Management Preterm Birth

Identity
Patient Husband
Name : Mrs. G Name : Mr. E
Age : 35 years old Age : 39 years old
MR : 01.21.86.57 Education : Senior High School
Education : Senior High School Occupation : Farmer
Occupation : Housewife Address : Tj. Ampalu, Sijunjung
Address : Tj. Ampalu, Sijunjung
Admission Date : 08/05/2023
Primary Survey
GC Cognition BP HR RR SpO2 T Urine

Moderate CMC 183/100 118x/m 22x/m 98 %  O2 5 L/l nasal 36.7 Urine 300cc/3
GCS 15 canule hours, dark
E4M6V5 yellow

Airway : Patent
Breathing : Spontan, RR 22x/min , SpO2: 98% with O2 5 L/I Nasal canule
Circulation : BP: 183/100 mmHg, HR 118x/min  IVFD RL 20 dpm + maintenance dose of MgSO4 regimen 1 gr/hour
Thorax: Cor : S1 S2 normal, pulmo : Lung sound vesicular, Rh -/-, Wh -/-
Abdominal: UC (-), FHR 145-148x/m
Genitalia I: V/U within normal limits, Vaginal bleeding (-)
Extremity : Pathologist reflex -/-, patellar reflex +/+

A/ • Eclampsia Antepartum on maintenance dose of MgSO4 regimen from other institution on G3P2A0L2 28-29 weeks of preterm pregnancy
• Fetal, alive singleton, intrauterine, head presentation

Th/ Control GA, VS, FHR

• IVFD RL 20 dpm + maintenance dose of MgSO4 regimen 1 gr/hour
• Nifedipine 10 mg
• Methyldopa 500mg
• Cardiologist consultation  Nicardipine drip start from 5mg/hours
• Internist consultation
• Perinatology consultation
• Ophtalmologist Consultation
• Neurologist consultation

P/ Stabilitation  Emergency CS
 CLINICAL DATA

Anamnese 08/05/2024 02.00 WIB Previous illness history :

Patient referred from RSUD Sijunjung with diagnosed Eclampsia Antepartum on • There is no history of hypertension before pregnancy
maintenance dose of MgSO4 regimen on G3P2A0L2 28-29 weeks of preterm • There is no history of heart, renal, lung disease
pregnancy + Fetal distress. Previously patient care in RSUD Sijunjung with chief
complaint seizure 1 times in Emergency room less than 5 minutes when the family Family illness history :
registration the name and the patient regain consciousness and blood pressure was • There were no history of congenital, psychiatric and
230/180 and urine protein +3. Because of limited facility, the patient referents to Dr contagious disease
M Djamil Padang General Hospital for further management with IV line (MgSO4
regiment and nicardipine) and catheter inserted. Before referred, the patient was History of marriage : 1x at 2008
given methyl dopa 500 mg and dexamethasone 1 x 6 mg.
• Headache (+), epigastric pain (-), ​Blurred vision (-) History of pregnancy/abortion/delivery : 5/1/3
• Pelvic pain referred to the groin (-) 1. 2009/female/2200 gr/term/vaginal
• Bloody show from the vagina (-)​ delivery/midwife/alive
• Fluid leakage from the vagina (-) 2. 2015/male/2700 gr/term/vaginal delivery/midwife/alive
• Massive bleeding from vagina (-)​ 3. Current Pregnancy
• Amenorrhea since 8 months ago
• LMP : 24-10-2023 EDD : 31-07-2024
• Fetal movement was felt since 4 months of pregnancy
• History of ANC : Control to midwife every month of pregnancy. ANC control at
obstetrician 1 times at 6 months of gestation and there are no abnormalities.
• Menstrual history : menarche at 13 years old, regular cycle 28 days, 5-7 days
each cycle with the amount of 3-4 times pad change/day, menstrual pain​(-)
• History early pregnancy : nausea (-), vomit (-), fluor albus (-)​, trauma (-)
 PHYSICAL EXAMINATION
6
Physical Examination
GA Cons BP HR RR T SpO2. Urine
Obstetric status

