Educational material for 4th year Med Students

1. Associate Clinical. Prof. Dr Aisha M EL- Bareg, MD, PhD
Senior Consultant Obs& Gyn
Faculty of Medicine, Misurata University, Libya
13/08/201711:33‫م‬ 1‫علما‬ ‫زدنى‬ ‫ربى‬ ‫وقل‬

2. Prematurity
 Prematurity is the leading cause of death
in about 75 - 80 % of all non anomalous
neonatal deaths.
 The survival rate in the best neonatal
centre in the world is 97 % at birth weight
1500 grams & 75 % at birth weight 1000
grams .

3. Pre-term labor (PTL)
 Definition: labor starting after the age of
viability (24 weeks) and before completed 37
weeks of GA.
 Incidence
 5-10% of live birth
 Causes 80% of perinatal morbidity and
mortality.

4. PTL
Spontaneous
75%
Induced
25%

5. Etiology (risk factors)
1. Maternal causes
a. Maternal characteristics
 Black , low SES
 Poor nutrition, smoking
 Low prepregnancy wt (BMI<19.6)
 < 18yrs, > 35yrs
 Sternous work, high level of personal
stress
 Poor ANC

6. b. Maternal disease
All maternal diseases- Miscrriage, PTL
c. Obstetric conditions
 Previous history of PTL  40 % recurrence
 APH = PP, AP, unexplained & recurrent
 PROM  30 % of PTL .
 Polyhydramnios
 Chorioamnionitis with or without ROM
 Oligohydramnios and IUGR.
Etiology (risk factors)

7. d. Uterine abnormalities
 Congenital uterine malformations- 25-50%
(Müllerian fusion defects)
 Cx incompetence- cx length <2.5mm
 Submucous fibroid
 Foreign body as IUCD
 Trauma to the uterus
 Partial Asherman’s syndrome
Etiology (risk factors)

8. 2. Fetal causes
 Multiple pregnancies- 10%
 CFMF or IUFD
 Rh isoimmunization
4. Infection
 Systemic infection- UTI, periodontal dis.
 Local infection- GBS, bacterial vaginosis
 Cx Softening & dilatation, ROM
 Release of PG- stimulate uterine contraction
Etiology (risk factors)

9. 5. Idiopathic- >30% no detectable cause
6. Induced
 Compromised mother or fetus
Etiology (risk factors)
3. Iatrogenic
 ECV, amniocentesis
 Surgery during pregnancy
 Inducing labour- wrong date
 Ovulation induction & ART

10. Complications
 Neonatal complications
 Respiratory distress syndrome
(RDS)
 Patent ductus arteriosus
 Recurrent apnoeic attacks-
immature RC
 Neonatal jaundice-
Kernicterus
 Anemia- Fe is stored in the
last weeks

11.  Malnutrition
 Infection- undeveloped immune system
 Pneumonia, Umbilical stump infection
 Necrotising enterocolitis
 Birth trauma
 Intracranial hage, cephalohematoma
 Bone fracture
 Hypothermia
 Hypoglycemia, hypo Ca, hypo Mg

12.  Remote complication of PTL
 Retrolental fibroplasia
 Bronchopulmonary dysplasia
 Cerebral plasy and neurological deficiet
(hypoxic ischemic encephalopathy)
 Psychological- reduced bounding
 Development delay
 Poor school grading
 Vision & hearing impairment
 Family, school, social burden

13. Diagnosis of PTL
1. Identification of patient at risk of PTL
 History
 Examination
 Investigation
 Screening methods

14. 2. Screening methods
a. Investigation for maternal general condition
b. Cervicovaginal fibronectin- 50ng/ml
c. Home uterine monitoring
d. Regular assessment of uterine activity
e. RegularTVS assessment of Cx length
f. High vaginal swab- bacteriology

15. 3. Dx and evaluation of established PTL
 S & S of labour
 General and obstetric examination
 Sterile speculum examination
 Abdominal USS/Trans vaginal USS
 Digital examination
 Amniocentesis

16.  Transvaginal USS for cx assessment
 Cx length < 20 mm and contraction
= PTL
 Cx length 20-30 mm and contraction=
=probable PTL
 Cx length > 30mm
= PTL is very unlikely regardless of
contraction frequency

17.  Digital Cervical examination
1. Cx is ≥ 3 cm dilation/80% effaced
 PTL diagnosis is confirmed
 Evaulate for tocolysis

18. 2. Cx is 2-3 cm dilation/<80% effaced
 PTL is likely but not established
 Monitor uterine contraction
 Repeat digital examination in 30-60 min
 PTL if findings changed
 If no cx change
 Send for fibronectin
 Trasvaginal cervical USS

19.  Amniocentesis if no PROM
 Confirm lung maturity
 Test for infections
 Fetal karyotyping

20. Management of PTL
1. Prophylactic (at high risk of PTL)
 Proper ANC, bed rest, avoid sexual activity
 Education of the patient about PTL
 Prophylactic tocolytics or progesterone
 Cx cerclage if indicated (all uterine causes)
 Tocolytics for any surgical operation
 Treatment of infection

21. 2. Management of threatened PTL
 Rapid admission to hospital
Interfere before cx dilatation is 4cm
 Assessment of uterine contraction
 Assessment of cx status
 Assessment of fetal condition- BPP
 If there is ROM- manage as in ROM
 Tocolytics after exclusion CI
 Prophylactic antibiotics against
(GBS, bacterial vaginosis)

