Preterm Labour and PPROM Overview

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Questions and Answers

What is a typical gestational age range for low birth weight infants?

Between 24 and 37 weeks.

What is a potential condition affecting lung development in low birth weight infants?

Hypoplastic lung.

What is the significance of a general urine analysis in a pregnant patient?

To identify potential infections or complications.

Which factors may contraindicate the use of tocolytics in preterm labor?

Infection and maternal complications. Signup and view all the answers

What condition might result in vaginal discharge and require differential diagnosis in a pregnant patient?

Prolapse. Signup and view all the answers

What is the significance of hypoplastic lung in infants born before 28 weeks of pregnancy?

Hypoplastic lung results in underdeveloped lung tissue, leading to respiratory distress in low birth weight infants. Signup and view all the answers

Explain the role of tocolytics in preterm labor management.

Tocolytics are used to delay preterm labor by inhibiting uterine contractions, allowing time for fetal development. Signup and view all the answers

What diagnostic test can help assess the risk of infection in a pregnant patient?

A general urine analysis can help identify infections and is essential for monitoring the health of a pregnant patient. Signup and view all the answers

What are the potential effects of vaginal discharge during pregnancy that must be differentiated?

Vaginal discharge can indicate infections or complications like prolapse, necessitating a differential diagnosis. Signup and view all the answers

What factors may lead to the contraindication of using certain medications in managing preterm labor?

Medical conditions such as infection or specific maternal health risks may contraindicate the use of tocolytics. Signup and view all the answers

What are two common risk factors that can increase the likelihood of preterm labor?

Previous preterm births and multiple pregnancies. Signup and view all the answers

Identify two key symptoms associated with the clinical presentation of preterm labor.

Uterine contractions and cervical changes. Signup and view all the answers

Name one management strategy used to prevent preterm birth.

Bed rest is a common management strategy. Signup and view all the answers

Explain how chronic conditions in a mother can contribute to preterm labor.

Chronic conditions can put additional stress on the body, potentially leading to preterm labor. Signup and view all the answers

What long-term health complications may preterm infants face?

Respiratory problems and developmental delays. Signup and view all the answers

How might lifestyle factors such as smoking affect the risk of preterm labor?

Smoking can increase stress on the body and lead to complications, increasing preterm labor risk. Signup and view all the answers

Describe the significance of cervical changes in the diagnosis of preterm labor.

Cervical changes, such as dilation and effacement, are crucial indicators of impending labor. Signup and view all the answers

What is the role of infections in preterm labor, and give an example?

Infections can trigger inflammatory responses that lead to preterm labor; an example is urinary tract infections. Signup and view all the answers

What role does progesterone play in maintaining pregnancy?

Progesterone promotes uterine quiescence and inhibits the production of proinflammatory cytokines and prostaglandins within the uterus. Signup and view all the answers

In which circumstances might a transvaginal cervical cerclage be indicated?

It may be indicated following multiple midtrimester losses, in cases of shortened cervix due to prior surgery, or for dilating cervix without contractions. Signup and view all the answers

How does hydroxyprogesterone caproate assist in preterm birth prevention?

Hydroxyprogesterone caproate is effective in reducing the risk of recurrence of preterm birth in women with a history of it. Signup and view all the answers

What is believed to be the mechanism through which cervical cerclage prevents preterm labor?

Cervical cerclage is thought to enhance cervical structure and immunological barriers, maintaining cervical length and preventing ascending infections. Signup and view all the answers

What role does the mucous plug play in pregnancy, particularly in conjunction with cerclage?

The mucous plug helps protect the uterus from infections, and cerclage may enhance its retention and support cervical integrity. Signup and view all the answers

What impact do inflammatory cytokines have on the developing brain of an unborn infant?

Inflammatory cytokines can cause periventricular white matter damage, known as periventricular leukomalacia (PVL), in the developing brain. Signup and view all the answers

How does multiple pregnancy affect the risk of preterm delivery?

Multiple pregnancies significantly increase the risk of preterm delivery (PTD), with a notable percentage delivering before 37 weeks. Signup and view all the answers

What percentage of multiple births delivers before 32 weeks of gestation?

10–15% of multiple births deliver before 32 weeks of gestation. Signup and view all the answers

What complications can arise from severe polyhydramnios during pregnancy?

Severe polyhydramnios can lead to preterm labor (PTL) and preterm premature rupture of membranes (PPROM). Signup and view all the answers

What is the effect of indomethacin treatment for polyhydramnios, and what must be monitored?

