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Preterm Labour
Preterm Birth
Medical Paper Presentation
Aditiawan, Fitriyani
OBSTETRICS AND GYNECOLOGY CLERKSHIP
TARUMANAGARA UNIVERSITY
RSUD CIAWI, BOGOR
Period February 2nd 2015 - April 11st 2015
Definition
Preterm labor is defined as the presence of contractions of sufficient strength and frequency to effect progressive effacement and dilatation of the cervix between 20 and 37 weeks gestation
(Williams Obstetric, 24ed)
Incidence
Overall incidence of PTL : 6 % - 10 %
Spontaneous : 40 50 %
PROM : 25 40 %
Obstetrically indicated : 20 25 %
(Slattery and Morrison 2002 )
Survival in Premature Infants
26 wks 80%
27 wks 90%
28-31 wks 90 to 95%
32-33 wks 95%
34-36 wks approaches term survival rates
4
Complications of Prematurity
RDS
Intraventricular Hemorrhage of the new born
Necrotizing enterocolitis
Apnea
PDA
Infection
Jaundice
Hypothermia
Neurobehavioral
Anemia
5
Risk Factors
I-Maternal factors :
Previous preterm delivery .
Low socioeconomic status .
Maternal age 40 years .
Preterm premature rupture of the membranes .
Multiple gestation .
second-trimester abortions .
Maternal complications (medical or obstetric) .
Lack of prenatal care .
Smoking. (Murphy.2007)
Risk Factors
II-Uterine causes :
Uterine septum .
Bicornuate uterus .
Cervical incompetence .
III-Fetal causes :
Intrauterine fetal death .
Intrauterine growth retardation .
Congenital anomalies .
IV-Placental causes :
Abnormal placentation (Murphy.2007)
Risk Factors
V- Infectious factors :
Genital :
* Bacterial vaginosis (BV) * Chlamydia
* Group B streptococcus * Mycoplasmas
Intra-uterine :
* Ascending (from genital tract)
* Transplacental (blood-borne)
* Transfallopian (intraperitoneal)
* Iatrogenic (invasive procedures)
Extra-uterine :
* Malaria
* Typhoid fever * Pneumonia
* Listeria * Asymptomatic bacteriuria
(Jane Norman.2005)
The Challenge: Identification
Labor = regular, painful uterine contractions that produce cervical dilation and/or effacement
Uterine contractions are seen in normal pregnancies at early gestational ages
Up to 50% of women hospitalized for PTL go on to deliver at term
9
Prediction of preterm labor
1. Risk factors .
2. Cervical ultrasonography (Cx. Length assessment) .
3. Salivary estriol .
4. Screening for bacterial vaginosis (BV) .
5. Screening for fetal fibronectin (fFN) .
( Edwin and Sabaratnam. 2005)
Fetal Fibronectin
99% negative predictive value for delivery within 2 wks
Positive predictive value worse, about 30%
22 to 35 weeks
Sample collection issues
11
Fetal fibronectin testing
Sample :
from the posterior fornix of the vagina
Indications:
1- Symptomatic preterm labour 24 - 36 weeks
2- Intact membranes and
3- Cervical dilatation less than 3 cm
Contraindications:
1- Ruptured membranes 2- Vaginal bleeding
3- Cervical cerclage insitu
Relative Contraindications:
1- After the use of lubricants or disinfectants
2- Within 24 hours of coitus or vaginal examination
(The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2008)
Prevention of premature labor
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
( Flood and Malone ,2012 )
Prevention of premature labor
Secondary prevention :
Aim :
Early identification of pregnant women at a risk of preterm labor and helped them to carry their pregnancies to term.
Measures :
1- Self-measurement of the vaginal pH for B.V. (Bitzer.,et al.2011)
2- Cervix length measurement by TVS . ( Crane and hutchens ,2008)
(The accepted cutoff value for cervix length is 25 before GW 24 )
3- Cerclage and complete closure of the birth canal (Berghella.,et al.2011 )
4- Progesterone supplementation . ( Romero.,etal.2012)
Assessment and management of PTL
Secondary prevention :
Aim :
Early identification of pregnant women at a risk of preterm labor and helped 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 25 before GW 24 )
3- Cerclage and complete closure of the birth canal
4- Progesterone supplementation
Queensland Maternity and Neonatal Clinical Guideline (2009)
Treatment of premature labor
Inhibition of uterine contractions with tocolysis
Corticosteroids to induce fetal lung maturation
Treatment of infection with antibiotics
Bed rest and hospitalization.
