Case Presentation on Preterm

Labour
 CASE
• Patient’s name: Savitri
• Age :22yrs
• w/o:Raju
• r/o: Mayapuri colony , Luckno
• DOAA: 8/09/2020
 Chief complaints:

• Amenorrhea since 8 months

• On and Off Pain abdomen for 1day
 History of presenting complaint

• She got admitted in labour room on 8/9/20

• Patients had pain abdomen for 1 day
• Pain was generalized and coliky in nature ,
intermittent , occuring at every 10 min .Pain was
regular increasing in intensity . Pain was associated
with backache. Pain was not associated with leaking
or bleeding p/v . Pain was not accompained by
vomiting . Pain had no diurnal pattern . Pain was not
relieved by any particular posture or particular food .
HISTORY OF PRESENT PREGNANCY

• Spontaneous conception
• Patient had 4 ANC visits 1st at Ram Manohar Lohia
hospital, Lucknow, in first trimester ( 3rd month )
• 2nd at CHC Fatehpur at 20 wk
• 3rd at Sai hospital ,Faizabad at 23 wk
• 4th at Navshri hospital at 32 wk
 FIRST TRIMESTER
• According to patient she was apparently
asymptomatic 8 months back when she developed
amenorrhea.
• UPT was positive at 15days of overdue, done at home
• No h/o excessive nausea and vomiting, drug and
radiation exposure, bleeding per vaginum.
• No h/o of fever , burning micturation .
• No h/o of folic acid intake.
• No h/o of blurring of vision , headache.
 SECOND AND THIRD TRIMESTER
• Patient had her 2nd ANC visit at a private hospital .
• Quickening felt around 5 month of POG.
• Patient was advised iron and calcium
supplementations, but patient was noncompliant .
• No h/o blurring of vision , pedal edema, watery
discharge, decrease fetal movement, abdominal
trauma, no h/o of bleeding p/v , leaking p/v . No h/o of
fever , burning micturation , Discharge p/v , suprapubic
pain , no h/o history of constipation .
 Menstrual history

• Menarche at the age of 14 years

• LMP=5/1/2020, Sure of dates ,No h/o of prolong
cycles
• EDD=12/10/2020, POG=35wk3day
• cycle: 28-30days
• Duration:4-5 days
• Flow: average
• Dysmenorrhea: absent
 Obstetric history:

• G1P0+0 with marriage life of 1 year

• LMP=5/1/2020 EDD= 12/10/2020
• POG= 35 wk 3day
Visit Place POG Complaints Treatment Investigations
1st ANC RamMano 3rd month Routine Folic acid TVS advised , but
VISIT har Lohia of Visit not done
Hospital, gestation Hb- 9.0 g/dl
LKO ABO RH- Bpositive

2nd ANC CHC 20wk Routine T. Iron and USG-SLIUF ,

VISIT FATEHPUR Visit T.calcium CEPHALIC , CGA OF
advised , but 20WK 2DAY . PL-
pt was ANT, AFI ADEQUATE
noncompliant
3RD ANC SRI SAI 23WK 3 Pain Inj tetvac im USG obs for foetal
VISIT HOSPITAL DAY abdomen stat given, Inj wellbeing advised ,
pan 40 i/v 12 but not done .
hrly ,
T.duadilon 10
mg 1 tds x 10
days . T. iron
od , T.calcium
od , T.
Doxinate forte
sos
Visit Palace POG Complaints Treatment Investigations
4th ANC NAVSHRI 32WK Routine To cont iron USG- SLIUF
VISIT HOSPITAL Visit , calcium CEHALIC ,
CGA33+6, PL
POST , AFI
ADEQUATE .
5th ANC Q.M.H 36WK PAIN ADMITTED
VISIT ABDOMEN
 PAST HISTORY:
There is no h/o DM, HTN, epilepsy, thyroid disorder,
asthma, jaundice, no h/o ATT intake, no h/o of
psychiatric illness. No h/o of trauma, recent sexual
contact .
FAMILY HISTORY:
There is no h/o DM, HTN, TB , any other chronic
illness, any congenital heart disease . No h/o of
preterm births in mother .
SOCIAL HISTORY:
Patient belong to lower middle socioeconomic class
according to Modified kuppuswamy socioeconomic
scale 2018 .
 DIET HISTORY:
Mainly vegetarian diet with calorie intake adequate
1800kcal
PERSONAL HISTORY:
No H/O smoking, any addiction(tobacco, cocaine,
alcohol). Bladder and bowel habits are normal, sleep
patterns normal. No h/o of physical abuse
 GENERAL EXAMINATION(POG=35wk3day)

