Suche senden
Hochladen
PREVENTION OF PRETERM BIRTH
•
10 gefällt mir
•
2,593 views
Aboubakr Elnashar
Folgen
ABOUBAKR ELNASHAR
Weniger lesen
Mehr lesen
Gesundheit & Medizin
Melden
Teilen
Melden
Teilen
1 von 32
Jetzt herunterladen
Downloaden Sie, um offline zu lesen
Empfohlen
Maternal Near Miss
Maternal Near Miss
Aboubakr Elnashar
PREVENTION OF PRETERM LABOUR - EVIDENCES FOR PROGESTERONE BY DR SHASHWAT JANI
PREVENTION OF PRETERM LABOUR - EVIDENCES FOR PROGESTERONE BY DR SHASHWAT JANI
DR SHASHWAT JANI
Fetal therapy
Fetal therapy
magdy abdel
Ndvh
Ndvh
Manjushree Boob
Cesarean Scar Pregnancy
Cesarean Scar Pregnancy
Aboubakr Elnashar
Unnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicine
Aboubakr Elnashar
Visual inspection of cervix
Visual inspection of cervix
Aboubakr Elnashar
CAESAREAN SCAR DEFECT
CAESAREAN SCAR DEFECT
Aboubakr Elnashar
Empfohlen
Maternal Near Miss
Maternal Near Miss
Aboubakr Elnashar
PREVENTION OF PRETERM LABOUR - EVIDENCES FOR PROGESTERONE BY DR SHASHWAT JANI
PREVENTION OF PRETERM LABOUR - EVIDENCES FOR PROGESTERONE BY DR SHASHWAT JANI
DR SHASHWAT JANI
Fetal therapy
Fetal therapy
magdy abdel
Ndvh
Ndvh
Manjushree Boob
Cesarean Scar Pregnancy
Cesarean Scar Pregnancy
Aboubakr Elnashar
Unnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicine
Aboubakr Elnashar
Visual inspection of cervix
Visual inspection of cervix
Aboubakr Elnashar
CAESAREAN SCAR DEFECT
CAESAREAN SCAR DEFECT
Aboubakr Elnashar
Unexplained Infertility - By Dr Dhorepatil Bharati
Unexplained Infertility - By Dr Dhorepatil Bharati
Bharati Dhorepatil
COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021
Aboubakr Elnashar
Role of Stem Cells in Obstetrics and Gynecology Practice
Role of Stem Cells in Obstetrics and Gynecology Practice
Asha Jain
Overview of IUGR FGR
Overview of IUGR FGR
Dr.Laxmi Agrawal Shrikhande
The role of the gynecologist in screening & prevention of Osteoporosis
The role of the gynecologist in screening & prevention of Osteoporosis
Aboubakr Elnashar
Intrauterine growth restriction
Intrauterine growth restriction
nermine amin
Multifoetal reduction in Infertility
Multifoetal reduction in Infertility
Sujoy Dasgupta
Aub ieta -lucknow
Aub ieta -lucknow
NARENDRA MALHOTRA
Hysteroscopy and infertility
Hysteroscopy and infertility
Radwa Rasheedy
FIGO 2018 Cancer Cervix
FIGO 2018 Cancer Cervix
Siddharth Sreemahadevan
Preterm labour NICE guideline November 2015
Preterm labour NICE guideline November 2015
Aboubakr Elnashar
ATOSIBAN IN PRETERM LABOR by Dr Sharda Jain
ATOSIBAN IN PRETERM LABOR by Dr Sharda Jain
Lifecare Centre
FETAL GROWTH RETARDATION In Modern Practice –Made Simple
FETAL GROWTH RETARDATION In Modern Practice –Made Simple
Lifecare Centre
ANTENATAL SURVEILLANCE AND MANAGEMENT OF MULTIPLE PREGNANCY – RECENT ADVANCES...
ANTENATAL SURVEILLANCE AND MANAGEMENT OF MULTIPLE PREGNANCY – RECENT ADVANCES...
Lifecare Centre
Dilemmas in Diagnosis and Management of FGR Dr NNC 06082022.pptx
Dilemmas in Diagnosis and Management of FGR Dr NNC 06082022.pptx
Niranjan Chavan
Maternal collapse in pregnancy & puerperium
Maternal collapse in pregnancy & puerperium
dr shabnam naz shaikh
Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
Nassr ALBarhi
Hysteroscopic endometial resection
Hysteroscopic endometial resection
Dr. Aisha M Elbareg
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
Aboubakr Elnashar
SCAR ECTOPIC
SCAR ECTOPIC
Niranjan Chavan
Strategy update
Strategy update
Gavi, the Vaccine Alliance
why life birth rate after ART declined?
why life birth rate after ART declined?
Aboubakr Elnashar
Weitere ähnliche Inhalte
Was ist angesagt?
Unexplained Infertility - By Dr Dhorepatil Bharati
Unexplained Infertility - By Dr Dhorepatil Bharati
Bharati Dhorepatil
COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021
Aboubakr Elnashar
Role of Stem Cells in Obstetrics and Gynecology Practice
Role of Stem Cells in Obstetrics and Gynecology Practice
Asha Jain
Overview of IUGR FGR
Overview of IUGR FGR
Dr.Laxmi Agrawal Shrikhande
The role of the gynecologist in screening & prevention of Osteoporosis
The role of the gynecologist in screening & prevention of Osteoporosis
Aboubakr Elnashar
Intrauterine growth restriction
Intrauterine growth restriction
nermine amin
Multifoetal reduction in Infertility
Multifoetal reduction in Infertility
Sujoy Dasgupta
Aub ieta -lucknow
Aub ieta -lucknow
NARENDRA MALHOTRA
Hysteroscopy and infertility
Hysteroscopy and infertility
Radwa Rasheedy
FIGO 2018 Cancer Cervix
FIGO 2018 Cancer Cervix
Siddharth Sreemahadevan
Preterm labour NICE guideline November 2015
Preterm labour NICE guideline November 2015
Aboubakr Elnashar
ATOSIBAN IN PRETERM LABOR by Dr Sharda Jain
ATOSIBAN IN PRETERM LABOR by Dr Sharda Jain
Lifecare Centre
FETAL GROWTH RETARDATION In Modern Practice –Made Simple
FETAL GROWTH RETARDATION In Modern Practice –Made Simple
Lifecare Centre
ANTENATAL SURVEILLANCE AND MANAGEMENT OF MULTIPLE PREGNANCY – RECENT ADVANCES...
ANTENATAL SURVEILLANCE AND MANAGEMENT OF MULTIPLE PREGNANCY – RECENT ADVANCES...
Lifecare Centre
Dilemmas in Diagnosis and Management of FGR Dr NNC 06082022.pptx
Dilemmas in Diagnosis and Management of FGR Dr NNC 06082022.pptx
Niranjan Chavan
Maternal collapse in pregnancy & puerperium
Maternal collapse in pregnancy & puerperium
dr shabnam naz shaikh
Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
Nassr ALBarhi
Hysteroscopic endometial resection
Hysteroscopic endometial resection
Dr. Aisha M Elbareg
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
Aboubakr Elnashar
SCAR ECTOPIC
SCAR ECTOPIC
Niranjan Chavan
Was ist angesagt?
