PTL/PPROM and
Multifetal Gestation
ANNA BUABBUD MD
MS3 LECTURE
PTL/PPROM Objectives
Identify risk factors
List the adverse outcomes associated with preterm birth
List the signs and symptoms, physical exam findings, and
diagnostic methods to confirm PTL/PPROM
Describe the management of PTL based on gestational age
Describe the counseling for reducing preterm birth risk in future
pregnancy
Describe the management of PROM based on gestational age
Describe the risks and benefits of expectant management versus
immediate delivery following PROM
List the indications and contraindications of medications used in
PTL and/or PROM
Case
32yo G3P1011 at 26 weeks 2 days by LMP and 6 week
ultrasound presents to the hospital.
HPI: feeling tightening of her abdomen every 5-10
minutes, somewhat painful, for the last hour; feels
some fetal movement; denies vaginal bleeding;
unsure if she had some leaking of fluid
What is PTL?
Preterm Labor
Preterm: Less than 37 weeks gestation (extreme preterm <28
weeks)
Labor: Regular contractions with cervical change
Leading cause neonatal morbidity in developed
countries
40-50% preterm birth
Adverse Outcomes in Preterm Birth
Neonatal morbidity: RDS, hypothermia, hypoglycemia,
jaundice, IVH, NEC, BPD, sepsis, PDA, seizures, CP,
retinopathy of prematurity
Case
32yo G3P1011 at 26.2 weeks by LMP and 6 week
ultrasound presents to the hospital.
HPI: feeling tightening of her abdomen every 5-10
minutes, somewhat painful, for the last hour; feels
some fetal movement; denies vaginal bleeding;
unsure if she had some leaking of fluid
What do we do from here?
OB history, Gyn history, PMH, PSH, Meds, Allergies, SH, FH
Work up for PTL
History:
Gestational age
Symptoms
Risk factors
Why does PTL occur?
Risks: Uterine malformations:
Prior PTD bicornuate, didelphys, fibroids
Infections:
VB in 2nd/3rd trimester-
placenta previa or abruption
UTIs, pyelonephritis
BV
Cervical insufficiency
Chorioamnionitis (IAI)- Maternal Smoking or illicit
ureaplasma, mycoplasma, drug use
gardnerella, peptostreptococci, Low SES
bacteroides Low BMI
Uterine over-distention: Iatrogenic (medical
multiples, polyhydramnios
Causes: indications)
Maternal or fetal HPA axis- stress
Decidual-chorioamniotic inflammation (infection)
Decidual hemorrhage
Uterine distention
Case
32yo G3P1011 at 26w2d by LMP and 6 week
ultrasound presents to the hospital.
HPI: feeling tightening of her abdomen every 5-10
minutes, somewhat painful, for the last hour; feels
some fetal movement; denies vaginal bleeding;
unsure if she had some leaking of fluid
What do we do from here?
OB history, Gyn history, PMH, PSH, Meds, Allergies, SH, FH
Physical Exam including vital signs, EFM/Toco
Work up for PTL
History
Gestational age
Risk Factors
Physical exam
Vitals
EFM/Toco
SSE: VB, pooling, dilation, membranes, purulent discharge
FFN, nitrizine, cultures
SVE
Labs
CBC, U/A, Ucx
Imaging
Ultrasound for position/presentation, EFW/GA, placenta, AFI, anomalies, CL
Management of PTL
If there is no fetal or maternal reason to deliver:
Hydrate
GBS ppx
Steroids (decreases RDS, IVH, NEC, death)
Betamethasone 12mg IM Q24h x2 (or dexamethasone 6mg IM Q6h x4)
Magnesium for neuroprotection
<32 weeks
Tocolysis for steroids
Contraindicated with infection, NRFHT, eclampsia, demise, fetal maturity, maternal
instability
Nifedipine, indomethicin (<32w)
Delivery method:
Breech:
<26w or <1000g vaginal delivery
>26w or >1000g CD (risk head entrapment)
Cephalic vaginal delivery
Management of PTL
Management of PTL
How to prevent PTL
Warning signs awareness
Cramps, low/dull backache, abdominal or pelvic pressure, abd
cramping, increased discharge, ctx
Treat infections
E.g. BV, chlamydia, UTI
Progesterone supplementation
17-OHP weekly from 16wks (to 36w) for women with prior PTB
Vaginal progesterone (100-200mg) if <20mm cervix at <24wks
Low dose aspirin at 12wks if:
Prior PEC, multiples, cHTN, DM1 or 2, renal dz; consider for
autoimmune, low PAPP-A, recurrent pregnancy loss
Cerclage?
