Preterm,PPROM,PROM,Post-Term & IUFD.pptx

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1. PRETERM LABOUR, PPROM, PROM, POST-MATURITY AND IUFD Presented By Okello Polycap 4.2

2. PRETERM LABOUR

3. Introduction These are regular uterine contractions, cervical effacement and dilation occurring between (26 – 37) weeks of gestation. Preterm birth is a live birth before 37 weeks of gestation. WHO Subcategories of preterm labour . Extremely preterm; (26 to < 28) woG . Very preterm; (28 to < 32) woG . Moderate to Late preterm; (32 to < 37) woG .

4. Epidemiologically, it accounts for approximately 10 – 12 % of all live births globally with higher rates in low and middle income countries. Risk Factors & Causes Idiopathic I atrogenic Maternal factors Age (< 17 and >35)yrs. Previous preterm birth. Multiple pregnancy (twins, triplets). Infections (eg. UTI, cervical cancer) Experienced vaginal bleeding during pregnancy. Pregnancy with a baby suspected with congenital anomaly.

5. Life style Lack of prenatal care. Over weight or under weight before pregnancy. Poor diet. Smoking, drinking alcohol and use of other illegal drugs. Medical Hypertensive disorders ( eg . HELLP syndrome, preeclampsia). Diabetes mellitus, gestational diabetes. Polyhydramnios , or oligohydramnios . PROM. Antepartum hemorrhage ( caused by placenta previa or abruption). Uterine anomalies ( eg . Uterine fibroids).

6. Clinical Presentations Regular uterine contractions (twice in 10 mins for about 20-40 secs). Cervical effacement and dilation. Increased vaginal discharge(Loss of mucus plug or bloody show). Rupture of membranes. Regular tightening or low, dull pain in the back(maybe consistent or not). Lower abdominal cramping, feels like gas pain( with or without diarrhea). Increased pressure in pelvis or vagina. Decreased fetal movements(<6 mov’ts in 1hr).

7. Diagnosis Of Preterm Labour . Examining the mother’s cervix(if effaced or dilated). Ultrasound; determine the fetus size and position in uterus, also problems with the placenta or the amniotic fluid. Fetal fibronectin test; assessing a sample of vaginal fluid for fibronectin(a protein that helps amniotic sac stick to uterus).If it’s in discharge, means labour has begun. Differential diagnosis ; Braxton-Hicks contractions ovarian tumors(or fibroid complications) UTI Acute appendicitis.

8. Investigations -Complete blood count -Urine for routine analysis, culture and sensitivity - Cervico -vaginal swab for culture and fibronectin - Ultrasonography for fetal well-being, cervical length and placental localization -Serum electrolytes and glucose levels when toco -lytic agents are to be used

9. Management Counsel mother, couple or her relative of the condition. Thorough history taking to pick possible risk factors. General examination on the mother and the also the fetus. Obstetric examinations (at least once a day). Ensure enough bed rest and fetal wellbeing should be monitored. If PPROM is present administer antibiotics. Glucocorticoids -IV/IM Dexamethasone, Betamethasone Tocolytics -Calcium channel blockers – nifedipine (delay onset of labour for 2-7days) -Oxytocin antagonists – atosiban (delay onset of labour for 2-7days) -Indomethacin -Beta 2 agonists – ritodrine , terbutaline , fenoterol (delay onset of labour for 48hrs) -Other smooth muscle relaxants: - Magnesium sulphate

10. Complications. Neonatal outcomes High risks of increased of respiratory distress syndrome. Intraventricular hemorrhage. Sepsis. Long term neurodevelopmental impairments. Patent ductus arteriosus (PDA). Necrotizing enterocolitis . Cord prolapse .

11. Maternal outcomes; Psychological stress. high risk of postpartum depression. Intrauterine infections. Placenta abruption .

12. Preventions. Address risk factors for preterm labor for all patients, including: - Screening for hypertensive pregnancy disorders. -Screening for gestational diabetes. -Screening for infections. -Counseling on smoking cessation. -Encouraging mothers to attend Antenatal Care programs.