(20)
Unexplained Infertility - By Dr Dhorepatil Bharati
Unexplained Infertility - By Dr Dhorepatil Bharati
COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021
Role of Stem Cells in Obstetrics and Gynecology Practice
Role of Stem Cells in Obstetrics and Gynecology Practice
Overview of IUGR FGR
Overview of IUGR FGR
The role of the gynecologist in screening & prevention of Osteoporosis
The role of the gynecologist in screening & prevention of Osteoporosis
Intrauterine growth restriction
Intrauterine growth restriction
Multifoetal reduction in Infertility
Multifoetal reduction in Infertility
Aub ieta -lucknow
Aub ieta -lucknow
Hysteroscopy and infertility
Hysteroscopy and infertility
FIGO 2018 Cancer Cervix
FIGO 2018 Cancer Cervix
Preterm labour NICE guideline November 2015
Preterm labour NICE guideline November 2015
ATOSIBAN IN PRETERM LABOR by Dr Sharda Jain
ATOSIBAN IN PRETERM LABOR by Dr Sharda Jain
FETAL GROWTH RETARDATION In Modern Practice –Made Simple
FETAL GROWTH RETARDATION In Modern Practice –Made Simple
ANTENATAL SURVEILLANCE AND MANAGEMENT OF MULTIPLE PREGNANCY – RECENT ADVANCES...
ANTENATAL SURVEILLANCE AND MANAGEMENT OF MULTIPLE PREGNANCY – RECENT ADVANCES...
Dilemmas in Diagnosis and Management of FGR Dr NNC 06082022.pptx
Dilemmas in Diagnosis and Management of FGR Dr NNC 06082022.pptx
Maternal collapse in pregnancy & puerperium
Maternal collapse in pregnancy & puerperium
Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
Hysteroscopic endometial resection
Hysteroscopic endometial resection
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
SCAR ECTOPIC
SCAR ECTOPIC
Ähnlich wie PREVENTION OF PRETERM BIRTH
Strategy update
Strategy update
Gavi, the Vaccine Alliance
why life birth rate after ART declined?
why life birth rate after ART declined?
Aboubakr Elnashar
Impact of Covid-19 on Family Planning Services.pptx.pdf
Impact of Covid-19 on Family Planning Services.pptx.pdf
Ghada Elhady
Rationale convergence planning
Rationale convergence planning
Lexi Ixel
Indonesia mdg overview_bnk
Indonesia mdg overview_bnk
Anggit T A W
Millenium development goals
Millenium development goals
hariprakashdr
Galgal png national stakeholder workshop presentation
Galgal png national stakeholder workshop presentation
Technical Centre for Agricultural and Rural Cooperation ACP-EU (CTA)
Financing Nutrition in India: Cost Implications of the Nutrition Policy Lands...
Financing Nutrition in India: Cost Implications of the Nutrition Policy Lands...
POSHAN
Universal Basic Income
Universal Basic Income
RobinsonRaja1
Marco safadi
Marco safadi
Meningitis Research Foundation
Ghana Priorities: Family Planning
Ghana Priorities: Family Planning
Copenhagen_Consensus
Annual ESG and Impact Report
Annual ESG and Impact Report
Clémence Bourrin
Making Growth Worth for the Poor
Making Growth Worth for the Poor
WBKDC
Did migration enhance economic sustainability Insights from a long running pa...
Did migration enhance economic sustainability Insights from a long running pa...
Parvez641710
Ingvar Theo Olsen - Norwegian Involvement in RBF
Ingvar Theo Olsen - Norwegian Involvement in RBF
RikuE
Population Growth and the Challenges of Human Capital Development by Dr. Ejik...
Population Growth and the Challenges of Human Capital Development by Dr. Ejik...
NigeriaFamilyPlannin
Healthworkforce development in Francophone West Africa
Healthworkforce development in Francophone West Africa
Dr. Adidja AMANI, MD MPH
GFPR Ousmane Badiane Presentation - IFPRI AFRICA
GFPR Ousmane Badiane Presentation - IFPRI AFRICA
IFPRI Africa
Philippines HDI Value and Ranking and Highlights of the 5th MDG Progress Report
Philippines HDI Value and Ranking and Highlights of the 5th MDG Progress Report
kukaii
Millenium development goals
Millenium development goals
Dr.Hari Prakash
Ähnlich wie PREVENTION OF PRETERM BIRTH
(20)
Strategy update
Strategy update
why life birth rate after ART declined?
why life birth rate after ART declined?
Impact of Covid-19 on Family Planning Services.pptx.pdf
Impact of Covid-19 on Family Planning Services.pptx.pdf
Rationale convergence planning
Rationale convergence planning
Indonesia mdg overview_bnk
Indonesia mdg overview_bnk
Millenium development goals
Millenium development goals
Galgal png national stakeholder workshop presentation
Galgal png national stakeholder workshop presentation
Financing Nutrition in India: Cost Implications of the Nutrition Policy Lands...
Financing Nutrition in India: Cost Implications of the Nutrition Policy Lands...
Universal Basic Income
Universal Basic Income
Marco safadi
Marco safadi
Ghana Priorities: Family Planning
Ghana Priorities: Family Planning
Annual ESG and Impact Report
Annual ESG and Impact Report
Making Growth Worth for the Poor
Making Growth Worth for the Poor
Did migration enhance economic sustainability Insights from a long running pa...
Did migration enhance economic sustainability Insights from a long running pa...
Ingvar Theo Olsen - Norwegian Involvement in RBF
Ingvar Theo Olsen - Norwegian Involvement in RBF
Population Growth and the Challenges of Human Capital Development by Dr. Ejik...
Population Growth and the Challenges of Human Capital Development by Dr. Ejik...
Healthworkforce development in Francophone West Africa
Healthworkforce development in Francophone West Africa
GFPR Ousmane Badiane Presentation - IFPRI AFRICA
GFPR Ousmane Badiane Presentation - IFPRI AFRICA
Philippines HDI Value and Ranking and Highlights of the 5th MDG Progress Report
Philippines HDI Value and Ranking and Highlights of the 5th MDG Progress Report
Millenium development goals
Millenium development goals
Mehr von Aboubakr Elnashar
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
Aboubakr Elnashar
hepatitis B.pdf
hepatitis B.pdf
Aboubakr Elnashar
hepatitis c2022.pdf
hepatitis c2022.pdf
Aboubakr Elnashar
Adenomyosis associated infertility
Adenomyosis associated infertility
Aboubakr Elnashar
Endometriosis associated infertility: ESHRE2022
Endometriosis associated infertility: ESHRE2022
Aboubakr Elnashar
Adenxal mass guidelines2020
Adenxal mass guidelines2020
Aboubakr Elnashar
Aesthetic gynecology controversy
Aesthetic gynecology controversy
Aboubakr Elnashar
Hormonal assay in clinical gyn
Hormonal assay in clinical gyn
Aboubakr Elnashar
FIRST TRIMESTER ANC OF IVF
FIRST TRIMESTER ANC OF IVF
Aboubakr Elnashar
Infertility prevention
Infertility prevention
Aboubakr Elnashar
Individualisation of controlled ovarian stimulation
Individualisation of controlled ovarian stimulation
Aboubakr Elnashar
Female infertility
Female infertility
Aboubakr Elnashar
Maternal near miss
Maternal near miss
Aboubakr Elnashar
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
Aboubakr Elnashar
cesarean birth: procedural aspects: NICE2021
cesarean birth: procedural aspects: NICE2021
Aboubakr Elnashar
Management of pregnancy of unknown location
Management of pregnancy of unknown location
Aboubakr Elnashar
Aerobic Vaginitis
Aerobic Vaginitis
Aboubakr Elnashar
Imaging in pregnancy 2 in1
Imaging in pregnancy 2 in1
Aboubakr Elnashar
update on PCOS
update on PCOS
Aboubakr Elnashar
PREECLAMPSIA‐ECLAMPSIA SPECTRUM
PREECLAMPSIA‐ECLAMPSIA SPECTRUM
Aboubakr Elnashar
Mehr von Aboubakr Elnashar
(20)
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
hepatitis B.pdf
hepatitis B.pdf
hepatitis c2022.pdf
hepatitis c2022.pdf
Adenomyosis associated infertility
Adenomyosis associated infertility
Endometriosis associated infertility: ESHRE2022
Endometriosis associated infertility: ESHRE2022
Adenxal mass guidelines2020
Adenxal mass guidelines2020
Aesthetic gynecology controversy
Aesthetic gynecology controversy
Hormonal assay in clinical gyn
Hormonal assay in clinical gyn
FIRST TRIMESTER ANC OF IVF
FIRST TRIMESTER ANC OF IVF
Infertility prevention
Infertility prevention
Individualisation of controlled ovarian stimulation
Individualisation of controlled ovarian stimulation
Female infertility
Female infertility
Maternal near miss
Maternal near miss
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
cesarean birth: procedural aspects: NICE2021
cesarean birth: procedural aspects: NICE2021
Management of pregnancy of unknown location
Management of pregnancy of unknown location
Aerobic Vaginitis
Aerobic Vaginitis
Imaging in pregnancy 2 in1
Imaging in pregnancy 2 in1
update on PCOS
update on PCOS
PREECLAMPSIA‐ECLAMPSIA SPECTRUM
PREECLAMPSIA‐ECLAMPSIA SPECTRUM
Kürzlich hochgeladen
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
Dipal Arora
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
GENUINE ESCORT AGENCY
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
vidya singh
Russian Call Girls Service Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
Russian Call Girls Service Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
parulsinha
Top Rated Hyderabad Call Girls Erragadda ⟟ 9332606886 ⟟ Call Me For Genuine ...
