Management of Preterm Labour

Diagnosis and Initial Assessment

The American College of Obstetricians and Gynecologists recommends initial assessment to include evaluation for signs of infection, placental abruption, and fetal well-being 2
Fetal biometry, amniotic fluid volume assessment, and fetal Doppler waveform analysis should be performed at first diagnosis 2
Intraamniotic infection is diagnosed clinically based on maternal temperature ≥38°C and other signs (maternal tachycardia, purulent cervical discharge, fetal tachycardia, uterine tenderness) 3
Some cases of intraamniotic infection may not initially present with maternal fever, so diagnosis and intervention should not be delayed due to absence of fever 3

The American College of Obstetricians and Gynecologists recommends that all patients with previable PPROM (<20 weeks) be offered abortion care due to high maternal risks and poor fetal outcomes 1
Expectant management can be offered in absence of contraindications 1
The American College of Obstetricians and Gynecologists recommends shared decision-making regarding antibiotic use 4
Contraindications to expectant management include intraamniotic infection, hemorrhage, and fetal demise 3, 5
Neonatal survival rates vary from 17% to 80%, with approximately 20% surviving after PPROM at 16-19 weeks, 30% after PPROM at 20-21 weeks, and 41% after PPROM at 22-23 weeks 8

A 7-day course of antibiotic therapy with IV ampicillin and erythromycin for 48 hours followed by oral amoxicillin and erythromycin for 5 days is recommended 2
Azithromycin can replace erythromycin if unavailable 4, 2
Avoid amoxicillin-clavulanic acid due to increased risk of necrotizing enterocolitis 4, 2
Antenatal corticosteroids should be administered between 24+0 and 34+0 weeks gestation to accelerate fetal lung maturity 4, 2
Magnesium sulfate is recommended for fetal neuroprotection when delivery is anticipated before 32 weeks 4, 2

Initial observation in hospital is reasonable to ensure stability 2
Monitor for signs of maternal complications such as hemorrhage or infection 2
Daily temperature monitoring to screen for maternal fever is recommended 9
Weekly outpatient visits for assessment of maternal vital signs, fetal heart rate, physical examination, and possible laboratory evaluation 2

Expectant management increases risk of maternal complications including infection, hemorrhage, and death compared to abortion care 6, 7
Composite maternal morbidity is higher with expectant management compared to abortion care (60.2% vs 33.0%) 6
Intraamniotic infection occurs in 38.0% of those choosing expectant management vs 13.0% choosing abortion care 6
Maternal sepsis has been reported in up to 6.8% of cases of previable and periviable PPROM 7
Maternal mortality rate associated with expectant management of PPROM at 14-24 weeks is approximately 45 per 100,000 patients 7

Delaying diagnosis and treatment of intraamniotic infection due to absence of maternal fever 3
Using amoxicillin-clavulanic acid, which increases risk of necrotizing enterocolitis 4, 2
Prolonged or repeated antibiotic courses beyond what would be used for PPROM at later gestational ages 4
Administering antenatal corticosteroids and magnesium sulfate before the time when neonatal resuscitation would be appropriate 1, 4