13. PPROM and PROM

14. PROM. This is the spontaneous rupture of the membranes (amnion and chorion ) before the onset of labor. It can be Pre-term PROM(PPROM) or Term PROM. PPROM. This is the spontaneous rupture of the membranes (amnion and chorion ) before the onset of labor at < 37 Weeks Of Gestations. Epidemiologically; - PROM complicates about 8% to 10% of pregnancies. -PPROM affects about 3% of pregnancies according to up to date PROM is associated with one-third of preterm births and is the single most common identifiable factor associated with preterm delivery

15. Risk Factors Previous history of PROM. Genital Tract infections. Antepartum bleeding. Cervical insufficiency. Uterine distension (Polyhydramnios, Multiple gestation). Cigarette smoking . Idiopathic 15

16. Clinical Presentations . Sudden “ gush ” of amniotic fluid or slow trickle of clear fluid from the vagina before onset of labour after 26 weeks. On speculum exam; fluid leakage maybe from cervix or pool of fluid in the posterior fornix of the vagina). Look for umbilical cord. Evidence of oligohydramnios but no active liquor leakage. Decreased symphyseal fundal length and fundal height in pregnancy.

17. Diagnosis. Clinical diagnosis: history of a sudden “gush” of pale yellow or clear fluid from the vagina. Sterile speculum examination: often required; clinical uncertainty is common in PROM and PPROM. Positive pool; amniotic fluid exiting the cervix and pooling in the vaginal fornix. Detection of amniotic fluid; Litmus test or nitrazine test: test strips turn blue(Alkaline (pH 7.0 – 7.5 )). Positive fern test: fern pattern on glass slide. 3 . Ultrasound scan: oligohydramnios suggestive of PROM.

18. Nitrazine paper Ferning View under low power microscope

19. Differential diagnosis Urinary incontinence, Amniotic fluid leakage is continuous or intermittent, whereas bladder leakage cease after the bladder is emptied Amniotic fluid has a pH of 7.0 to 7.5 different from the pH of urine <6.0 but may be higher Amniotic fluid and urine have different chemical compositions (urine has higher creatinine and urea levels 2. Hydrorrhea gravidarum(polyhydramnios). 3. Vaginitis or cervicitis. 4. Increased vaginal secretions. 5. Vesicovaginal or rectovaginal fistula in women with a history of previous delivery. 6. Urogenital tract trauma.

20. Management Recommend bed rest; plan delivery by 37 weeks if no complications Avoid digital vaginal examinations Monitor for signs of infection (uterine tenderness, temperature, pulse, colour of liquor and foetal heart sounds) twice daily. Do ultrasound scan twice a week and CBC every 72 hours Perform fetal heart rate monitoring to assess for non-reassuring fetal status.

21. Pharmacologically Administer broad spectrum antibiotics; Iv ampicillin 2gm start or 1g Azithromycin Then tabs Erythromycin 500mg QID for 5/7 for prophylaxis Coordinate with a paediatrician for new-born care. Administer steroids to induce lung maturity; IM dexamethasone 6mg 12 hourly for 48 hours prior to planned delivery. Repeat the dose of dexamethasone if delivery does not occur within seven days after the last dose. IV magnesium sulphate , 4g of 20% single dose for fetal neuroprotection

22. For unstable patient: Prompt delivery in: -Patients with signs of intraamniotic infection, abruptio placentae, cord prolapse -Signs of fetal distress ( nonreassuring fetal heart rate) -Additionally , collect cervical cultures and commence empiric antibiotic therapy ampicillin and gentamicin . For Stable patient: Delivery at gestational age: ≥ 37 weeks (term) -Delivery by induction of labor is generally recommended. -Expectant management for up to 12–24 hours is reasonable in otherwise uncomplicated pregnancies and in the absence of infection.

23. Precautions to avoid complications Encourage mother to maintain good personal hygiene. Bed rest; to avoid cord prolapse. Avoid digital vaginal examinations(V/E). Observe aseptic technique.

24. Follow-up If there are no complications after delivery; The mother should undergo postnatal care routines. Monitoring baby and mother for any infections. If the baby is premature, refer to the Intensive care unit (ICU) to manage to the baby.

25. Indications of immediate delivery regardless of gestational age. Chorioamnionitis . Placental abruption. Non-reassuring Fetal testing. Established preterm labour . IUFD.

26. POSTMATURITY (POST-TERM PREGNANCY)

27. Post Term Pregnancy - Pregnancy that extends beyond 42 weeks from first day of LNMP Post Date Pregnancy - Pregnancy that extends beyond 40 weeks from first day of LNMP. The incidence of pregnancies continuing beyond 42 completed weeks (> 294 days) ranges between 4 and 14 percent. When pregnancy overruns the expected date, there is risk of placental insufficiency due to placental aging.

