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Preterm LABOUR

PRETERM LABOUR

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Preterm LABOUR

  1. 1. PRETERM LABOUR -DR.DIVYA JAIN
  2. 2.  Preterm labor (PTL) is defined as the onset of labor after the gestation of viability i.e.20 weeks, and before 37 completed weeks of pregnancy with cervical changes. (ACOG JUNE 2016)
  3. 3. Incidence Overall incidence of PTL : 6 % - 10 %  Spontaneous : 40 – 50 %  PPROM : 25 – 40 %
  4. 4. Why has preterm birth decreased?
  5. 5. Does prenatal care decrease preterm delivery?
  6. 6. RISK FACTORS Maternal factors :  Previous preterm delivery .  Low socioeconomic status .  Maternal age <18 years or >40 years .  Preterm premature rupture of the membranes .  Maternal complications (medical or obstetric) .  Lack of prenatal care .  Smoking.
  7. 7. Uterine causes :  Myomata (particularly submucosal )  Uterine septum .  Bicornuate uterus .  Cervical incompetence .  Multiple gestation  Polyhydroamnios Placental causes :  Abnormal placentation
  8. 8. Infectious factors :  Genital : Bacterial vaginosis , Chlamydia, GBS, Mycoplasmas  Intra-uterine : 1)Ascending (from genital tract) 2) Transplacental (blood-borne) 3)Transfallopian (intraperitoneal) 4)Iatrogenic (invasive procedures)  Extra-uterine : Pyelonephritis,Malaria,Typhoid fever, Pneumonia Listeria , Asymptomatic bacteriuria
  9. 9. PATHOGENESIS OF PRETERMLABOUR
  10. 10. Diagnosis  Occurrence of regular uterine contractions with or without pain (at least one in every 10 minute.)  Cervical changes – effacement >80% and dilatation> 1cm.  Length of cervix <2.5cm and funelling of the internal os.  Pelvic pressure, backache and or vaginal discharge or bleeding.
  11. 11. Tocodynamometry to evaluate for the presence of uterine contractions contractions
  12. 12. Speculum examination to assess for ruptured membranes or bleeding
  13. 13. Laboratory evaluation for urinalysis & culture
  14. 14. FFN testing  High negative predictive value  More than 99% of symptomatic patients with a negative fFN did not deliver within 14 days  Cannot be performed with: 1. Vaginal bleeding 2. Ruptured membranes 3. After recent intercourse 4. After vaginal examination 5. After transvaginal ultrasound
  15. 15. Sonography  Cervical length  Internal os diameter  Presence or absence of funelling – funnel length and width, percentage funelling  Pathology
  16. 16. PREVENTION Primary prevention :  Aim : lower the prevalence of premature labor by improving maternal health in general and by avoiding risk factors before or during pregnancy  Measures : 1- Smoking cessation . 2- Nutritional counseling . 3- lower workload for women with stressful jobs
  17. 17. Secondary prevention  Aim : Early identification of pregnant women at a risk of preterm labor and help them to carry their pregnancies to term.  Measures : 1- Self-measurement of the vaginal pH for B.V. 2- Cervix length measurement by TVS . (The accepted cutoff value for cervix length is ≤ 25mm before GW 24 ) 3- Cerclage and complete closure of the birth canal 4- Progesterone supplementation
  18. 18. Is progesterone our new silver bullet?
  19. 19.  Progesterone is a hormone that inhibits the uterus from contracting. It is involved in maintaining pregnancy, especially early in gestation.  Progesterone has been recommended for pregnant women with prior preterm birth.  Dose- 1) 17-OH Progesterone caproate :250 mg im weekly 2) Micronized progesterone :200 mg vaginally
  20. 20.  A woman with a singleton gestation and a prior spontaneous preterm singleton birth should be offered progesterone supplementation starting at 16–24 weeks of gestation, regardless of transvaginal ultrasound cervical length, to reduce the risk of recurrent spontaneous preterm birth.  Vaginal progesterone is recommended as a management option to reduce the risk of preterm birth in asymptomatic women with a singleton gestation without a prior preterm birth with an incidentally identified very short cervical length less than or equal to 20 mm before or at 24weeks of gestation. RECOMMENDATION (ACOG 2012)