Top Rated Hyderabad Call Girls Erragadda ⟟ 9332606886 ⟟ Call Me For Genuine ...
chandars293
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Dipal Arora
Call Girls Rishikesh Just Call 9667172968 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 9667172968 Top Class Call Girl Service Available
perfect solution
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
Anamika Rawat
Most Beautiful Call Girl in Bangalore Contact on Whatsapp
Most Beautiful Call Girl in Bangalore Contact on Whatsapp
Inaaya Sharma
Models Call Girls In Hyderabad 9630942363 Hyderabad Call Girl & Hyderabad Esc...
Models Call Girls In Hyderabad 9630942363 Hyderabad Call Girl & Hyderabad Esc...
GENUINE ESCORT AGENCY
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
parulsinha
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
chandars293
Low Rate Call Girls Bangalore {7304373326} ❤️VVIP NISHA Call Girls in Bangalo...
Low Rate Call Girls Bangalore {7304373326} ❤️VVIP NISHA Call Girls in Bangalo...
Sheetaleventcompany
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
GENUINE ESCORT AGENCY
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
jennyeacort
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
adilkhan87451
Call Girl In Pune 👉 Just CALL ME: 9352988975 💋 Call Out Call Both With High p...
Call Girl In Pune 👉 Just CALL ME: 9352988975 💋 Call Out Call Both With High p...
chetankumar9855
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls * UPA...
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls * UPA...
mahaiklolahd
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Call Girls Delhi
Coimbatore Call Girls in Thudiyalur : 7427069034 High Profile Model Escorts |...
Coimbatore Call Girls in Thudiyalur : 7427069034 High Profile Model Escorts |...
chennailover
Kürzlich hochgeladen
(20)
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
Russian Call Girls Service Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
Russian Call Girls Service Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
Top Rated Hyderabad Call Girls Erragadda ⟟ 9332606886 ⟟ Call Me For Genuine ...
Top Rated Hyderabad Call Girls Erragadda ⟟ 9332606886 ⟟ Call Me For Genuine ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Call Girls Rishikesh Just Call 9667172968 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 9667172968 Top Class Call Girl Service Available
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
Most Beautiful Call Girl in Bangalore Contact on Whatsapp
Most Beautiful Call Girl in Bangalore Contact on Whatsapp
Models Call Girls In Hyderabad 9630942363 Hyderabad Call Girl & Hyderabad Esc...
Models Call Girls In Hyderabad 9630942363 Hyderabad Call Girl & Hyderabad Esc...
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
Low Rate Call Girls Bangalore {7304373326} ❤️VVIP NISHA Call Girls in Bangalo...
Low Rate Call Girls Bangalore {7304373326} ❤️VVIP NISHA Call Girls in Bangalo...
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
Pondicherry Call Girls Book Now 9630942363 Top Class Pondicherry Escort Servi...
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Call Girl In Pune 👉 Just CALL ME: 9352988975 💋 Call Out Call Both With High p...
Call Girl In Pune 👉 Just CALL ME: 9352988975 💋 Call Out Call Both With High p...
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls * UPA...
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls * UPA...
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Coimbatore Call Girls in Thudiyalur : 7427069034 High Profile Model Escorts |...
Coimbatore Call Girls in Thudiyalur : 7427069034 High Profile Model Escorts |...
PREVENTION OF PRETERM BIRTH
1.
PREVENTIONOFSPONTANEOUS PRETERMBIRTH EVIDENCE-BASEDGUIDELINES Prof.ABOUBAKRELNASHAR BenhaUniversityHospital ABOUBAKRELNASHAR GUIDELINES 1.FIGO,2015 2.FSOG,2017 3.NICE,2019 4.SOGC,2020 5.SMFM,2017,2020 6.USPSTF,2020 ABOUBAKRELNASHAR
2.
CONTENTS I.INTRODUCTION II.PREDICTION III.PRIMARYPREVENTION IV.SECONDARYPREVENTION ▪CONCLUSION IV ABOUBAKRELNASHAR I.INTRODUCTION ▪Prevalence ▪11%oflivebirthswerebornpreterm ▪5%insomehigh-incomecountries(HICs) ▪upto25%inmanylow-&-middle-income countries(L&MICs) ▪Ofthe38countries(2017) ▪PTBrateshaveincreasedsince2000in26 countries ABOUBAKRELNASHAR
3.
▪ComplicationsOfPTB ▪NeonatalMortality: ▪Leadingcauseof deathinchildren under5ysofage ▪inHICsand L&MICs,despite advancesin neonatalcare ▪Neonatalmorbidity ▪Temperatureinstability ▪RDS,infections ▪Apnoea,hypoglycaemia ▪Seizures,jaundice ▪feedingdifficulties ▪Necrotizingenterocolitis ▪Periventricular leukomalacia ABOUBAKRELNASHAR PTLSyndrome(Romeroetal,2006) Uterine Overdistension Vascular Infection Cervical Disease Hormonal Immunological Unknown ABOUBAKRELNASHAR
4.
▪PreventionofPTBcanbeclassifiedas 1.Primary:whenthetargetisthegeneralpopulation, includingwomenathigher-or–lower-riskofPTB 2.Secondary:whenthetargetiswomenatrisk 3.Tertiary:interventionsusedafterPTLhas commenced,tooptimizeneonataloutcomes ABOUBAKRELNASHAR II.PREDICTION 1.ObstetricHistory(FSOG,2017) 1.HistoryofsPTB 2.Multiplepregnancy 3.Uterinemalformation, 4.Cervicaltreatment 5.Atleasttwopreviouselectiveabortions ▪Riskscoringsystems: ▪Age,race,andsmokingstatus ▪obstetrichistory ▪Lowdetectionrate&highfalse-positiverateABOUBAKRELNASHAR
5.
2.MeasurementOfCLByTVSAt16-24W ▪HasbeencorrelatedwiththeriskofPTBbothinsingleton& twinpregnancies ▪TheriskofPTBisinverselyrelatedtoCL ▪Indications: ▪HistoryofPTB:allsocieties ▪Otherriskfactors(SOGC,2018) ▪Twinpregnancy ▪Uterineanomaly ▪PreviousexcisionaltreatmentforCIN ▪Priormultipledilatation&evacuationbeyond13w’ CL(mm)sPTB(%) 600.2 251.1 154 578 ABOUBAKRELNASHAR ▪Universal: ▪Recommended:FIGO2015 ▪Notrecommended:FOGS,2017;SOGC,2018: {poorpositivepredictivevaluesandsensitivities lackofproveneffectiveinterventions}(II-2E). ▪Maybeconsidered:ACOG;SMFM,2012:. ▪SMFM,2019 1.UniversalCLscreeninghasgreatpromise. 2.Itfulfillsalmostallofthecriteriafora screeningtest. ABOUBAKRELNASHAR
6.