28. Etiology Wrong dates: Due to inaccurate LMP (most common) Biological variability (Hereditary) may be seen in the family Maternal factors: Primiparity , previous prolonged pregnancy, sedentary habit, elderly multipara Fetal factors: Congenital anomalies: Anencephaly → abnormal fetal HPA axis and adrenal hypoplasia → diminished fetal cortisol response Placental factors: Sulphatase deficiency → low estrogen.

29. Diagnosis Menstrual history- If the patient is sure about her date with previous history of regular cycles Clinical findings when a pregnancy exceed the expected date by 2 weeks are: Weight record: Regular periodic weight checking reveals stationary or even falling weight. Girth of the abdomen: diminishes gradually because of diminishing liquor. Obstetric palpation: Height of the uterus, size of the foetus and hardness of the skull bones. As the liquor amnii diminishes, the uterus feels “ full of foetus ”— a feature usually associated with post maturity.

30. Retrospective Diagnosis Baby General appearance: Baby looks thin and old. Skin is wrinkled. There is absence of vernix caseosa . Head is hard without much evidence of molding . Nails are protruding beyond the nail beds. Weight often more than 3 kg and length is about 54 cm. Liquor amnii : Scanty and may be stained with meconium. Placenta: There is evidence of aging of the placenta manifested by excessive infarction and calcification. Cord: There is diminished quantity of Wharton’s jelly which may precipitate cord compression.

31. Complications Fetal Complications -Fetal hypoxia and acidosis -Meconium aspiration -Risks of cord compression due oligohydramnios . -Shoulder dystocia -Increased incidence of birth trauma due to non- moulding of head due to hardening of skull bones -Increased incidence of operative delivery -Infection -Stillbirth

32. Maternal Complications -Shoulder dystocia -Risk of cesarean delivery -Forceps delivery - Perineal lacerations -PPH

33. INTRAUTERINE FETAL DEATH (IUFD)

34. Introduction Definition ( WHO 2015) “Fetal death prior to complete expulsion or extraction from the mother irrespective of the duration of pregnancy and which is not an induced termination of pregnancy. Death of a fetus prior to delivery after 26 weeks of gestation (for Uganda). It literally embraces all fetal deaths weighing 500 gram or more occurring both during pregnancy (antepartum death) or during labor ( intrapartum ).

35. It can be classified as; Early stillbirth; fetal demise at <27 WOA Late still birth; fetal demise after 27WOA. FSB( Fresh still birth) MSB(Macerated still births)

36. Etiology and risk factors The fetal deaths are related to maternal (5–10%), placental (20–35%) or fetal (25–40%) complications and 25-35% unknown. Maternal (5–10%) Hypertensive disorders in pregnancy Diabetes in pregnancy Maternal infections (malaria, hepatitis, influenza, toxoplasma, syphilis) Hyperpyrexia (temp > 39.4°C)

37. Antiphospholipid syndromes (APS), presence of lupus anticoagulant (LA), anticardiolipin antibodies (ACA) → decidual vasculopathy with fibbrinoid necrosis, placental vascular atherosis and intervillous thrombosis → IUFD Thrombophilias : Factor V Leiden, protein C, protein S-deficiency, hyperhomocysteinemia . Mechanism of IUFD is similar to (APS) Abnormal labor (prolonged or obstructed labor, ruptured uterus) Post-term pregnancy Systemic lupus erythematosus Renal disease Thyroid disease Obesity Smoking prior stillbirth Maternal age

38. Fetal (25–40%) Chromosomal abnormalities. Major structural anomalies. Infections ( virus, bacteria, chorioamnionitis ). Rh-incompatibility. Non-immune hydrops . Growth restriction. Multifetal gestation

39. Placental (20–35%) Antepartum hemorrhage : Both placenta previa and abruptio placentae can cause fetal death by producing acute placental insufficiency. Cord accident (prolapse, true knot, cord round the neck). Twin transfusion syndrome (TTTS) . Placental insufficiency. Idiopathic (25–35%) Iatrogenic like ECV, quinine overdose The causes of fetal death are often complex and sometimes unknown; however The major causes of fetal loss in each of the trimesters can be summarized as follows:- • First trimester: genetic abnormalities • Second trimester : fetal infection and placental thrombosis • Third trimester: cord accident and placental thrombosis