• Patients sitting comfortably on bed, well oriented to

time, place and person
• Ht= 156 cm, wt= 50KG ,BMI=20.5kg/m2
• PR=90/min, regular, normovolumic
• RR=18/min
• B.P= 138/90mm hg in right arm sitting position
• Urine albumin by dipstick is +1
• Temperature= 98.7F
• Pallor+ ,no icterus/cyanosis/clubbing.
• Oral hygiene adequate
• No thyromegaly, B/L breast soft.
 SYSTEMIC EXAMINATION
• Respiratory system: B/L vesicular sound heard, no
added sound heard.
• Cardiovascular system: S1,S2 heard normally, no
added sound or murmur heard
• Central nervous system:well oriented to time , place
and person.
ABDOMINAL EXAMINATION
(POG=35wks3day )
INSPECTION:
• Abdomen longitudinally ovoid.
• Umbilicus central and everted
• No dilated vein over abdomen
• Linea nigra and stria gravidarum marks present over
abdomen
• Hernial sites intact.
PALPATION
(after bladder evacuation and correcting Dextrorotation
• FH=34week
• Cephalic presentation (4/5 palpable)
• Mild Uterine contractions present (20-25sec, 2
contractions in 10 min)
• Liquor average
• EFW ~2.5 kg
• SFH=36cm
• AG= 38inches
 AUSCULTATION:
• FHS=140/min regular, heard in left spinoumbilical
line.

P/S EXAMINATION: no leaking present, show +

P/V EXAMINATION: os 1 finger loose , cervix

soft/post /early effaced (30%) , membrane present ,
pp -4 station , pelvis adequate .
PROVISIONAL DIAGNOSIS:
• 22 year old G1P0+0 35 week 3day pregnancy
with preterm labor with Nonsevere
preclampsia with mild anemia.
 INVESTIGATIONS
ROUTENE INVESTIGATIONS VALUES
HB 9G%
ABO RH B positive
HIV, HCV, HBSAG , VDRL NR
Platlet count 1.6 Lac
PT/INR 25.1/1
KFT WNL
LFT WNL
S. LDH 954.63 U/L
S. URIC ACID 5.42 mg/dl
THANK YOU
 GREEN TOP GUIDELINES 2015
• Established preterm labour
A woman is in established preterm labour if she has
progressive cervical dilatation from 4 cm with regular
contractions
• Preterm prelabour rupture of membranes (P-
PROM)
A woman is described as having P-PROM if she has ruptured
membranes before 37+0 weeks of pregnancy but is not
in established labour
Offer a choice of either prophylactic vaginal progesterone or
prophylactic cervical cerclage to women:
• with a history of spontaneous preterm birth or mid-trimester loss between 16+0 and
34+0 weeks of pregnancy and in whom a transvaginal ultrasound scan has been carried out
between 16+0 and 24+0 weeks of pregnancy that reveals a cervical length of less than 25 mm.
• Discuss the benefits and risks of prophylactic progesterone and cervical cerclage with the woman and
take her preferences into account.

Offer prophylactic vaginal progesterone to women with no

history of
• spontaneous preterm birth or mid-trimester loss in whom a transvaginal ultrasound scan has been
carried out between 16+0 and 24+0 weeks of pregnancy that reveals a cervical length of less than 25
mm.