Mod CMC 183/100 118 22 36.7 98%  NK 5 LPM. 300 cc/3 Head : chloasma gravidarum (-)
hour
Mammae : enlargement (+), hyperpigmentation areola mammae
Body Height : 147 cm (+)
Body Weight before pregnancy : 45kg
Body weight now : 50 kg Abdomen :
BMI : 32.69 kg/m2 (Obesity) Ins : Enlarge equal to preterm pregnancy. Median line
hyperpigmentation (+), striae gravidarum (+), cicatrix (-)
Generalist status Palpate :
Head : Normochepal L1 : Uterine fundal palpated 2 fingers above the umbilical. A big
nodular, soft mass was palpable
Eyes : Conjunctiva wasn’t anemic, Sclera Icteric (-/-) L2 : Resistance was palpated on right side, fetal small parts was
palpated on the left side
Neck : JVP 5+3 cmH20, thyroid glands was normal L3 : Hard, round mass was palpable, not fixated
L4 : was not performed
Thorax : Cor and Pulmo was normal
UFH : 20 cm UC : - FHR : 115-120 x/m
Abdomen : bowel sounds (+), describe in status obstetrics
Genitalia : V/U normal, bleeding (-)
Extremitas : oedem (-), CRT < 2 second, patellar reflex +/+
VT : was not performed
 SUPPORTIVE EXAMINATION PROCESS

Laboratorium 08-05-2024 CTG : 2 category

Hb : 11.8 PONEK Ultrasound:

Leu : 7.270 Fetal, alive singleton, intrauterine, head presentation
Fetal movement was good
Trombo : 137.000
Ht : 35 USG
Impression:
Ur : 12 • Gravid 28-29 weeks according to biometry
Cr : 0.6 •
•
Placenta implantation in the posterior corpus maturation grade II
Fetal, alive singleton, intrauterine, head presentation
Sgot : 13 • Absent end diastolic
Sgpt : 6
Alb : 3.2
Tot protein : 5.8
D-dimer : 1904
PT : 9.2
APTT : 25.3
GDS : 113
Na : 139
K : 3.6
Cl : 111
Proteinurin : +3
LDH : 305
HIV : nr
Diagnose Pre Op : May 8th 2024 05.35  Emergency LSCS
• Eclampsia Antepartum on maintenance dose of MgSO4 regimen from other A Male baby was born at ​05.40 pm
institution on G3P2A0L2 28-29 weeks of preterm pregnancy + Absent End BW : 750 gram​
Diastole BL : 36 cm
• Fetal, alive singleton, intrauterine, head presentation A/S : ​3/5
Placenta was born complete with mild traction, size 13x10x4 cm,
Plan : weight 125s grams
• Stabilization  Emergency CS Bleeding during operation 250 cc​

Instruction : Diagnose Post Op :

• Control GA, VS, FHR • P3A0L3 post LSCS oi Eclampsia Antepartum on maintenance
• O2 5lpm nasal canul dose of MgSO4 from other institution regimen + Absent End
• IVFD RL 20 dpm + MgSO4 drip maintenance dose 1gr/hour Diastole + IUD Insertion
• IVFD D5% loading • Mother and baby in care​
• Dexametasone 2 amp IV
• Cardiologist consultation  Nicardipine drip start from 5mg/hours Instruction :
• Internist consultation , opthalmologist consultation , perinatologist consultation • Control GA, VS, Vaginal bleeding, Contraction
• Report to OK room • IVFD RL + 20 IU Oxytocin  20 dpm​​
• Emergency CS • IVFD RL + MgSO4 maintenance dose ​1gr/hour
• Inj. Ampicilin Sulbactam 2x1.5 gram IV​
Process : • Nicardipine on up titration
Eclampsia Antepartum on maintenance dose of MgSO4 regimen from other • Misoprostol 2 tab prerectal /8 hours
institution on G3P2A0L2 28-29 weeks of preterm pregnancy + Absent End Diastole  • Laboratory check 6 hours post op
Stabilization  LSCS + IUD Insertion • Care in ICU
• Another therapy in accordance intensivist
Admission Letter Referral Letter
Laboratorium 08-05-2024
Laboratorium 08-05-2024
CTG 08-05-2024