ABOUBAKRELNASHAR 3.QUiPPApplication(Shennanetal.2018) ▪Freeofchargeontheinternetandasamobile application ▪Appliedfrom18ws’gestationonwards ▪8Variables:historyofcervicalsurgery;CL;quantitativefetal fibronectin(qfFN);currentgestation;numberoffetuses. ▪Probabilityofbirthwithin1,2&4w&priorto30,34& 37w. ABOUBAKRELNASHAR
7.
▪Increaseininterventionswithoutevidencethat currentlyavailabletreatmentoptionsarebeneficialfor thisparticulargroup(Goodfellowetal,2019) ABOUBAKRELNASHAR ▪Notrecommendation:(FOGS,2017) ▪Routinedigitalcervicalexaminationateach prenatalvisit ▪Regularrecordingofuterineactivity(GradeB). ▪Routinefetalfibronectinassays(GradeC). ABOUBAKRELNASHAR
8.
III.PRIMARYPREVENTION 1.LDA ▪Anadeijdaetal,2018 ▪sPTB<34woccurredsignificantlylessintheaspirin-group (1.03%)comparedwiththeplacebo-group(2.34%) ▪Independentoftimeofinitiationoftherapy(<16vs≥16w) ▪SignificantafterexclusionofwomenwhodevelopedPET ▪Initiationofaspirintherapybetween8&16isimportantfor preventionofPET{thisistheperiodthatplacentation& transformationofspiralarteriesoccurs}. ▪IncaseofsPTBtheanti-inflammatorypropertiesofaspirinare beneficialthroughoutpregnancy. ABOUBAKRELNASHAR ▪Hoffmanetal,2020,Lancet ▪RCT,multicountry,double-masked: ▪NulliparouswithsingletonpregnanciesfromL&MICs. ▪(RR0·89[95%CI0·81to0·98],p=0·012). ❖Aspirin ▪Atadailydoseof81mg, ▪Initiatedbetween6&14Wupto37w:decrease PTBinnulliparouswomenwithsingleton pregnanciesfromL&MICs. LDAPlacebo Number59905986 PTB11.6%13.1% ABOUBAKRELNASHAR
9.
2.SmokingCessation(FOGS,2017) ▪Smooking: ▪hasadose-dependentrelationshipwithPTB ▪:increasedincidenceofplacentalabruption,placenta previa,PPROM,andFGR ▪Smokingcessation: ▪14%reductioninPTB ▪Recommendedforpregnantwomenatanystageof pregnancy(GradeA). ▪Nicotinesubstitutesalone,suchaspatches,havenoeffecton eithersmokingcessationorPTB. ABOUBAKRELNASHAR 3.DecreasingRatesOfMultipleGestationInART ▪TheincidenceofPTBis6-to-8timesinmultiple gestation. {overdistentionandearliercervicalshortening}. ▪ART: ▪increaseoftwin&HOMP. ▪1.Restrictingthenumberoftransferredembryos 2.Selectiveembryoreduction ABOUBAKRELNASHAR
10.
4.ReducingOccupationalFatigue(FOGS,2017) ▪Work≥40hoursaweekor ▪Highcumulativeworkfatiguescore ▪workinghours ▪standing, ▪lifting ▪amountofphysicalactivity ▪Avoidstressfactors. ▪Workweekof35hrs,sickleavebeforematernityleave isnotroutinelyrecommended(GradeB).. ABOUBAKRELNASHAR 5.ImprovingNutritionalHabits&MaintainingNormal BMI ▪Dietrichinfruit,vegetables,wholegrains:±reduced riskofPTB ▪Advisewomentoeatadietrichinfruit,vegetables wholegrains(GradeC)(FOGS,2017) ▪Zincsupplementationforpregnantwomen(CochraneSR, 2018) ▪VitD&Omega-3supplements:noeffectontermof delivery(FOGS,2017) ABOUBAKRELNASHAR
11.
6.AvoidingShortInterpregnancyIntervals(FSOG,2017) ▪Aninterval≤18monthsbetween2pregnanciesis associatedwithariskofPTB ▪Informwomenoftherisksofcloselyspaced pregnancies. ABOUBAKRELNASHAR ▪Regularsports&exerciseduringpregnancy(FSOG, 2017) ▪donotincreasetheriskofPTB ▪recommendedforwomenwithnormalpregnancies (GradeA). ▪Sexualrelationsduringpregnancy ▪donotincreasetheriskofPTB,eveninwomen withahistoryofPTB ▪Treatmentofperiodontaldiseasedoesnotreduce riskofPTB,itstreatmentshouldnotbedelayedonaccountof pregnancy(GradeB). ABOUBAKRELNASHAR
12.
▪Bedrest&hospitalization(FSOG,2017,SMFM,2020) ▪NotassociatedwithdecreasePTB ▪associatedwithahigherriskofDVT ▪Bedrestorreducedactivityisnotrecommendedin womenwith ▪previousPTB ▪shortCL,or ▪multiplepregnancy(strong/moderate). ABOUBAKRELNASHAR ▪Screeningforbacterialvaginosiscombinedwith treatmentininasymptomaticpopulationatlowrisk (definedbytheabsenceofahistoryofPTB) ▪CochraneSR,2018: ▪Clearevidenceofbenefitforprimaryprevention ▪FOGS,2017,USPSTF,2020 ▪NotreducetheriskofPTB ▪Nobenefits ABOUBAKRELNASHAR
13.
IV.SECONDARYPREVENTION ▪Target ▪womenatrisk,withknownoridentifiedriskfactor/s ▪Aims ▪EarlydetectionofpatientsatriskforPTB ▪Treatmentbasedonthisdiagnosis. ▪Severalstrategies ▪withconflictingresultsconcerningtheirefficacy ABOUBAKRELNASHAR 1.Diagnosis&TreatmentOfGenitalTractInfectionin populationathighrisk(definedbyahistoryofPTB) ▪FSOG,2017: ▪Nobenefits ▪Notrecommended(GradeC) ▪USPSTF2020: ▪Conflicting&insufficientevidence ▪Balanceofbenefits&harmscannotbedetermined. ABOUBAKRELNASHAR
14.
2.CervicalPessary ▪Notrecommendedinthispopulation(GradeA)(FOGS, 2017) ▪Inconclusiveevidencethatcervicalpessaryuse, decreasestherateofPTBathighriskforPTB(SMFM, 2017) ABOUBAKRELNASHAR 3.ProgestationalAgents ▪SMFM,2017 ▪Singletongestationand ▪HistoryofsPTB:17OHP-Cat250IMweekly, startingat16-20wuntil36w ▪ShortCL:vaginalprogesterone ABOUBAKRELNASHAR
15.
Maternal–FetalmedicineSociety, 2012 ABOUBAKRELNASHAR ▪FSOG,2017 ▪Theonlyindicationforprogestationaltreatmentis ▪asymptomaticpregnantwomenwith ▪singletonpregnancies& ▪NohistoryofPTBwhohave ▪shortCL≤20mmbetween16and24w: ▪VagNaturalmicronizedprogesterone(GradeB). ABOUBAKRELNASHAR
16.