Indomethacin reduces fetal urine production but requires close monitoring of blood flow through the ductus arteriosus. Signup and view all the answers

What are congenital müllerian anomalies and how frequently do they occur?

Congenital müllerian anomalies are abnormalities of the uterine cavity that occur in up to 4% of women of reproductive age. Signup and view all the answers

How does the risk of cerebral palsy differ among multiple births?

Twins have a six to seven fold increased risk of cerebral palsy, which rises to a 100-fold risk if one twin dies antenatally. Signup and view all the answers

What are the potential medical complications linked to multiple pregnancies?

Multiple pregnancies are associated with increased risks of pre-eclampsia, fetal growth restriction (FGR), and other complications. Signup and view all the answers

What is the primary benefit of using progesterone supplementation in patients at high risk for recurrent preterm delivery?

Progesterone supplementation helps reduce the risk of preterm birth in high-risk patients. Signup and view all the answers

Describe the mechanism by which calcium channel blockers exert their effects in the management of preterm labor.

Calcium channel blockers inhibit uterine contractions by binding to L-type calcium channels and reducing intracellular calcium levels. Signup and view all the answers

What are the main adverse drug reactions associated with the use of beta-sympathomimetics in the treatment of preterm labor?

Beta-sympathomimetics have the highest incidence of adverse drug reactions, including maternal side effects and neonatal complications. Signup and view all the answers

What is the role of magnesium sulphate in the context of neuroprotection for infants?

Magnesium sulphate is used to reduce the risk of cerebral palsy in surviving infants. Signup and view all the answers

How does indomethacin function as a tocolytic agent and what risk does it pose to fetal health?

Indomethacin works as a COX inhibitor to delay delivery but can lead to premature closure of the ductus arteriosus. Signup and view all the answers

What is the impact of magnesium sulphate on smooth muscle contraction during preterm labor?

Magnesium sulphate decreases the frequency of uterine contractions by modulating calcium uptake in smooth muscle. Signup and view all the answers

Identify one significant risk associated with the use of NSAIDs, specifically indomethacin, in managing preterm labor.

Indomethacin is associated with an increased risk of necrotizing enterocolitis and neonatal renal dysfunction. Signup and view all the answers

Compare the neonatal outcomes associated with OTR-A and nifedipine as tocolytic agents.

Neonatal outcomes are generally better with OTR-A, showing lower rates of adverse effects compared to nifedipine. Signup and view all the answers

What is one major maternal complication associated with preterm premature rupture of membranes (PPROM)?

Infection, specifically endometritis. Signup and view all the answers

What management strategy is typically followed for PPROM before 34 weeks' gestation?

Conservative management with intensive clinical surveillance. Signup and view all the answers

How does cervical length measurement impact the prediction of preterm delivery (PTD)?

Cervical length measurement can accurately predict the risk of PTD, with a direct relationship between shorter lengths and higher risk. Signup and view all the answers

What two interventions are available for women identified as high risk for preterm delivery?

Progesterone and cervical cerclage. Signup and view all the answers

What is one fetal complication linked to PPROM?

Preterm birth leading to complications such as respiratory distress syndrome (RDS). Signup and view all the answers

What does a rising white cell count indicate in patients with PPROM?

It may indicate the development of chorioamnionitis. Signup and view all the answers

What is the relation between a previous preterm delivery and the risk of subsequent preterm labor?

Having a previous preterm delivery increases the risk of preterm labor in a subsequent pregnancy by four times. Signup and view all the answers

Why is tocolysis contraindicated in patients with PPROM?

Tocolysis increases the risk of maternal and fetal infection. Signup and view all the answers

What are some adverse pregnancy outcomes associated with antepartum hemorrhage?

Adverse outcomes include miscarriage, preterm birth, and caesarean section. Signup and view all the answers

How does a subchorionic hematoma affect the risk of preterm labor?

It increases the risk of later PPROM, potentially due to thrombin's effect on membrane strength. Signup and view all the answers

What role does maternal stress play in preterm labor?

Maternal stress is linked to an increased prevalence of preterm labor and may involve elevated corticotrophin-releasing hormone levels. Signup and view all the answers

What is the significance of fetal fibronectin (fFN) testing in managing threatened preterm labor?

fFN testing helps predict the likelihood of preterm delivery, with negative results indicating a high chance of not delivering soon. Signup and view all the answers

What are the risk factors associated with placental abruption?