• Baseline : 110
• Variability : 5-10
• Acceleration : (-)
• Deceleration : (-)
• Fetal movement : (+)
• Contraction : (-)
• Impression : 2nd
category
USG PONEK
(08-05-2024)
USG PONEK
(08-05-2024)
 INTERPRETATION
Fetal, alive singleton, intrauterine, head presentation
Fetal movement was good

Biometri
• BPD : 6.97 cm HC : 24.69 cm EFW : 797 gram
• AC : 18.94 cm AFI : 5.85
• FL : 4.91 cm FHR : 149 bpm

Placenta implantation in the posterior corpus maturation grade II

Kesan:
• Gravid 28-29 weeks according to biometry
• Fetal, alive singleton, intrauterine, head presentation
• Absent end diastolic
Opthalmologist consultation

A/
• Currently, no anterior and posterior
segment abnormalities have been
found

• P/
therapy according to obgyn
Internist consultation

A/
• Eclampsia Antepartum on maintenance dose of
MgSO4 regimen from other institution on G3P2A0L2
28-29 weeks of preterm pregnancy
• P/
At this time to take action in narcotics with risks
Cardiovascular risk: Lee revised Cardiac risk cannot be
assessed
mild metabolic risk
mild pulmonary risk
hemostasis function: cannot be assessed
methyldopa 3x500 mg
 Cardiologist consultation
A/
• Eclampsia Antepartum on maintenance dose
of MgSO4 regimen from other institution on
G3P2A0L2 28-29 weeks of preterm pregnancy

P/
• drip nicardipine 5 mg / hour titrate up if
blood pressure > 180, with target blood
pressure when < 160 , if blood pressure < 160
metildopa 3x500 mg, nifedipine 1x30 mg
 Neurologist consultation
A/
• Generalize seizure on Eclampsia

P/
• therapy according to obgyn
 Operation Report
• Patient on supine position under General anaesthesia​
• Antiseptic and septic procedure was performed​
• Installed a sterile dug
• Pfannenstiel incision was performed​until peritoneal​
• Low uterine incision was performed​
• A male baby was born ​with head extraction BW : 750 gram​,
BL : 38, A/S : 3/5
• Placenta was born with mild traction, the IUD was inserted
• Uterine sutured 2 layer, plica sutured 1 layer​
• Abdomen was closed layer by layer​
• Skin closed by subcuticular closure​
• Bleeding during operation approximately 350 cc​
Documentation
Lubchenko Curve
DISCUSSION
1. Introduction

• Preterm birth (PTB), defined as birth before the 37th week of gestation, affects up to 15
million pregnancies each year globally
• Preterm infants born before 27 weeks of gestation are at greatly increased risk of
mortality and morbidity than infants born at later gestations. Several recent studies have
documented declines in their mortality over time without showing concomitant increases
in severe neonatal morbidity
• A current understanding of the complex pathogenesis of PTB is still poor, which also
explains the limited availability of targeted and effective strategies for PTB prevention.
• Several risk factors for PTB are well recognized, such as twin pregnancies,
chorioamnionitis, pre-existing maternal diseases, genetic factors, previous PTB, and
uterine abnormalities
• Interestingly, inflammation is also a key trigger of the physiological onset of labor at term
2.1 Preterm birth: A disease of the placenta

FIGURE 1
Disease states in the placenta contributing to preterm birth. Placental inflammation, endocrine dysfunction, and uteroplacental
insufficiency can lead to inflammatory activation and propagation of inflammatory mediators towards other gestational tissues. CRH
may play the predominant role in these placental disease states, with inflammation providing a feed-forward mechanism. This figure
was created with BioRender.com.
2.2 Preterm birth: A disease of the fetal membranes

FIGURE 2
Disease states in the fetal membranes contribute to preterm birth. Premature membrane senescence, chorioamnionitis, and uterine
overdistension can all lead to dysfunctional membrane remodeling, generation of danger signals (senescence-associated secretory
phenotype [SASP], and damage associate molecular pattern markers [DAMPs], and chemotaxis and immune cell activation. The localized
presence of danger signals provides greater contributions toward untimely membrane rupture, while immune cell activation in the
3.1 Preterm birth: A disease of the decidua