  21. 21. Prophylactic cerclage  Cerclage is effective treatment for short cervical length(less than 15-25mm) with history of preterm birth.  Cerclage is indicated in history of cervical injury, progressive cervical shortening <25mm despite progesterone therapy.
  22. 22. History of preterm birth Prescribe 17- OHP, 250 mg IM weekly from 16 to 37 weeks Measure TVCL every 14 days rom 16–24 wk of gestation, every 7 days, if CL<30 mm If TVCL <25 mm before24 wk of gestation: 1. Consider CERCLAGE (especially if patient had prior spontaneous preterm birth at <28 wk or if membranes are visible) 2. Continue progesterone
  23. 23. Treatment  Inhibition of uterine contractions with tocolytics  Corticosteroids to induce fetal lung maturation  Treatment of infection with antibiotics  Magnesium sulfate for neuroprotection (24 and 32 weeks)  Bed rest and hospitalization.
  24. 24. Tocolysis  Aim of tocolysis : Suppress uterine contractions and delay preterm delivery to : 1-allow in-utero transfer to an appropriate level facility . 2-allow for the administration of corticosteroids.
  25. 25. Contraindications : • Labour is too advanced • In utero fetal death • Lethal fetal anomalies • Suspected fetal compromise • Placental abruption • Suspected intra-uterine infection • Maternal hypotension: BP < 90 mmHg systolic Relative contraindications : • pre-eclampsia . • placenta praevia .
  26. 26.  Tocolytic drugs that are used in clinical practice 1) Calcium antagonists . ( Nifedipine ) 2) Oxytocin-receptor antagonist (Atosiban) 3) NO donors . ( Nitroglycerin) 4) Betamimetics . ( Terbutaline & Ritodrine ) 5)Magnesium sulfate . ( MgSO4 )
  27. 27. Neuroprotection  MgSO4 reduces the severity and risk of cerebral palsy if administered when birth is anticipated before 32 weeks of gestation.  4gm loading dose followed by1gm/hr for 12 hours (RCOG 2013)
  28. 28. Corticosteroids  Antenatal corticosteroids are associated with a significant reduction in rates of RDS, NEC and IVH.  Two 12 mg doses of betamethasone given IM 24 hours apart, Or Four 6 mg doses of dexamethasone given IM 12 hours apart.  MOA of steroids. 1. Stimulates type II pneumocyctes to produce surfactant. 2. Accelerated maturation of fetal intestines
  29. 29. Antibiotics  All patients in preterm labor are considered at high risk for neonatal GBS sepsis and should receive prophylactic antibiotics regardless of culture status.  CDC Advises Screening All Pregnant Women for GroupB Strep 35-37weeks  The goal of this strategy is to prevent neonatal sepsis, and not to prevent preterm birth. (ACOG 2012 GUIDELINES)
  30. 30. In cases of suspected chorioamnionitis, determination of CRP is useful. Value < 0.9 mg/dl- continue expectant management. Value between 0.9-1.6- repeat in 12-24 hrs depending on clinical situation. Value of 3-4 mg/dl-almost certainly indicative of infection.
  31. 31.  The decision to place a rescue suture should be individualised, taking into account the gestation at presentation, as even with rescue cerclage the risks of severe preterm delivery and neonatal mortality and morbidity remain high.  Insertion of a rescue cerclage may delay delivery by a further 5 weeks on average compared with expectant management/bed rest alone. It may also be associated with a two-fold reduction in the chance of delivery before 34 weeks of gestation. However, there are only limited data to support an associated improvement in neonatal mortality or morbidity.  Advanced dilatation of the cervix (more than 4 cm) or membrane prolapse beyond the external os appears to be associated with a high chance of cerclage failure. RESCUE CERCLAGE (RCOG 2012)

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