Risk factors include pre-eclampsia, trauma, smoking, and advanced maternal age. Signup and view all the answers

Describe the management strategies for women with a positive fFN test.

Women with a positive fFN test should be admitted for tocolysis and corticosteroids for fetal lung maturation. Signup and view all the answers

What is the relationship between acute bleeding and preterm labor?

Acute bleeding can lead to myometrial contractions through thrombin release, potentially resulting in preterm labor. Signup and view all the answers

What conditions are suggested to be associated with an increased risk of preterm labor?

Poor socioeconomic conditions and stressful life events are linked with increased risk of preterm labor. Signup and view all the answers

What is the primary mechanism through which atosiban acts as an oxytocin receptor antagonist?

Atosiban acts by competitively binding to oxytocin and vasopressin receptors, inhibiting uterine contractility. Signup and view all the answers

State one major disadvantage of using beta-sympathomimetics in threatening preterm labor.

Beta-sympathomimetics can cause significant maternal side effects, particularly pulmonary edema. Signup and view all the answers

How do corticosteroids influence neonatal outcomes in preterm infants?

Corticosteroids significantly reduce neonatal mortality by improving fetal lung maturation and reducing risks of respiratory distress syndrome (RDS). Signup and view all the answers

What was observed in more patients treated with atosiban compared to those on placebo?

More atosiban-treated patients remained undelivered at 24 hours, 48 hours, and 7 days. Signup and view all the answers

Explain the importance of the fetal urine output in the context of oligohydramnios.

Reduced fetal urine output can lead to oligohydramnios, which may resolve after discontinuing drugs that inhibit prostaglandin synthesis. Signup and view all the answers

What is the relationship between beta-agonists and cyclic AMP in myometrial relaxation?

Beta-agonists stimulate the production of cyclic AMP, which promotes myometrial relaxation. Signup and view all the answers

Discuss how atosiban compares in efficacy and tolerability to beta sympathomimetics.

Atosiban has similar efficacy as beta sympathomimetics but is better tolerated with fewer side effects. Signup and view all the answers

What is one key factor in making corticosteroid therapy integral during pregnancy?

Corticosteroid therapy profoundly impacts fetal organ system maturation, especially in lung development. Signup and view all the answers

Study Notes

Preterm Labour and Preterm Rupture of Membranes

Preterm labour (PTL) is the onset of labour before 37 weeks' gestation.
Preterm rupture of membranes (PPROM) occurs between 24-37 weeks of gestation
PPROM accounts for up to one-third of preterm deliveries.
50% of women deliver within 1 week of PPROM, and 75% within 2 weeks.
Postnatal survival following PPROM is directly related to birthweight and gestational age at delivery.

Objectives

Define preterm labour
Identify risk factors for preterm labour
Categorize risk factors for preterm labour
Predict preterm labour
Design a prevention plan for preterm labour
Create a management plan for preterm labour
Define premature rupture of membranes (PPROM)
Identify risk factors for PPROM
Understand current interventions to treat PPROM
Discuss care for women experiencing PPROM

Case Scenario

A 17-year-old primigravida with twins, low BMI, non-smoker, was pregnant with a twin pregnancy with LMP on June 7, 2022.
She experienced spontaneous premature pre-labor rupture of fetal membranes (PPROM) in November 2022, which was managed conservatively.
Oligohydramnios (low amniotic fluid) was observed on ultrasound.
Spontaneous preterm labor led to a Cesarean section delivery of viable twin boys in December 2022.
Gestational age at delivery, and birth weight for the twins were below expected levels for their gestational age.

Causes of Preterm Birth

Cervical weakness
Ascending infection (including hematogenous or latrogenic infection).
Decidual hemorrhage
Placental abruption
Uterine distension
Multiple pregnancy
Maternal stress
Fetal stress

Cervical Weakness

Painless premature cervical dilatation
History of painless second trimester pregnancy loss
Overlap with other factors like ascending infection.

Infection

Chorioamnionitis is a major cause of preterm birth, particularly in deliveries before 32 weeks.
Infection may be transplacental or introduced during invasive procedures.
Infection can lead to fetal brain damage.

Multiple Pregnancy

56% of multiple births deliver before 37 weeks, with 10-15% delivering before 32 weeks.
Increased risk of pre-eclampsia, fetal growth restriction (FGR), and other medical complications of pregnancy.
Six-to-seven-fold increased risk of cerebral palsy in twins, rising to a 100-fold increase if one twin dies antenatally.