22. 3. Management of established PTL
 Goals of treatment for PTL
 Permits 3 intervensions
↓ neonatal morbidity and mortailty
1. Antenatal maternal transfere to the
most appropriate hospital
2. Antibiotics - neonatal infection
3. Corticosteroids -RDS, ICH, others

23. Management of established PTL (cont.)
a. First stage
 Strict intrapartum monitoring
 Avoid heavy sedation,Vit K 10mg IM
b. Second stage
 Wide episiotomy- avoid sudden compression
& decompression- ICH
 No benefit of prophylactic forceps delivery

24. c. Indication of CS
 Preterm breech
 Fetal distress
 Maternal indication
 Obstetric indication

25. 4. Management of newborn
 Admission in neonatal ICU
 Resuscitation
 Control of temperature & humidity
 Feeding- Breast, bottle, Nasogastric, IV
-Vit K & vitamines
 Prophylaxis against infection (strict aseptic
handling)
 Treatment of complication- ICH, RDS
(surfactant,Thyrotropin-releasing h)

26. Tocolysis &Tocolytics drugs
 Abolishing or delaying the uterine contraction
 Using Uterine muscle relaxants
 Indications and contraindications

27. indication CI
GA < 37 weeks > 37 weeks
Fetal life Living fetus IUFD
CFMF -VE +VE
IUGR -VE +VE
Membranes intact ROM (except for
short tocolysis
chorioamnionitis -VE +VE
CX Changes < 4cm > 4cm

28. indication CI
Fetal distress -VE +VE
APH -VE +VE
L/S ration < 2 > 2
EFW < 2 kg < 2 kg
Medical
disease
No disease +VE

29.  Goals of tocolysis
 Long term tocolysis
 To prolong pregnancy till the end of 37 weeks
(prophylactic)- progesterone.
 Short term tocolysis
 To prolong pregnancy for 48-72 hrs.
 PROM till corticosteroids enhance lung
maturity.
 PTL till referred to a hospital with NICU.

30. A. General Lines of tocolysis
1. Bed rest & fluids
2. Sedative and analgesia
3. Sexual abstinance

31. B. tocolytics- uterine muscle relaxants
1. Prostaglandin synthetase inhibitors (anitPG)
Cyclooxygenase (COX) inhibitor
NSAID (Indomethacin)
 ↓ PG synthetase → ↓ PG (PG F)
 Oral tables, rectal suppositories
 Limit the use for 48 – 72 hrs & < 32 wks

32. • Contraindications
 Active peptic ulcer
 Poorly controlled HTN, Asthma
 Coagulation disorders
 Impaired renal and liver function
 IUGF & oligohydramnios
 Renal anomalies

33.  Maternal complications
 GIT upset & ulcers
 Bleeding tendency (prolonged BT)
 Nephrotoxicity
 Fetal complications
 Premature closure of Ductus arteriosis if
used > 32 weeks → neonatal pulmonary
HTN
 Oligohydramnios- fetal oligouria
 Bleeding tendency

34. 2. Oral B-sympathomimetics
 Stimulate B-receptors on the myometrial cells
↓
↑ Intracellular cAMP
↓
↓ Intracellular Ca concentration
↓
↓ uterine contraction

35. 2. Oral B-sympathomimetics
 Examples –Terbutaline
- Ritodrine (Yutopar)
- salbutamol (Ventoline)
 Route- subcutaneous, intravenous, oral

36. 2. Oral B-sympathomimetics
 Maternal Side effects
 Palpitation, tachycardia, arrhythmias
 Nausea, vomiting, headache, tremors
 Hypotension, dysnea & chest pain
 Hyperglycemia- ↑ hepatic glucogenolysis
 hyperkalemia
 Pulmonary odema especially with corticosteroids

37. 2. Oral B-sympathomimetics
 Fetal side effect
 Tachycardia, hypoglycemia,
hypocalcemia, ileus
 Contraindications
 Cardiac disease
 Hyperthyroidism & severe anemia
 Uncontrolled DM
 Hypersensitivity to drugs
 APH

38. 3. Calcium channel blockers
Inhibit intracellular Ca influx
↓
inhibit muscle contraction
 As effective as β mimetics
 Used when - β mimetics is contraindicated
- or not tolerated

39. 3. Calcium channel blockers
 Nifedipine - (Epilat or Adalat)
- Sublingual then oral
 Contraindications
- Congestive HF - Aortic stenosis
- Concomittent use of B- mimetics or Mg SO4

40. 3. Calcium channel blockers
- Side effects
- Hypotension - headache & flushing
- Nasal congesion - tachycardia
- Moycardial infarction
- No fetal side effects

41. 4. Mg sulfate-
 Complete with Ca
 Tocolytic effect is poor
 Relatively safer then B-mimetics
5. Other tocolytics
- Oxytocin antagonist- Atosiban
- Transdermal glyceryl trinitrate

42.  Combined tocolytics
 Different mechanism with synergistic effect
 Reduce the dose of each agents
 Such as β sympathomimetics
+
NSAIDS

43. 13/08/201711:33‫م‬ 43
‫وقل‬
‫ربى‬
‫زدنى‬
‫علما‬