Indicated for cervical insufficiency (painless cervical
dilation)
History-indicated:
One or more second trimester pregnancy losses related to painless
cervical dilation in the absence of labor or abruptio placentae
Prior cerclage due to painless cervical dilation in the second trimester
Physical exam-indicated:
Painless cervical dilation in the second trimester
Short cervix (<20mm) before 24 weeks
Ultrasound finding with history of prior preterm birth:
Current singleton pregnancy, prior spontaneous preterm birth at less
than 34 weeks and short cervix (<25mm) before 24 weeks
How to screen for PTL
Cervical length
Fetal fibronectin
22-34 weeks if S/Sx of preterm labor
False positive with: lubricant, VB, ROM, intercourse or exam
within 24h
Collect via speculum (or blindly) from posterior fornix
Reassuring if negative
NPV 99% for delivery within 7d
Bad PPV (14% for delivery within 7d)
Screening for PTL
What is PPROM?
Preterm:
less than 37 weeks gestation
Prelabor:
prior to onset of labor
ROM:
rupture of membranes
3-19% deliveries, 30% preterm deliveries
Interval to labor varies by GA
<26w: 50% labor within 1wk
28-34w: 50% labor within 24h, 80-90% labor within 1wk
Risks for PPROM
Intrauterine infection
Prior history PPROM or PTL
Multifetal gestation
Vaginal bleeding
Trauma
Amniocentesis
Polyhydramnios
Case
32yo G3P1011 at 26w2d by LMP and 6 week
ultrasound presents to the hospital.
HPI: notes significant amount of clear fluid leaking
vaginally for the past day; denies tightening of her
abdomen; feels some fetal movement; denies vaginal
bleeding
What do we do from here?
OB history, Gyn history, PMH, PSH, Meds, Allergies, SH, FH
Physical Exam including vital signs, EFM/Toco
Work up for PPROM
Same as PTL
Specific history of ROM
Avoid digital exam (increases risk neonatal sepsis and maternal
infection, decreases latency)
If work up negative initially, repeat after laying down for some hours-
could do tampon test (blue dye)
Differential:
Urinary incontinence
Increased vaginal secretions (leukorrhea)
Increased cervical discharge
Infection
Exogenous fluid (semen, douche)
Vesicovaginal fistula
Work up for PPROM
Management of PPROM
Rule out infection, abruption
Inpatient management
Bedrest if fetal head not well applied (cord prolapse)
<34w:
Latency antibiotics:
IV amp 2g q6h, IV erythromycin q6h for 48h
PO amoxicillin 250mg q6h, PO erythromycin 250mg q6h- 5 additional days (can also use
azithromycin)
Single dose of azithryomycin?
Steroids
Betamethasone 12mg IM Q24h x2 (or dexamethasone 6mg IM Q6h x4)
NO TOCOLYSIS (except to give BMZ)
Delivery
32-34w consider delivery
>34w or chorio/IAI, NRFHT, hemorrhage delivery (vaginal or cesarean)
Case
32yo G3P1011 at 26 weeks 2 days by LMP and 6 week
ultrasound diagnosed with PPROM.