▪SOGC,2020 ▪VaginalPisindicatedin 1.Singletonormultiplepregnancy&shortCL (≤25mmbetween16and24w(strong/moderate). 2.PreviousPTB:(strong/moderate). 3.Aneffective&potentiallysuperioralternate therapytocervicalcerclageinsingleton pregnancy&apreviousPTBorshortCL≤25 mmbetween16and24w(strong/moderate). ABOUBAKRELNASHAR ▪VaginalprogesteroneforpreventionofPTB: ▪Additionaltherapiessuchascerclage(with exceptionofarescuecerclage)orapessaryare notrecommended(strong/moderate) ▪Dose: ▪Insingletonpregnancy:daily200mg(strong/moderate) ▪Inamultiplepregnancy:daily400mg(conditional [weak]/low) ▪Startbetween16and24w,dependingonwhenthe riskedfactorisidentified(strong/moderate). ▪Continuedupto34–36w(strong/moderate).ABOUBAKRELNASHAR
17.
4.CERVICALCERCLAGE ▪MRCOG,2013;FSOG,2017: ▪Indicated 1.History:Singletonpregnancy&historyof3MTMorPTB (GradeA) 2.US:ShortCL&oneormoreMTM 3.HistoryofMTMorsPTBinsingletonpregnancy:US monitoringofCLifthecervixshortens≤25mmbefore24 w(GradeC). 4.Emergencyduring2ndT,majorclinicalmodificationsofthe cervix,insingletonpregnancieswithoutPROMor chorioamnionitis(GradeC). ABOUBAKRELNASHAR ▪Notindicated: 1.Shortcervixofasingletonpregnancywithno relevantobstetricorgynecologichistory(GradeB) 2.Historyofconization(GradeC), 3.uterinemalformation, 4.isolated́previousPTB(GradeB) 5.Twinpregnancies,forprimary(GradeB)orsecondary (GradeC)prevention. 6.Shortcervix&multiplepregnancy(GradeC). ▪SMFM2018:advisedagainstcerclageinwomen withshortcervix&twingestationABOUBAKRELNASHAR
18.
▪NICE,2019 ▪VaginalprogesteroneORcerclagetowomenwho haveboth: ▪HistoryofPTB(upto34+0wofpregnancy)orMTM (from16+0wofpregnancyonwards)and ▪Shortcervix:TVSbetween16+0and24+0wof pregnancythatshowCL25mmorless. ▪Discusstherisks&benefitsofbothoptionswiththe woman,andmakeashareddecisiononwhich treatmentismostsuitable ABOUBAKRELNASHAR ▪Considervaginalprogesteroneforwomenwhohave either: ▪Shortcervix:TVS.CL25mmorless.or ▪HistoryofPTBorMTM ▪Considercervicalcerclagewhen ▪Shortcervix:TVS.CL25mmorless,AND ▪whohavehadeither: ▪P-PROMinapreviouspregnancyor ▪Historyofcervicaltrauma. ABOUBAKRELNASHAR
19.
CONCLUSION 1.Introduction:PTBisamajorpublichealthproblemwithhigh neonatalmorbidity&Mortality 2.Prediction:CLmeasuredbyTVSat16-24wisareliabletestto identifypregnancywithahigherriskforsPTB. 3.Primaryprevention: ▪LDA,smokingcessation ▪Reducemultiplepregnancy,reduceoccupationalfatigue ▪Znsupplementation,Avoidshortinterpregnancyintervals 4.Secondaryprevention ▪NaturalprogesteronehalvestheriskofPTBinsingleton pregnantwomenwithashortCL. ▪Cervicalcerclagemaybeindicatedhistoricallyorultrasound ABOUBAKRELNASHAR Youcangetthislecturefrom: 1.MyscientificpageonFacebook:Aboubakr ElnasharLectures. https://www.facebook.com/groups/2277448840913 51/ 2.Slidesharewebsite 3.elnashar53@hotmail.com 4.Myclinic:Althwarast,Mansura,Egypt 1/12/2021ABOUBAKRELNASHAR
20.
Conclusions ▪Identificationofriskfactorsforpretermdeliverybefore conceptionorearlyinpregnancymayprovideanopportunityfor primaryprevention.Aninterpregnancyintervalofmorethansix monthsmayreducetheriskofPTB.Womenwithperiodontal diseaseareatincreasedriskof ▪pretermdelivery.Periodontaldiseaseshouldbetreatedasa componentofgooddentalhygiene,butthereareinadequate datatosuggestatreatmentforpreventionofPTB. ▪Thereisinsufficientevidencetosupporttheuseofbedrest;on thecontrary,dailyphysicalactivityshouldbesupportedamong womenatriskofsPTB. •Utilizingstrategiestopreventmultiplegestations resultingfromassistedreproductionshoulddecrease thenumberofpretermbirthsrelatedtomultiplegestations. ▪However,mostpretermbirthsoccuramongwomenwithno obviousriskfactorsandthenumberofeffectiveinterventionsis limited ▪Secondarypreventivestrategiessuchasacervicalcerclage, ABOUBAKRELNASHAR TheNationalInstituteofClinicalExcellenceintheUnitedKingdom,35 FIGO,andtheSMFMintheUnitedStatesallrecommendtheuse ofprogestogensforwomenathighriskofpretermbirth.Thelatter advisesthatwomenbetween20and366gestationalweeksreceive 17‐hydroxyprogesteronecaproate(250mgintramuscularlyweekly) startingat16–20weeksuntil36weeksordeliveryforwomenwitha singletongestationandahistoryofpriorspontaneouspretermbirth.36 Thetwoformerorganizationsendorsetheuseofvaginalprogesterone forwomenwithashortcervix. Asdiscussedinthisreview,however,theevidenceonefficacy forthoseatriskofpretermbirth,impactonpretermbirthrates,and long‐termeffectsforthebabyofimplementingtheserecommendations remainsinconclusive.Cliniciansandpregnantwomencanlook forwardtosomeresolutionoftheconflictingviewsonefficacyonce thePCORI‐fundedindividualpatientdatameta‐analysisispublished. Recommendationsshouldbeupdatedoncethefulldetailsofthe PCORIindividualpatientdatameta‐analysisisinthepublicdomain. ABOUBAKRELNASHAR
21.
Conclusion 1.Introduction:PTBisamajorpublichealthproblemwithhighneonatal morbidityandMortality 2.Prediction:Cervicallength(CL)measuredbytransvaginalultrasoundat 20e24weeksisareliabletesttoidentifypregnancywithahigherriskfor spontaneousPTB. 3.Primaryprevention:LDA,smokingcessation,reducemultiplepregnancy, occupationalfatigue,znsupplementation,avoidshortinterpregnancy intervals 4.Secondaryprevention ▪NaturalprogesteronehalvestheriskofPTBinsingletonpregnant womenwithashortCL. ▪Cervicalcerclagemaybeindicatedhistoricallyorultrasound Insingletonpregnancywithmid-gestationultrasoundshortCL,vaginal progesteroneisassociatedwithastatisticallysignificantreductionintheriskof (RDS),LBW),verylowbirthweight(VLBW),andlessadmissiontothe neonatalintensivecareunit(NICU). Intwin-pregnantwomenwithaCLlessthan25mm,vaginalprogesterone mightbeassociatedwiththereductionofPTBandneonatalmorbidityincluding reductionintheriskofRDS,neonatalandperinataldeath,VLBW,andalsoless needformechanicalventilation. However,RCTareneededtoconfirmthesefindings. ABOUBAKRELNASHAR ABOUBAKRELNASHAR
22.
