Membrane rupture.

  Matrix metalloproteases are a family of enzymes with

varied substrate specificities that decrease membrane
strength by increasing collagen degradation.

 Tissue inhibitors of MMPs (TIMPs) bind to matrix

metalloproteinases and shut down proteolysis.
 CTD…
 The four primary processes in pathgenesis of PTL are:

1-Premature activation of the maternal or fetal hypothalamic-pituitary-

adrenal axis

2-Inflammation/infection

3-Decidual hemorrhage

4-uterine distention
 CTD………..
1.Maternal/fetal HPA axis

 Maternal physical/psychological stress

 Placental vasculopathy,other risk factors

Two mechanisms:
a)CRH
b)Estrogens
 CTD…..
a)CRH:
 Major maternal physical or psychological stress, the maternal
HPA axis.
 Premature fetal HPA activation can result from the stress of
uteroplacental vasculopathy

CRH enhances prostaglandin production myometrial

contraction.
 CTD………….
b)Estrogens: Fetal pituitary ACTH secretion stimulates
adrenal synthesis of dehydroepiandrosterone sulfate
(DHEA) converted to 16-hydroxy-DHEA-S ( fetal liver).
Placental CRH augment fetal adrenal DHEA production
directly .

The placenta converts these androgen to estrone (E1),

estradiol (E2), and estriol (E3)--- activate the
myometrium by increasing gap junction formation,
oxytocinreceptors, prostaglandin activity, and enzymes
responsible for muscle contraction.
 CTD……

2.Decidual hemorrhage:

 The development of abruption may be related to the high decidual

concentration of tissue factor( cellular mediator of hemostasis.)

 Following intrauterine hemorrhage from placental abruption or

previa, decidual tissue factor combines with factor Vlla to activate
factor X, which in turn complexes with its cofactor, Va, to generate
thrombin. In addition to its hemostatic properties, thrombin binds
to decidual protease-activated receptors .
 CTD…..

3.INFLAMMATION:

Amniochorionic-decidual infection is the presence of activated

neutrophils and macrophages that induce proinflammatory
mediators, such as cytokines (eg, interleukins 1,6,8, tumor
necrosis factor-alpha (TNF).
Interleukin-1beta and TNF enhance prostaglandin production
 CTD…..

4.pathologic uterine distension: 

 Multiple gestation, polyhydramnios, and other causes of excessive

uterine distention are factors for PTL.

 Enhanced stretching of the myometrium induces the formation of

gap junctions, up regulation of oxytocin receptors, and production
of prostaglandin E2 and F2 and myosin light chain kinase, which
are critical events preceding uterine contractions and cervical
dilation..
 CLINICAL MANIFESTATION &DX
 History — The classic clinical presentation of PPROM is a
sudden "gush" of clear fluid from the vagina.

 Physical examination — The best method of confirming the

diagnosis of PPROM is direct observation of amniotic fluid
coming out of the cervical canal or pooling in the vaginal fornix.
 ….DX
 Nitrazine test: Amniotic fluid has a pH range of 7.0 to 7.7
compared to the normally acidic vaginal pH of 3.8 to 4.2.

 Ferning test: Fluid from the posterior vaginal fornix is swabbed

onto a glass slide and allowed to dry for at least 10 minutes.
Amniotic fluid produces a delicate ferning pattern.
 ….DX

 Ultrasonography

 Instillation of indigo carmine — In equivocal cases, instillation of

indigo carmine into the amniotic cavity can be considered and
usually leads to a definitive diagnosis.
Under ultrasound guidance, 1 mL of indigo carmine in 9 mL of
sterile saline is injected transabdominally into the amniotic fluid
and a tampon is placed in the vagina. One-half hour later, the
tampon is removed and examined for blue staining, which
indicates leakage of amniotic fluid.
 …DX
 Dx of PTL

 Symptoms of preterm labor such as pelvic pressure,

increased vaginal discharge, backache, and menstrual-like
cramps.

 Contraction frequency of six or more per hour, cervical

dilation of 3 cm, effacement of 80 percent

 Cervix ≥3 cm dilation /80% effaced

Preterm labor diagnosis confirmed
 …DX
 Cervix 2 to 3cm dilation / < 80% effaced
Preterm labor likely but not established. Monitor contraction
frequency and repeat digital examination in 30–60 minutes.
Diagnose preterm labor if cervical change. If not, send fibronectin
or obtain transvaginal cervical ultrasound.

 Cervix <2cm dilation and <80% effaced

Preterm labor diagnosis uncertain. Send fibronectin and/or obtain
cervical sonography, and repeat digital examination in 1 to 2
hours. If there is a 1-cm change in cervical dilation, effacement
>80%, cervical length <20 mm or positive fibronectin
 TREATMENT
 Initial evaluation — 
 Expeditious delivery of women with PPROM is indicated if
 intrauterine infection
 abruption placenta
 repetitive FHR decelerations
 cordprolapse is present or suspected
 TREAT…
  A course of glucocorticoids is given to pregnancies less than 34
weeks of gestation.

 Antibiotic prophylaxis 

 All women with PPROM should be monitored for signs of

infection.
 TREAT…

 At a minimum, routine clinical parameters(eg, maternal

temperature, uterine tenderness and contractions, fouly smelling
vaginal discharge WBC maternal and fever ,FHB

 Fetal surveillance (eg, kick counts, NST, biophysical profile [BPP])

.
 TREAT…
 Timing of delivey:At 37 weeks

 Term PROM: prompt induction of labor in women

with term PROM .

 Compared to expectant management, induction of labor is

associated with small reductions in maternal and neonatal
infection rates and lower treatment costs, but no increase in
cesarean delivery.

 Start antibiotics if >12hrs.

COMPLICATION OF PROM
Maternal Fetal

 Endomyometritis  Chorioamnionitis
 Sepsis  Neonatal sepsis
 PPH  Pulmonaryhypoplasia
 APH  Cord prolapse
 Wound infection  Limb deformity
 Cesarean deliver
 TREAT…

 PTL:
 Tocolytics
1.Indomethacin
2.Calcium channel blockers(Nifedipine)
3.Magensium sulphate
4.Beta-agonists(ritodrine,terbutaline)
5.Atosiban(Oxytocin antagonist)
 Screening for possible infectious and non infectious
cause
 Steroids

 Hydration

 Antibiotic
 COMPLICATIONS PTL

 PTB is one of the leading causes of infant mortality along with

congenital anomalies
 cerebral palsy
 Vision & hearing impairment
 Chronic lung disease
 reduced motor performance
 academic difficulties
 attention deficit disorders
Thank you