FIGURE 3
Disease states in the decidua contribute to preterm birth. Deciduitis, decidual hemorrhage, and premature decidual senescence all
eventually converge towards premature decidual activation characterized by leukocyte activation, inflammatory mediator production,
and decidual apoptosis. This figure was created with BioRender.com.
3.2 Preterm birth: A disease of the myometrium

Figure 4
Disease states in the myometrium contribute to preterm birth. Uterine overdistension and myometrial hemorrhage, and to a
lesser extent,
oxidative stress, may all lead to myometrial activation that produces contractions. This figure was created with
3.3 Preterm birth: A disease of the cervix

Figuree 5
Disease states in the cervix contribute to preterm birth. Cervical insufficiency and cervicitis may lead to localized
inflammatory responses that can propagate towards other tissues. Similarly, a weakened epithelium may allow passage of
How mechanism infection in preterm labour?
An integrated model for PTB. Static risk
factors may provide susceptibility to
inherited dysregulations in the fetal and
maternal tissues. An interaction with
‘pregnancy environment’ can contribute
to dynamic risk factors, such as those
from acquired disease states as discussed
per tissue subsection, may occur
throughout the pregnancy. Inflammation,
and oxidative stress, provides the central
tenet for PTB as they are inseparable in
this process. As inflammation may
propagate across different feto-maternal
tissues, and tissue cross-talk may occur
via various mechanisms, multiple
contributions from affected tissues will
eventually culminate to PTB
How to manage extremely preterm birth?
• A normal pregnancy lasts about 40
weeks. Babies born before 37 weeks of
pregnancy are called preterm or
premature. Babies born before 28
weeks of pregnancy are considered
extremely preterm.
• The earlier a baby is born, the less likely
the baby is to survive. Those who do
survive often have serious, sometimes
long-term, health problems and
disabilities.
Fig. 3 Current understanding of the inflammatory pathways of parturition.
Obstetric management
Active (survival focused) obstetric management
• When it has been agreed that potentially life-sustaining care for the baby is appro-
priate, active obstetric management is important to ensure the baby is born in the
best possible condition.
• An individualised package of obstetric intervention should be offered in all cases
where a commitment to active neonatal care is in place.The potential for each
component intervention to optimise the condition of the individual baby at birth
should be considered and not excluded on the basis of gestational age alone.
Obstetric management should be regularly reviewed, particularly if events suggest
changing prognosis for the baby.
The package of obstetric care to be offered to parents may (but not
necessarily) include any or all of the following:
• Antenatal steroids.
• Tocolysis.
• Antenatal transfer to a tertiary obstetric centre co-located with a NICU.
• Magnesium sulfate for neuroprotection.
• Deferred cord clamping, ideally for 60s or more.
• Intrapartum fetal heart rate monitoring.
• Caesarean section (if potential benefits are considered to outweigh risks)
MATERNAL CORTICOSTEROIDS
• Maternal corticosteroids are considered in preterm labor as they have been demonstrated to
reduce the risk of respiratory distress syndrome and intraventricular hemorrhage.
• Betamethasone or dexamethasone can be given as two doses of 12 mg intramuscular injections
24 hours apart. It has been demonstrated that there is no risk of neonatal necrotizing
enterocolitis, neonatal sepsis or APGAR score of less than 7 at 5 minutes
• Care needs to be taken when considering corticosteroids as they have certain side effects:
1. Will increase maternal blood sugar.
2. Will increase white blood cells.
3. Caution in the presence of cardiac disease, active tuberculosis, gastric ulcers,
chorioamnionitis and placental abruption.
• NICE recommends considering administering corticosteroids between 23 and 35 +6 weeks of
gestation in the following situations:
1. In the presence of PPROM.
2. In suspected or established preterm labor.
3. In planned preterm birth.
TOCOLYTICS
Tocolytics refer to medications intended to supress contractions.
NICE shows that multiple factors are taken into account when making the decision of whether to start a woman on
tocolysis:
• Presence of suspected or diagnosed preterm labor;3
• Gestational age at presentation;3
• The likely benefit from maternal corticosteroids;3
• The need to transfer the mother to another unit with neonatal care facilities; 3