Polyhydramnios

Too much amniotic fluid increases PTL and PPROM risk.
Occurs in 7-25% of fetuses, depending on the degree of polyhydramnios.
Managed with amnio-drainage, but can precipitate PTL/PPROM.
Indomethacin (NSAID) can reduce fetal urine production, but ductus arteriosus must be closely monitored.

Uterine Müllerian Anomalies

Estimated to occur in up to 4% of women of reproductive age.
Abnormal embryologic fusion and canalization of the Müllerian ducts.
Varying degrees of uterine abnormalities, ranging from arcuate uterus to complete failure of fusion (e.g., didelphys).
Associated with adverse pregnancy outcomes, including miscarriage, PPROM, preterm birth, FGR, breech presentation, and Cesarean section.

Hemorrhage

Antepartum hemorrhage, particularly subchorionic hematoma in early pregnancy, increases risk of PPROM.
Acute bleeding releases thrombin, directly stimulating myometrial contractions.
Complicates 1% of pregnancies
Maternal/fetal outcomes depend on severity and gestational age at occurrence..
Risk factors include pre-eclampsia, hypertension, previous abruption, trauma, smoking, cocaine use, multiple pregnancy, polyhydramnios, thrombophilias, and advanced maternal age.
Severe abruption (involving 50% or more of the placenta) is frequently associated with fetal death

Stress

Maternal or fetal stress may be associated with preterm labour.
Link suggested by increased prevalence among unmarried and underprivileged mothers, who may experience stressful sociodemographic conditions (e.g., job loss, housing insecurity, partner problems).

Management of Preterm Labour

fFN testing (fetal fibronectin): used to determine risk of preterm labour, with a high negative predictive value. Enables most at risk women to be sent home.
Women with positive test results may be admitted to monitor labour.
Corticosteroids and tocolytics (e.g., magnesium sulphate) can be implemented in the management of threatened preterm labour, to improve neonatal lung function.

Medical Treatment for PTL

Progesterone supplementation is useful for high-risk patients to prevent recurring preterm births.
Tocolytics (such as calcium channel blockers) are used to delay delivery long enough for corticosteroids to improve neonatal lung function.

Magnesium Sulphate

Magnesium is useful for neuroprotection
Helps lower uterine contractions.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Indomethacin (first NSAID for PTL)
Delays delivery (for 7-10 days).
Can reduce preterm birth risk but can also have adverse fetal effects (prolonged use can lead to closure of ducts leading to persistent pulmonary hypertension and necrotising enterocolitis).

Oxytocin Receptor Antagonists (OTRAs)

Atosiban is a competitive antagonist of oxytocin and vasopressin within the myometrium.
Dose-dependent inhibition of uterine contractility and PG release.
Only minimal placental transfer.

Beta-sympathomimetics

Ritodrine, salbutamol, terbutaline
Relax uterine muscles by stimulating AMP production
Used for delay delivery but do not improve neonatal outcomes.

Corticosteroids

Antenatal corticosteroids to reduce neonatal mortality by addressing respiratory distress syndrome (RDS) and intraventricular hemorrhage (IVH).
Affect fetal lung, brain development, immune function and the hypothalamic-pituitary-adrenocortical axis.
Dexamethasone or betamethasone are recommended.

Antibiotics

ORACLE trials show that antibiotics for PPROM do not benefit women with intact membranes.
May be beneficial in PPROM with infection.

Management of PPROM

Conservative management before 34 weeks, unless evidence of chorioamnionitis.
Delivery should be induced after 37 weeks unless evidence of chorioamnionitis.
Pulmonary hypoplasia risk increases with PPROM occurring before 23 weeks.

Prediction of Preterm Delivery

Past obstetric history of having a previous preterm delivery significantly increases the risk of recurrent preterm deliveries.
Ultrasound measurement of cervical length is a more accurate method compared to transabdominal ultrasound.

Prevention of Preterm Delivery

Progesterone and/or cervical cerclage if high risk of PTD.
Progesterone to sustain pregnancy by reducing uterine contractions and inflammatory cytokines.
Cervical cerclage to provide structural support to a weakened cervix and prevent infection.

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Description

This quiz covers critical aspects of preterm labour (PTL) and preterm rupture of membranes (PPROM). You will explore definitions, risk factors, prevention strategies, and management plans related to these conditions. Additionally, a case scenario will help apply your knowledge to real-world situations.