Mateietal,2019 Intotal,112reviewswereincludedinthisstudy.Overalltherewere49Cochraneand63non- Cochranereviews.Eightwereindividualparticipantdata(IPD)reviews.Sixtyreviewsassessed theeffectofprimarypreventioninterventionsonriskofPTB.Positiveeffectswerereportedfor lifestyleandbehaviouralchanges(includingdietandexercise);nutritionalsupplements (includingcalciumandzincsupplementation);nutritionaleducation;screeningforlowergenital tractinfections.Eighty-threesystematicreviewswereidentifiedrelatingtosecondaryPTB preventioninterventions.Positiveeffectswerefoundforlowdoseaspirinamongwomenatrisk ofpreeclampsia;clindamycinfortreatmentofbacterialvaginosis;treatmentofvaginal candidiasis;progesteroneinwomenwithpriorspontaneousPTBandinthosewithshort midtrimestercervicallength;L-arginineinwomenatriskforpreeclampsia;levothyroxineamong womenwithtyroiddisease;calciumsupplementationinwomenatriskofhypertensive disorders;smokingcessation;cervicallengthscreeninginwomenwithhistoryofPTBwith placementofcerclageinthosewithshortcervix;cervicalpessaryinsingletongestationswith shortcervix;andtreatmentofperiodontaldisease.Conclusion:Theoverviewservesasaguide tocurrentevidencerelevanttoPTBprevention.Onlyafewinterventionshavebeen demononstratedtobeeffective,includingcerclage,progesterone,lowdoseaspirin,and lifestyleandbehaviouralchanges.Forseveraloftheinterventionsevaluated,therewas insufficientevidencetoassesswhethertheywereeffectiveornot. ABOUBAKRELNASHAR Conclusion ▪prophylacticprogesteroneadministrationinwomenpresentingwithashortCL reducestheincidenceofPTB. ▪Vaginalprogesteroneisassociatedwithastatisticallysignificantreductionintherisk ofneonatalmorbidityandalowerfrequencyofearlyPTB,loweradmissiontothe NICU,andshorterlengthofNICUstay[18e20]. ▪nosignificantrelationshipbetweenclinicallyadministerednaturalprogesteroneand congenitalmalformations[83,84]. ▪ProphylacticadministrationofprogesteroneforthepreventionofPTBshouldbe offeredtowomenwithapriorspontaneousPTBandtothosepregnantwomenwitha shortcervixof25mmorlessatmid-gestationscan. ▪ForsingletonpregnantwomenwithapriorhistoryofspontaneousearlyPTBanda shortCL(<25mm)incurrentpregnancy,bothcerclageandvaginalprogesteroneare aneffectivetreatmentforpreventingPTBandimprovingneonataloutcomes. However,thechoiceoftreatmentwilldependonadverseeventsand patient/physician'spreferences. ▪routineuseofprogesteroneintwinpregnancieswithCLlessthanorequalto25mm. Nevertheless,furtherRCTsareneededtoconfirmsuchevidenceandmaybe determinedifthereareotherindicationsforprogesteronetherapyfortheprevention ofPTBespeciallyinsymptomaticpatients. ABOUBAKRELNASHAR
23.
thanks ABOUBAKRELNASHAR Preventionofspontaneouspretermbirth ▪Thereissubstantialevidenceshowingthatvaginalprogesteronesignificantlydecreasesthe riskofpretermbirth≤34weeksby34%amongwomenwithpriorhistoryofpretermdelivery and/oramidtrimesterCL≤25mm.Furthermore,pooledestimatesobtainedbycombining datafromfourtrialsindicatethatvaginalprogesteronewasassociatedwithastatistically significantreductionintheriskofpretermbirthfrom<28to<36weeks’gestation, respiratorydistresssyndrome,compositeneonatalmorbidityandmortality,birthweight <1500g,andadmissiontoNICU.Vaginalprogesteroneissafeandhadnoeffectontherisk ofbothfetaldeath[37]andontheriskofadverseneurodevelopmentaloutcomes.Therewere nosignificantdifferencesinthecognitivecompositescoresorratesofneurodevelopmental impairmentuptosixyearsofagebetweenchildrenexposedinuterotovaginalprogesterone andthoseexposedtoplacebo[37-41]. ▪Cervicalcerclagedoesnotappeartobeeffectiveforwomenwithashortcervixwhohave not hadapriorpretermbirth[42].Inameta-analysisoffourrandomizedtrialsinwhichsingleton pregnancieswerescreenedwithcervicalultrasoundexaminationandrandomlyassignedto cerclageornocerclageifthecervixwasshort,cerclageplacementinwomenwithnoprior 15pretermbirthdidnotresultinsignificantreductioninbirth<35weeks(21%vs31%without cerclage:relativerisk0.84,95%CI0.60-1.17)[42]. Inwomenwithashortcervix(≤25mm)atmidtrimester,singletongestationandpriorpreterm birthearlierthan34weeks,cerclageandvaginalprogesteroneareequallyeffectiveinan indirectcomparisonmeta-analysisforpreventingpretermbirthandimprovingperinatal outcomes[43].However,thechoiceoftreatmentshoulddependontheriskofadverseevents andcost-effectivenessofinterventions,andpatient/physician’spreferences.ABOUBAKRELNASHAR
24.
Controversieswithinobservationalstudiesmaybe attributedtodifferentoperativeskillsandclinicalsurveillance. Itcanhardlybedeniedthattheefficacyofboththe vaginalandabdominalcerclageishighlydependentonthe surgeon`sskills,andunfortunately,thishasnotsufficiently beenconsideredorauditedinpublishedstudies.Therefore, itsimplementationcannotbeconsideredininexperienced handsastheclinicalrisks,althoughrarecanbedevastating, astheseincludehemorrhage,sepsis,perinatal,neonatal,or evenmaternaldeath. ABOUBAKRELNASHAR 4.Cervicalcerclage Inanindividualpatientmeta-analysis,Jorgensenetal.suggested thattheuseofcerclageeffectivelyreducestheriskofpregnancy lossorneonataldeathpriortodischargefromthe hospital[84].Twomaintechniqueshavebeendescribed,the McDonaldandtheShirodkarprocedure.Althoughthelatter permitstheintroductionofthestichinanuppercervical level,evidencedoesnotsupportitssuperioritycomparedto theMcDonaldtechnique[85].Theintroductionofasecond cervicalstichhasbeeninvestigatedbyameta-analysisthat includedsixobservationalstudiesandsuggestedthatthis approachmightreducesPTBrates<28and<34weeksABOUBAKRELNASHAR
25.
SOGC,2020 ▪Progesteronetherapyreducestheriskofspontaneouspretermbirthin womenatanincreasedriskbasedonhistoryofpreviousspontaneous pretermbirthorinwomenwithashortcervicallength(moderate). ▪Thereisinsufficientevidencetosupporttheuseofprogesteronefor preventionofspontaneouspretermbirthinwomenwithapregnancyinthe absenceofcervicalshortening(moderate). ▪Thereisinsufficientevidencetosupporttheuseofprogesteronefor preventionofspontaneouspretermbirthinwomenwithanormalcervical lengthandapriorconizationprocedureonthecervixorabnormaluterine anatomy(low). ▪Useofvaginalprogesteroneforpreventionofspontaneouspretermbirthhas notbeenassociatedwithanincreaseincongenitalmalformationsorwitha worseningofpostnatalneurodevelopmentaloutcomes(moderate). ABOUBAKRELNASHAR FSOG,2017 ▪17OHPC ▪notrecommendedfortheprimarypreventionofpretermdeliveryina populationofwomenwithsingletonpregnanciesandnohistoryof pretermdelivery(GradeC). ▪Wecannotrecommendtheroutineadministrationof17OHPCtowomen withahistoryofpretermdeliverytoreducetheirriskonthebasisofthis singlerandomizedtrial,especiallyinviewofitslimitedexternalvalidity ▪notshownanybenefitsinwomenwithasingletonpregnancy,ahistory ofpretermdelivery,andacervicallengthlessthan25mmduringthe secondtrimester.Accordinglytheuseof17OHPCinthissituationisnot recommended(GradeB).Inthesamepopulation,vaginalprogesterone mightreducetheriskofpretermdelivery ▪Progestationalagents ▪whetheradministeredvaginallyorbyinjectionas17OHPC,arenot associatedwithareducedriskofpretermdelivery,afterpretermlabor,for asymptomatictwinpregnancieswithnormalorunknowncervicallength measurements.Theyarethereforenotrecommendedinthesetwotwin- pregnancysituations(respectivelyGradeAandGradeB). ▪Amongwomenwithtwinpregnanciesandacervixlessthan25mm,the preventiveadministrationof17OHPChasshownnobenefitsforprolonging pregnancyorreducingperinatalrisk.Itisthusnotrecommendedinthis ABOUBAKRELNASHAR
26.