40. Diagnosis History Signs And Symptoms. Absence of maternal fetal movements perceptions. Mild abdominal pain or cramping. Vaginal spotting or light bleeding Retrogression of physiological changes for example decrease in the breast size. Details of antenatal events and risk factors History of Hypertension, Diabetes Mellitus, Fetal growth restriction or abnormal screening examinations (biochemistry, ultrasound) Offensive PV Discharge, PV Bleeding, abdominal pain SROM (spontaneous rupture of membranes) Exposure to any known viral illness

41. Examination Temp, BP, P, RR Assess for pallor, oedema , jaundice Assess for uterine irritability abruptio placentae or chorioamnionitis Assess for signs of preeclampsia Per abdomen: Gradual retrogression of the fundal height and it becomes smaller than the period of gestation. Uterine tone is diminished and the uterus feels flaccid. Fetal movements are not felt during palpation. Fetal heart sound is absent. Use of Doppler ultrasound is better than the stethoscope. Speculum: SROM or offensive PV Discharge VE: in the event of planned IOL

42. Investigations 1. Sonography : Lack of all fetal motions (including cardiac) during a 10-minute period Oligohydramnios and collapsed cranial bones for 7 days are evident Spalding sign —The irregular overlapping of the cranial bones on one another is due to liquefaction of the brain matter and softening of the ligamentous structures supporting the vault. usually appears 7 days after death Hyperflexion of the spine

43. Robert’s sign : Appearance of gas shadow especially in fetal heart(in 12 hours) , Ball sign : Hypoechoic (dark) areas in fetal thorax Helix sign : Gas in umbilical vessels giving a helical umblical cord shape. Crowding of the ribs shadow

44. 2. BLOOD To estimate the blood fibrinogen level and partial thromboplastin time periodically, when the fetus is retained for more than 2 weeks. Tests should be directed to identify scientifically proven causes of late IUFD. Commonly associated antepartum conditions include congenital malformation, congenital fetal infection, antepartum haemorrhage , pre- eclampsia and maternal disease such as diabetes mellitus . The common causes of intrapartum death include placental abruption, maternal and fetal infection, cord prolapse, idiopathic hypoxia–acidosis and uterine rupture.

45. Transplacental infections associated with IUFD include cytomegalovirus, syphilis and parvovirus B19 as well as listeria, rubella, toxoplasmosis, herpes simplex , coxsackievirus , leptospira , Q fever, and Lyme disease. Malaria parasitaemia has also been associated with stillbirth.

46. Recommended Evaluation For A Stillbirth Hematological examination consists of ABO and Rh grouping, Kleihauer-Betke test, VDRL, postprandial blood sugar, HbA1 C, urea, creatinine estimations, thyroid profile, viral serology, lupus anticoagulant, anticardiolipin antibodies and thrombophilia studies. Urine examination for casts and pus cells. Thorough examination of the fetus and placenta should be done : fetus—for malformations (skeletal X-ray) umbilical cord for entanglement, number of vessels , placenta for meconium staining, malformations and weights are to be recorded. Placental pathology will test for evidence of abruption, thrombosis, or infarction. signs of viral or bacterial infection.

47. Autopsy and chromosome studies are done for fetuses with anomalies and dysmorphic features. Or history of recurrent stillbirths or if either parent is a carrier for balanced translocation. Fetal skin, blood are usually taken for aneuploidy and single gene disorder study. Fetal karyo -type may be obtained by testing amniotic fluid obtained via amniocentesis before delivery of the fetus .

48. Complications (1) Psychological upset . (2) Infection—membranes are intact, infection is unlikely but once the membranes rupture, infection, especially by gas forming organisms like Clostridium welchii may occur. The dead tissue favors their growth with disastrous consequences. (3) Blood coagulation disorders are rare. If the fetus is retained for more than 4 weeks (10–20%), there is a possibility of defibrination causing disseminated intravascular coagulopathy (DIC). It is due to gradual absorption of thromboplastin , liberated from the dead placenta and decidua, into the maternal circulation. (4) During labor—Uterine inertia(failure of uterus to contract effectively during labor), retained placenta and postpartum hemorrhage.

49. Management Prevention The following guidelines may help to reduce its recurrence: Preconceptional counseling . To screen the “at-risk mothers ” during antenatal care ie DM, HTN, treat TORCHS etc. Careful assessment of fetal well-being and to terminate pregnancy with the earliest evidences of fetal compromise.

