4.10 Threatened preterm delivery

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    Regular uterine contractions and cervical changes before 37 weeks LMP.

    4.10.1 Risk factors

    – Preterm rupture of membranes before 37 weeks LMP
    – Maternal infection
    – Pregnancy-related disorder (e.g. pre-eclampsia, polyhydramnios, placenta praevia)
    – Multiple pregnancy
    – Cervical insufficiency
    – Age < 18 years
    – Malnutrition

    4.10.2 Management

    – Look for and treat any maternal infection; always perform urinalysis (dipstick test); perform rapid malaria test in endemic areas. 

     

    – Let the woman deliver:
    • If > 34 weeks LMP and membranes have ruptured.
    • If labour is too advanced to be stopped (cervix effaced, 5 cm dilation), no matter what gestational age.
    • If the mother’s life is threatened (poor general condition, pre-eclampsia, eclampsia, abruptio placentae, severe haemorrhage, etc.), no matter what gestational age.
    • If foetal death is confirmed (no foetal movements and no foetal heart tones at several checks or ultrasound confirmation of foetal death).

     

    – Otherwise, try to stop the contractions:
    • Strict bed rest in a medical setting. Bed rest alone may be enough for mild forms (contractions but no cervical changes).
    • Tocolytic therapy:
    The main objective is to postpone delivery in order to administer corticosteroids for accelerating foetal lung maturation.
    nifedipine PO (immediate release tablet): 10 mg to be repeated every 15 minutes if uterine contractions persist (max. 4 doses or 40 mg), then 20 mg every 6 hours. Never administer sublingually (risk of placental hypoperfusion and foetal death); always use the oral route. Duration of the treatment is 48 hours.

     

    – Prepare the foetus for preterm birth:
    After 26 weeks LMP and before 34 weeks LMP, help lung maturation with dexamethasone IM: 6 mg every 12 hours for 48 hours. In case of severe maternal infection, start antibiotherapy prior to dexamethasone.

    4.10.3 Preterm delivery

    – Delivery is usually rapid and often breech.
    – Avoid aggressive treatment (drugs or procedures), but above all, avoid a long labour. Expulsion should be rapid: consider episiotomy, even if the foetus is small; before 34 weeks LMP vacuum extraction is contra-indicated, use forceps if instrumental extraction is required.
    – Prepare for neonatal resuscitation (Chapter 10, Section 10.2). Closely monitor neonate's temperature (risk of hypothermia) and blood glucose (risk of hypoglycaemia).

    4.10.4 Preventing preterm delivery

    – Treatment of infections and other disorders during pregnancy.
    – Rest for women with predisposing factors: multiple pregnancy, polyhydramnios, previous preterm delivery.