FSOG,2017 ▪Theonlypopulationforwhichprogestationaltreatmentisrecommendedis asymptomaticpregnantwomenwithsingletonpregnanciesandnohistoryof pretermdeliverywhohaveacervicallengthlessthan20mmbetween16 and24weeks. ▪17OHPC ▪notrecommendedfortheprimarypreventionofpretermdeliveryina populationofwomenwithsingletonpregnanciesandnohistoryof pretermdelivery(GradeC). ▪Wecannotrecommendtheroutineadministrationof17OHPCtowomen withahistoryofpretermdeliverytoreducetheirriskonthebasisofthis singlerandomizedtrial,especiallyinviewofitslimitedexternalvalidity ▪notshownanybenefitsinwomenwithasingletonpregnancy,ahistory ofpretermdelivery,andacervicallengthlessthan25mmduringthe secondtrimester.Accordinglytheuseof17OHPCinthissituationisnot recommended(GradeB).Inthesamepopulation,vaginalprogesterone mightreducetheriskofpretermdelivery ▪Progestationalagents ▪whetheradministeredvaginallyorbyinjectionas17OHPC,arenot associatedwithareducedriskofpretermdelivery,afterpretermlabor,for asymptomatictwinpregnancieswithnormalorunknowncervicallength measurements.Theyarethereforenotrecommendedinthesetwotwin- pregnancysituations(respectivelyGradeAandGradeB). ABOUBAKRELNASHAR 3.Progestationalagents(FSOG,2017) ▪17OHPCisnotrecommendedfortheprimarypreventionofpretermdelivery inapopulationofwomenwithsingletonpregnanciesandnohistoryof pretermdelivery(GradeC). ▪naturalmicronizedprogesteroneadministeredvaginallydailyforupto36 weeksisrecommendedforasymptomaticwomenwithasingleton pregnancy,nohistoryofpretermdelivery,andacervicallengthlessthan20 mmat16to24weeks(GradeB). ▪Onetrialhasassociated17OHPCwithareductionintheriskofdelivery before34weeksandwithareductioninneonatalmorbidity(LE3)in singletonpregnanciesamongwomenwithahistoryofatleastonedelivery before34weeks. ▪Wecannotrecommendtheroutineadministrationof17OHPCtowomenwith ahistoryofpretermdeliverytoreducetheirriskonthebasisofthissingle randomizedtrial,especiallyinviewofitslimitedexternalvalidity ▪Vaginalprogesteroneforasymptomaticwomenwithahistoryofpreterm deliverydoesnotappeartobeassociatedwithareducedriskofdelivery before34weeks ▪Thevaginaladministrationofprogesteronetoreducetheriskofpreterm deliveryinwomenwithahistoryofpretermdeliveryisnotrecommended ▪Treatmentwith17OHPChasnotshownanybenefitsinwomenwitha singletonpregnancy,ahistoryofpretermdelivery,andacervicallengthless ABOUBAKRELNASHAR
27.
2.Supplementalprogestogens SingletonpregnanciesThepreventiveeffectofprogestogens wasalreadydiscussedbyPapiernik-Berkhauerin 1970andthenbyKeirsein1990[62,63].Progestogens havebeenusedtoreducePTBintheformofthesynthetic 17α-hydroxyprogesteronecaproateadministeredweeklyas 250mgortheformofnaturalprogesteroneapplieddailyas vaginalsuppositoriesorgel.Bothsubstanceshavedifferent half-timelivesanddifferenteffectsandshouldbeseparately analyzed. Tworandomizedplacebo-controlledtrialsfrom2003 foundthatprogesterone,administeredaseitherweekly intramuscularinjectionsof250mgof17α-hydroxyprogesterone caproateordailyprogesteronevaginalsuppositories, reducedtherateofrecurrentpretermdeliverybyabouta third[64,65].Otherwise,thebenefitof17-OHPCiscontroversially discussed[66].ThestillongoingPROLONGtrial isintendedtoinvestigatetheuseof17-OHPCinhigh-risk pregnancieswiththepreviousPTB. ABOUBAKRELNASHAR Challengesinlow-andmiddle-incomecountries ▪WhilemosteffortsonpreventionofsPTBcomefromhigh- incomecountries,manyLMIChavetodealwithmore challengingconditions. ▪Poorlydevelopedpublicinstitutions,limitedfundinganda relativelylownumberofskilledstaffcompoundedbycontextual factorssuchascorruptionandpatronagemayleadtoadverse andunpredictableneonataloutcomes. Unfortunately,manyLMIChavefailedtopromotemodernisation inhealthcareadministration[125].Consequently, theremaybeakindofpublic/privatecollaboration, supportedinpartbyexternalaidagencies.These conditionsmaybemetinwell-equippedhospitals,butare oftenabsentinlowerlevelfacilities,suchassecond-level hospitalsandprimaryhealthcarecenters,wheremostof thedeliveriesoccurinthesecountries[126]. Ithasbeenrecognizedthatthelackofawarenessand educationofstakeholdersoutsidethehealthcaresector,asABOUBAKRELNASHAR
28.
Singletonpregnancies SeveralstudieshaveshowedthattheriskofPTBisinverselyrelatedtothe lengthofthecervix[9e14],andearlypretermdeliveryincreaseswiththe decreaseinCL,fromabout0.2%at60mmto1.1%at25mm,4.0%at15mm, and78%at5mm[10]. Combineddatafromthethreelargeststudiesinvolvingatotalof7861women showedthatthedetectionrateofbirthbefore35weekswas34%forafalse- positiverateofabout5%[9,10,13].Celiketal.[13]conductedapopulation- basedprospectivemulticenterstudyin58,807womenwithsingleton pregnanciesattendingforroutinehospitalantenatalcare.Thecervicallength (CxL)measuredbyTVUat20e24þ6/7dayswasnormallydistributedwitha meanof36mm.Thelengthwas25mmorlessinabout10%ofwomen,20 mmorlessin5%,and15mmorlessinabout1%.Usingthesecutoffvalues,the respectivedetectionratesofspontaneousearlyPTBbefore32weekswere 35%,48%,and55%.Furthermore,theCLof15mmaccountsfor25.8%ofthe spontaneousearlydeliveriesbefore34weeksandbetween16and25mm accountsfor20.4%oftheearlydeliveriesbefore34weeks. Twinpregnancies Intwinpregnancies,therateofearlyPTBisabout10%,comparedwith1e2% insingletons[38].Inthelargeststudy,CLwasmeasuredat20e24weeksin 1163twinpregnanciesattendingforroutineantenatalcare[15,39].Therateof deliverywasinverselyrelatedtotheCL,being66%for10mm,24%for 20mm,12%for25mm,andlessthan1%for40mm.ThemedianCxLwas35 ABOUBAKRELNASHAR Universalscreeningforshortcervicallength Recommendationfortheuseofvaginalprogesteroneforpregnancieswithno historyofspontaneousPTDbutashortcervixbeforeorat24weeksraisesthe issueofuniversalCLmeasurementat18e24weeks(21).Theansweris complexandraisesthreeissues:first,giventhelowprevalenceofthe shortcervixmeasuringbetween10and20mmbefore24weeksinthegeneral population,between1.7%(27)and2.3%(29),itisnecessarytoscreen between400and588pregnanciestoavoidonePTB. However,thenumberofcaseswithashortCLneededtotreatisonly7e13.4to preventonePTB;second,disseminationofsuchscreeningrequiresthe developmentofqualitystandardsforthemeasurement ofCLbyTVU;andthird,thereisariskofinsidiousslidingwitharbitrary extensionoftheeligibilityandmanagementcriteria,suchasrepeated ultrasoundsperformedoutside18e24weeks,treatmentadministeredoutside theboundsofCLstudied(bordereffect),useofotherinterventionsnot justifiedincaseofshortCL,andthereforepotentiallyundesirable consequenceswithintramuscularinjectionsof17P[40]. Infact,theCLmeasuredbyTVUisaneffectivescreeningtestforthe preventionofPTB,andthecriteriaforaneffectivescreeningtestareallmetby CL.AlthoughroutineCLscreeningisnotclearlyrecommendedbysome internationalsocieties,suchscreeningisseenasreasonableforallofthem [41e44].Furthermore,bothAmericancollegeofobstetriciansandgynecologistsABOUBAKRELNASHAR
29.