• The preference of the woman.3
Contraindications:
• Chorioamnionitis;3
• Vaginal bleeding;3
• Indications for immediate delivery.3
NICE states:
• Nifedipine is the tocolytic of choice for women between gestational ages 24 and 33 +6 weeks with suspected
preterm labor plus intact membranes;3
• Nifedipine is the tocolytic of choice for women between gestational ages 26 and 33 +6 weeks with diagnosed
preterm labor plus intact membranes;3
• Oxytocin receptor antagonists are the tocolytic of choice in women whom nifedipine is contraindicated; 3
• Do not offer betamimetics for tocolysis.3
• RCOG concludes that there is insufficient evidence in support of the administration of tocolytics in women with
PPROM. This is due to an increase risk of chorioamnionitis, a 5 minute APGAR score of <7 and an increased need for
ventilation support.19 There is also no significant benefits to the neonate.19
MAGNESIUM SULFATE
Magnesium sulfate has been shown to offer neuroprotection for the fetus, reducing fetal cerebral
palsy and motor dysfunction.
NICE and the RCOG recommend that magnesium sulfate administration is considered during:
• Established preterm labor;
• Planned preterm delivery within 24 hours.
• Magnesium sulfate has the greatest benefit before 30 weeks of gestation.3
• RCOG suggests offering magnesium sulfate between 24–29+6 weeks of gestation after PPROM.
• NICE suggests offering it between 24 and 33+6 weeks of gestation during established preterm
labor and planned preterm delivery within 24 hours.
• An intravenous (IV) bolus of 4 g of magnesium sulfate is administered over 15 minutes which is
followed by IV infusion of 1 g per hour until the delivery or for 24 hours, whichever comes
sooner.
Maternal monitoring for toxicity every 4 hours is required, or more frequently if there are signs
of renal failure. The following signs are monitored:
• Pulse;
• Blood pressure;
• Respiratory rate;
• Deep tendon reflexes.
ROLE OF ANTIBIOTICS
• Intrauterine infection should be assessed by a combination
of clinical assessment, maternal C-reactive protein (CRP) and
white blood count, plus fetal heart rate. These tests should
not be used in isolation to diagnose infection.
• According to NICE and RCOG, antibiotics should be given
following diagnosis of PPROM. Preferably erythromycin
250 mg four times per day is given for 10 days or up until the
woman is in established labor, whichever is sooner.
• Do not offer co-amoxiclav for prophylaxis, due to its
increased risk of neonatal necrotizing enterocolitis.3
MODE OF DELIVERY
• A discussion is required with the mother about the risks
and benefits of both cesarean section and vaginal birth.
There are increased difficulties associated with cesarean
sections performed in preterm birth. There is an
increased risk of requiring a vertical uterine incision
which may have implications for future pregnancies.
• Consider cesarean section for women in established
preterm labor between 26 and 36+6 in whom the fetus is
in breech presentation.
• There was a significant advantage for women in the
vaginal delivery group with respect to puerperal pyrexia
and maternal infection. However, more research is
required before a policy can be formed from this review.
• RCOG does not routinely recommend cesarean section
for breech presentation in spontaneous preterm labor,
the mode of delivery depends on the stage of labor,
fetal well-being, type of breech presentation and skill of
operator in vaginal breech delivery.
• Cesarean section is recommended in preterm breech
presentation when delivery is planned due to
indications such as maternal and/or fetal compromise. 22
Flowchart 3: Preterm Labour Management
• ``
Fetal Fibronectin
• After identification of the glycoprotein fetal fibronectin (fFN) in 1988, it was quickly identified as
being clinically useful in helping to predict which women presenting with symptoms of threatened
preterm labour were at greatest risk of preterm birth.
• Fetal fibronectin promotes adhesion between the fetal chorion and maternal decidua and is typically
absent from cervicovaginal secretions between 24 and 36 weeks’ gestation.
• In 2013 it was shown that quantifying the level of fFN in symptomatic women enhances its
predictive value over qualitative measurement alone.
• Other biomarkers present in vaginal secretions are promoted as predictors of preterm birth but
revert to a qualitative measurement and have not been found to have as high a negative predictive
value, of great import when deciding not to administer interventions to improve neonatal outcomes.
Thank You