50. Expectant management A) Noninterference In about 80% of cases, spontaneous expulsion occurs within 2 weeks of death. The woman with intact membranes, no evidence of DIC or sepsis may remain at home then later comes to the hospital for delivery. Fibrinogen estimation should be done twice weekly. In 20% of the cases where spontaneous expulsion does not occur within 2weeks, it can be complicated with DIC.

51. B) Interference (Induction Of Labor) Mgt Done by two methods. - Medical induction by the use of drugs -Mechanical induction by the insertion of a foleys catheter to dilate the cervix. Indications for early Interference include Psychological upset of the patient, Manifestations of uterine infection, Tendency of prolongation of pregnancy beyond 2 weeks, Fetal maceration or advanced decomposition, Maternal risk of coagulopathy, Patient preference for induction

52. Methods of delivery The delivery should always be done by medical induction: (a) A combination of mifepristone and a prostaglandin preparation is recommended as the first-line choice for induction of labor. A single dose (200 mg) of oral mifepristone and misoprostol (PGE1) intravaginal 25 μg 4 hourly are safe, effective and of low cost. (b) Misoprostol (PGE1) 25–50 μg either vaginally or orally is also found effective . Vaginal route use is more effective compared to oral route. (c) Prostaglandins (PGE2): Vaginal administration of prostaglandin (PGE2) gel or lipid pessary high in the posterior fornix is very effective for induction where the cervix is unfavorable. This may have to be repeated after 6–8 hours. The procedure may be supplemented with oxytocin infusion.

53. (d) Oxytocin infusion: where the cervix is favorable. To begin with, 5–10 units of oxytocin in 500 mL of Ringer’s solution is administered through intravenous In case of failure, dose of oxytocin is used on the next day. To start with, a drip is set up with 20 units of oxytocin in 500 mL of Ringer’s solution and run 30 drops per minute (80 mU /minute). Oxytocin infusion may be used as a supplementary therapy when vaginal prostaglandins are used. Induction of labor in women with previous LSCS: PGE2 gel may be used safely in women with previous one LSCS, but for women with previous two LSCS, risk (rupture uterus) is slightly more. Hysterotomy or caesarean delivery is generally reserved for patients who fail induction of labor.

54. Intracervical Ballon Aseptic technique throughout. Pass sterile speculum. Disinfect the cervix. Choose catheter with at least 30mls bulb, preferably 50mls. Pass Foley’s catheter tip through internal os of cervix. Inflate balloon and retract until resistance. Tie 500mls bag fluid to catheter and suspend over the edge of bed for traction or tape end of catheter to inner thigh of patient to allow mobilization.

55. EASI technique E-evaluation, A- amniotomy , S-sweeping, I-instrumentation Considered if indication urgent or catheter expulsion has not occurred after 4-6 hours. Infuse initial 200mls N/saline solution at room temperature through intracervical catheter. Now at room temperature, infuse 40-50mls N/Saline per hour through intracervical catheter. Do not exceed 2L in total. Oxytocin can be commenced once catheter expelled (as per protocol). Use with caution in previous c/section. If completely impossible to do EASI, then consider Caesarean Section

56. Postpartum Mgt Caregivers should be aware of and respectful towards the differences in individual and cultural responses to death If baby macerated, prepare the couple for the appearance of the baby If they have named the baby, address the baby by his or her name If parents decline mementos – staff should offer to store them securely with the maternal records in the event they change their minds or Footprints and photo to be given to parents in sealed envelope

57. Offer suppression of lactation - Cabergoline ( Dostinex ®, Arigoline ®) except if Hypertensive or preeclamptic and bromocriptine Thromboprophylaxis but not routine Postnatal bed away from other babies. Consider transferring patient to another ward if she is >6 hours post NVD or 24 hours post c/section in uncomplicated cases. Offer psychological counselling to patient and her family Be vigilant for postpartum depression

58. References DC Dutta’s Textbook of obstetrics.9 th edition.Pages 294-304 Up-to-date –PROM –Epidemiology, Clinical features and management. Normal and problem pregnancy Gabbe et al. Essential Maternal and Newborn Clinical Care Guidelines for Uganda, 2022. William text book of obstetric 26 th edition, chapter 35, page 624-630. RCOG (Royal College Of Obstetricians And Gynaecologists ).