Treatmentofperiodontaldisease Severalstudiessuggestedthatperiodontaldiseasemaybea predisposingfactorforpretermbirth.Therationalebehind thisassociationisbasedontheactionofbacterialpathogens andinflammatorycytokinesthatarereleasedfromthe mother’smouthcavityperiodontalinfectionisnotadirect causeofPTB,butratheramarkerthatdesignatesa predispositiontowardstheinductionofanexcessivelocalor systemicinflammatoryresponsetobacterialinfections.Based onthisassumption,itisbelievedthatthesewomentendto hyperrespondtovaginalinfections,thusproducingan abundanceofinflammatorycytokinesthatultimatelyleadto preterm labororruptureofmembranes[118].Nevertheless,dataon theuseofmouthrinseareconflicting[119,120]andgood oralhealthisdesirable,sothatperiodontaldiseaseshouldbe treatedasacomponentofgooddentalhygiene. ABOUBAKRELNASHAR ▪Aproportionalinversecorrelationbetweengestationalageat deliveryandneonatalmortalityhasbeenobserved,but dependsalsoonthestandardofneonatalcareindifferent continents. ▪Moderateprematuritybetween32and36weeksismore prevalent,andepidemiologicstudiessuggestthattheratesstill increaseovertime[1]. ABOUBAKRELNASHAR
30.
thattheriskofadelivery<33weekswasreducedby45% [67].Significantdifferenceswerealsoreportedconcerning theratesofsPTB28weeks,respiratorydistresssyndrome, andneonatalmorbidityandmortality.Thisstudywasdifferently analyzedbystatisticiansoftheFDAwhofoundno evidencewhencorrectingthesedataformaternalparameters andnodifferenceinoutcomeaftertwoyears.Thismight havebeenareasonwhytheFDAdidnotagreethatvaginal progesteronewasapprovedintheUS[68].Thereafter,the OPPTIMUMtrialinvestigatedthelong-termeffectofvaginal progesteroneversusplaceboforthepreventionofPTB untiltheageof2yearsandfoundneithersignificantbenefits norharmsrelatedtothepost-neonataloutcome,neithera significantprolongationofpregnancy[69].Therefore,the authorJaneNormanconcludedthatadrugforwhichno differencescouldbedeterminedaftertwoyearsshouldatleast requirethatpatientsarewell-informed.Criticsofthisstudy wererelatedtotheinclusioncriteriaandallowcompliance ofonly60%.Meanwhile,Romeroetal.haveconductedthree ABOUBAKRELNASHAR Indirectanddirectcomparisonsofcervicalpessary, cerclage,andprogesterone Currentresearchstillfocussesontheoptimaltreatmentof pregnancieswithashortcervixdetectedbytransvaginal ultrasound.In2013,Alfirevicetal.publishedthefirstretrospective studycomparingcerclage,vaginalprogesterone, andcervicalpessaryinpatientsatriskforPTBandashort CLandfoundthattheywereallefficaciousinpreventing PTBwithsomemorebenefitsofthecervicalpessary[92]. Conde-Agudeloetal.publishedanindirectcomparison meta-analysisofvaginalprogesteroneversuscervicalcerclage andfoundnoclinicallyrelevantdifferences[93]and a“networkmeta-analysis”whichincluded36trials,suggested thatprogesteroneseemstobebetterthancerclage andpessary[94].However,thereareseveralproblemsin theseindirectcomparisons.AnopenlabelmulticenterRCT iscurrentlyrecruitingpatientstodirectlycomparecervical cerclage,cervicalpessary,andvaginalprogesteronein womenwithashortcervix[95]. Somedirectcomparisonsoftwostrategieshave,meanwhile, beenpublishedasRCTscomparingvaginalprogesterone andcervicalpessaryinsingletonsandintwins[96, 97].TheRCTinsingletonpregnanciescouldnotfinda significantdifferencebetweencervicalpessaryandvaginal ABOUBAKRELNASHAR
31.
Recently,Wolnickietal.[102]investigatedthecombined treatmentofcerclageandArabinpessaryversuscerclage aloneinsingletonpregnancieswithcervicalshortening. Althoughtherewerenodifferencesbetweenthetwostudy armsintheratesofpretermbirth<28,<32,<34,and< 37weeks,theauthorsstatedasignificantlyshorteradmission timeintheNICUaswellashigherratesofbirthweight infavorofthecombinedtreatmentarm.Thelowerincidence ofneonatalinfectionsfollowingtheadditionalpessarytreatment mightbetheresultofreductioninthestretchingofthe cervicalcellsandpreventionofatypicalinterleukinproduction asanimmunologicalbarrier[103]. ABOUBAKRELNASHAR Bacterialvaginosisandpretermbirth ▪Bacterialvaginosisisadysbiosisexpressedasan imbalanceofthevaginalflorafavoringthemultiplicationof anaerobicbacteriaandthesimultaneousdisappearanceof thelactobacilliconsideredtobeprotective. ▪ItsdiagnosisisbasedonAmsel'sclinicalcriteriaand/or GramstainingwiththedeterminationofaNugentscore. ▪Itsprevalencevariesaccordingtoethnicand/orgeographic origin(4-58%);inFranceitiscloseto7%inthefirsttrimester ofpregnancy(LE2). ▪Theassociationbetweenbacterialvaginosisand spontaneouspretermdeliveryislow,withoddsratios rangingfrom1.5to2inthemostrecentstudies(LE3). ▪Metronidazoleandclindamycinareeffectiveintreatingthis vaginosis(LE3).Oneoftheseantibioticsshouldbe prescribedforpregnantwomenwithsymptomaticbacterial vaginosisABOUBAKRELNASHAR
32.
Diagnosisandtreatmentofgenitaltractinfection LowergenitaltractinfectionspredisposewomentoPTB [111,112].Ureaplasmaandmycoplasmainfectionsseem tobesignificantlymoreprevalentamongwomenwith sPTBthanamongcontrols.Positiveswabsseemtobe associatedwithneonatalsystemicinflammatoryresponse syndromeandbronchopulmonarydysplasia. SomestudiescouldnotshowareductioninPTBafter treatmentofasymptomaticvaginalorcervicalcolonization andacertainmicrobiome[113],butthedataareconflicting [114]. Onlyonemeta-analysiswhichwasbasedon10 studiesthatrecruited3696pregnantwomenwithbacterial vaginosissuggestedasignificantreductionPTBratesafter antibiotictreatment(OR0.42;95%CI0.27–0.67)[115]. Ontheotherhand,ameta-analysisthatevaluatedtheeffect ofprophylacticantibioticadministrationinwomenwith abnormalvaginalswabs,inwomenwithahistoryofthe previoussPTBandinthosewithpositivefetalfibronectin ABOUBAKRELNASHAR
Jetzt herunterladen