(Schleuner.2013)
Goals of Treatment of PTL
Tocolysis often halts contractions only temporarily
Allow 48 hr+ for steroids to be given
Allow for transport to delivery location with NICU capability
Allow for correction of reversible causes
19
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.
(King .,et al.2003)
Tocolysis
Contraindications :
Gestation > 34 weeks
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 . Multiple pregnancy
placenta praevia . Rupture of membrane
(Di Renzo et al., 2007)
c
Tocolysis
Tocolytic drugs that are used in clinical practice
Calcium antagonists . ( Nifedipine )
Oxytocin-receptor antagonists . ( Atosiban )
Inhibitors of prostaglandin synthesis . ( Indomethacin )
NO donors . ( Nitroglycerin)
Betamimetics . ( Terbutaline & Ritodrine )
Magnesium sulfate . ( MgSO4 )
Tocolysis
(Schleuner 2013)
Mechanisms of action of tocolytic drugs
Calcium channel blockers (Nifedipine)
Dosage and administration :
30 mg loading dose,|then 1020 mg every 46 h.
Contraindications :
. Cardiac disease . . Renal disease .
. Maternal hypotension (< 90/50 mm Hg) .
. Avoid concomitant use with magnesium sulphate .
Maternal side effects :
. Flushing, headache . . Nausea .
. Transient hypotension . . Transient tachycardia .
Fetal and neonatal side effects :
. Sudden fetal death . . Fetal distress .
(Conde et al.,2011)
Atosiban (Tractocile)
Dosage and administration :
Initial bolus dose 6.75 mg over one minute, followed by an
Infusion of 18 mg/h for 3 h and then 6 mg/h for up to 45 h.
Contraindications :
. None .
Maternal side effects :
. Nausea .
. Allergic reaction .
. Headache .
Fetal and neonatal side effects :
. None
( De Heus et al.,2009 )
Prostaglandin synthetase inhibitors( Indomethacin )
Dosage and administration :
loading dose of 50 mg rectally or 50-100 mg orally, then
25-50 mg orally every 6 hr 48 hr.
Contraindications :
. Renal or Hepatic impairment
Maternal side effects :
. Nausea, heartburn gastritis . Renal impairment function
. Increased PPHge . Headache, dizziness
Fetal and neonatal side effects :
. Constriction of ductus arterious . Pulmonaryhypertension
. Oligohydramnios, . Intraventricularhemorrhage
. Hyperbilirubinemia, . Necrotizing enterocolitis
( Haas et al.,2009 )
Nitric oxide donors
Dosage and administration :
10 mg patch for every 12 hr continuing until contraction
cease up to 48 hours
Contraindications :
. Headache
Maternal side effects :
. Headache .
. Hypotension .
Fetal and neonatal side effects :
. Neonatal hypotension
( Smith et al.,2007 )
Betamimetics
Dosage and administration :
1-Terbutaline 0.25 mg subcutaneously every 20 min. to 3 hr .
2-Ritodrine initial dose of 50-100 g/min i.v., increase 50 g/min
every 10 min until contractions cease or side effects develop,
maximum dose = 350 g/min
Contraindications :
. Uncontrolled thyroid desease, & diabetes mellitus
. Cardiac arrythmias (Anotayanonth et al.,2010 )
Maternal side effects :
. Hypokalemia . Hyperglycemia . Hypotension
. Pulmonary edema . Arrhythmias . Myocardial ischemia
Fetal and neonatal side effects :
. Tachycardia. . Hyperinsulinemia . Hyperglycemia
Magnesium sulfate
Dosage and administration :
Loading dose: 4g MgSO4 as a SLOW BOLUS over 15-30 minutes
Maintenance dose: 1g/hr. for 24/hr.
( Stop infusion if: RR
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