Consider prophylactic cervical cerclage for women in whom

• a transvaginal ultrasound scan has been carried out between 16+0 and 24+0 weeks of pregnancy that
reveals a cervical length of less than 25 mm and who have either:
A)had preterm prelabour rupture of membranes (P-PROM) in a previous pregnancy or
B)a history of cervical trauma.
'Rescue' cervical cerclage Do not offer 'rescue' cervical cerclage
to women with:
• signs of infection or
• active vaginal bleeding or
• uterine contractions.

Consider 'rescue' cervical cerclage for women

between 16+0 and 27+6 weeks of pregnancy with a dilated cervix and exposed,
unruptured fetal membranes: take into account gestational age (being aware that
the benefits are likely to be greater for earlier gestations) and the extent of cervical
dilatation

• Consider fetal fibronectin testing as a diagnostic test to determine likelihood

of
• birth within 48 hours for women who are 30+0 weeks pregnant or more if
• transvaginal ultrasound measurement of cervical length is indicated but is
not
• available or not acceptable
 Diagnosing preterm labour for women with
intact membranes
If the clinical assessment suggests that the woman is in suspected preterm
• labour and she is 29+6 weeks pregnant or less, advise treatment for pretermlabour
If the clinical assessment suggests that the woman is in suspected preterm
labour and she is 30+0 weeks pregnant or more
• consider transvaginal ultrasound measurement of cervical length as a diagnostic
test to determine Preterm labour and birth and likelihood of birth within 48 hours.
Act on the results as follows:
• if cervical length is more than 15 mm, explain to the woman that it is unlikely that
she is in preterm labour and think about alternative diagnoses discuss with her the
benefits and risks of going home compared with continued monitoring and
treatment in hospital advise her that if she does decide to go home, she should
return if symptoms suggestive of preterm labour persist or recur
• if cervical length is 15 mm or less, view the woman as being in diagnosed preterm
labour and offer treatment
 TOCOLYSIS
• Take the following factors into account when making a
decision about whether to start tocolysis:
• whether the woman is in suspected or diagnosed preterm labour
• other clinical features (for example, bleeding or infection) which may suggest that
stopping labour is contraindicated
• gestational age at presentation
• likely benefit of maternal corticosteroids
• availability of neonatal care (need for transfer to another unit)
• the preference of the woman.
 Consider nifedipine for tocolysis[3] for women between 24+0 and 25+6 weeks of
pregnancy who have intact membranes and are in suspected preterm labour.
 Offer nifedipine for tocolysis[3] to women between 26+0 and 33+6 weeks of
pregnancy who have intact membranes and are in suspected or diagnosed preterm
labour.
 If nifedipine is contraindicated, offer oxytocin receptor antagonists for tocolysis.
 Do not offer betamimetics for tocolysis
 Maternal corticosteroids

• 1 For women between 23+0 and 23+6 weeks of pregnancy who are in suspected or
established preterm labour, are having a planned preterm birth or have PPROM
discuss with the woman the use of maternal corticosteroids in the context of her
Preterm labour and birth
• Consider maternal corticosteroids for women between 24+0 and 25+6 weeks of
pregnancy who are in suspected or established preterm labour, are having a planned
preterm birth or have P-PROM.
• Offer maternal corticosteroids to women between 26+0 and 33+6 weeks of
pregnancy who are in suspected, diagnosed or established preterm labour, are having
a planned preterm birth or have P-PROM.
• Consider maternal corticosteroids for women between 34+0 and 35+6 weeks of
pregnancy who are in suspected, diagnosed or established preterm labour, are
having a planned preterm birth or have P-PROM.
• Do not routinely offer repeat courses of maternal corticosteroids, but take into
account: a)the interval since the end of last course
b)gestational age
 Magnesium sulfate for neuroprotection

• Offer intravenous magnesium sulfate for

neuroprotection of the baby to women
between 24+0 and 33+6 weeks of pregnancy
who are:in established preterm labour or
having a planned preterm birth within 24 hours.
• Give a 4 g intravenous bolus of magnesium
sulfate over 15 minutes, followed by an
intravenous infusion of 1 g per hour until the
birth or for 24 hours (whichever is sooner)