Admitted
Betamethasone, Magnesium
Antibiotics
Monitored on L+D
Transferred to Antepartum
Continued to have LOF
Felt pain at 28 weeks
Vaginal delivery, infant to NICU
PTL/PPROM Objectives
Identify risk factors
List the adverse outcomes associated with preterm birth
List the signs and symptoms, physical exam findings, and
diagnostic methods to confirm PTL/PPROM
Describe the management of PTL based on gestational age
Describe the counseling for reducing preterm birth risk in future
pregnancy
Describe the management of PROM based on gestational age
Describe the risks and benefits of expectant management versus
immediate delivery following PROM
List the indications and contraindications of medications used in
PTL and/or PROM
Multifetal Gestation
Multifetal Gestation: Objectives
List the risk factors for multifetal gestation
Describe the embryology of multifetal gestation
Describe maternal and fetal physiologic changes
associated with multifetal gestation
Describe diagnosis and multidisciplinary
management of multifetal gestation
Describe the potential maternal and fetal
complications and safety concerns associated with
multifetal gestation
Multifetal Gestation
Risk Factors
AMA
Genetics
Assisted Reproductive Technologies
Maternal Physiologic Changes
Blood volume increases 50-60% (only 40% increase in
singletons)
Increased cardiac output (stroke volume)
Increased iron needs
Increased uterine size
Increased shortness of breath
Multifetal Gestation
• Embryology:
Monozygotic Dizygotic
Multifetal Gestation
Monozygotic twin pregnancy
Early embryo splits
Chorionicity and amnionicity depend on when split occurs
Chorion = placenta
Amnion = sac
Split occurs
0-4 days: Dichorionic diamniotic (2 placentas, 2 sac)
4-8 days: Monochorionic diamniotic (1 placenta, 2 sacs)
8-12 days: Monochorionic monoamniotic (1 placenta, 1 sac)
> 12 days: Conjoined twins
Always SAME SEX (Identical twins)
Dizygotic twin pregnancy
Dichorionic diamniotic (2 placentas, 2 sacs)
Sometimes same sex (fraternal twins)
Multifetal Gestation
Monozygotic twin pregnancy
0-3 Days 4-8 Days 8-12
Days
Dichorionic Monochorionic Monochorionic
diamniotic diamniotic monoamniotic
Multifetal Gestation
Diagnostic testing: Ultrasound
Used to determine chorionicity before 14 weeks
Membrane thickness at site of insertion of amniotic
membrane into the placenta (chorion)
Lambda (λ) sign = Dichorionic T sign = Monochorionic
Multifetal Gestation
Risks (all twins) Placental abruption
Pre-eclampsia
Abortion
Anemia Gestational diabetes (GDM)
Cerebral Palsy Postpartum hemorrhage
Cesarean Delivery
(PPH)
Postpartum Depression
Growth Restriction
Prematurity
Hyperemesis gravidarum
IVH 2x
Preterm labor (PTL)
Necrotizing enterocolitis
Prelabor rupture of RDS
membranes (PROM) Stillbirth (5x)
Preterm birth (PTB) 6x
Neonatal death (7x)
Placenta previa
Multifetal Gestation
Risks by type of twin:
Monochorionic twins
Congenital anomalies (i.e. heart defects)
Weight discordance
Monochorionic diamniotic
Twin twin transfusion syndrome (TTTS)
Twin anemia polycythemia sequence (TAPS)
Twin reversed arterial perfusion (TRAP)
Monochorionic monoamniotic
Cord entanglement/accident
Multifetal Gestation
Management
Increased weight gain recommendations
Delivery
Dichorionic/Diamniotic (DCDA) 38 wks
Growth scan q4 weeks
Delivery
Monochorionic/Diamniotic (MC/DA) 34-37 wks
Growth scan q4 weeks
Fluid/bladder scan q2 weeks (start @ 16wks) – screening TTTS
MCA dopplers q2 weeks (start @ 20wks) – screening TAPS
Non-stress tests weekly (start @ 32wks)
Monochorionic/Monoamniotic (MC/MA) Delivery
Above + 32-34 wks
Inpatient management @ 24-28 wks Cesarean
Multifetal Gestation
Management: Mode of delivery
Depends on presentation of presenting twin (Twin A)
Vertex-vertex Vaginal delivery
Vertex/Breech or Transverse Vaginal or Cesarean
Vaginal IF < 20% weight discordance, provider trained in breech
extraction
Non-vertex Twin A Cesarean section
Multifetal Gestation- Case
36yo G2P1001 at 12w3d gestation found to have a dichorionic
diamniotic twin gestation.
What did the ultrasound look like to determine this?
Lambda sign
Can you tell zygoticity from this ultrasound?
No
If it was a monozygotic pregnancy, when did the split occur?
Between 0-3 days
What are her risks factors of having a twin gestation?
Age >35
What do you recommend for the patient during her prenatal care?
Increased weight gain (37-54lb if BMI 18.5-25)
Iron supplementation, consider calcium supplementation
Multifetal Gestation- Case
36yo G2P1001 at 12w3d gestation found to have a dichorionic
diamniotic twin gestation.
What is she at risk of during the pregnancy?
Preeclampsia, GDM, anemiaWhat are the risks to the fetus?
Preterm delivery, growth restriction, stillbirth
What do you recommend for prenatal monitoring
Growth ultrasounds
Can she have a vaginal delivery?
Yes, if first twin is cephalic
When should she deliver?
38 weeks
What are her risks at the time of delivery?
Hemorrhage, cesarean delivery
Questions?
Thank you! Good Luck!
