BYM. ZEESHAN KHAN

RIZWAN ANWERZEESHAN LODHI

PRETERM AND POST-TERM LABOUR

CONTENTS

PRETERM LABOUR DEFINITION RISK FACTORS DIAGNOSIS INVESTIGATIONS PREDICITON AND PREVENTIONS TOCOLYTIC AGENTS MANAGEMENT PPROM(INTRODUCTION, DIAGNOSIS,MANAGEMENT)

POST-TERM LABOUR INTRODUCTION SIGNIFICANCE CLINICAL APPROACH MANAGEMENT

DEFINITIONS

PRE TERM PREGNANCY DELIVERY BEFORE 37 WEEKS OF GESTATION

TERM PREGNANACY GP FROM 37 TO 41 + 6 days WEEKS

POSTERM PREGNANCY GP FROM 42 WEEKS ONWARDS

PRETERM LABOUR

Preterm labour is defined by WHO as Onset of labour prior to the completion of 37 weeks of gestation, in a pregnancy beyond 20 wks of gestation.

Preterm labour is considered to be established if regular uterine contractions can be documented atleast 4 in 20 minutes or 8 in 60 minutes with progressive change in the cervical score in the form of effacement of 80% or more and cervical dialatation >1cm.

CONT’

This condition tends to be over diagnosed and over treated.

Nearly 50-60% of preterm births occur following spontaneous labour.

30% due to preterm premature rupture of membranes

Rest are iatrogenic terminations for maternal or fetal benefit.

Half of all neonatal morbidity occurs in preterm infants.

Inspite of all major advances in obstetric and neonatal care, there has been no decrease in incidence of preterm labour over half a century.

On the contrary , it has been increasing in the developed countries as more and more high risk mothers dare to get pregnant.

Incidence

Preterm birth occurs in 5-12% of all pregnancies and accounts for majority of neonatal deaths and nearly half of all cases of congenital neurological disability, including cerebral palsy.

A neonate weighing 1000- 1500 g today has ten times greater chance of surival then what it had in 1960s.

The focus is hence shifting to early preterm births(<32 weeks) which account for 1-2% of all births but contribute to 60% of perinatal mortality and nearly all neurological morbidity.

One of the major reasons for increase in incidence of premature births is the increase in numbers of multiple pregnancies , particularly higher order pregnancies, resulting from the use of fertility drugs and assisted reproduction.

PRETERM LABOUR

5 -> 4 -> 4

Mildly preterm 32 – 36 weeks

Very preterm 28 – 31 days weeks

Extremely preterm 24 – 27 weeks

AETIOLOGY

INFECTIONSOVER-DISTENSIONVASCULARSURGICAL PROCEDURES AND

INTERCURRENT ILLNESSABNORMAL UTERINE CAVITYCERVICAL WEAKNESSIDIOPATHIC

NON MODIFIABLE(MAJOR AND MINOR)

MODIFIABLE

RISK FACTORS

RISK FACTORS

MAJOR NON MODIFIABLE Last birth preterm: 20% risk Last two birth preterm : 40%risk Twin pregnancy: 50% risk Uterine abnormalities Cervical Anomalies Factors in current pregnancy

Non modifiable , Minor Parity 0 or >5 Ethnicity(Black) Poor socioeconomic status Education Teenagers having second or subsequent babies

Modifiable Smoking :2x risk of PPROM Drug abuse : especially cocaine BMI <20 Inter Pregnancy interval: <1year

DIAGNOSIS

SYMPTOMS WITH CERVICAL WEAKNESS Increased vaginal discharge Mild Lower abdominal pain Bulging membranes on examination

SYMPTOMS WITH INFECTION, ABRUPTION Lower abdominal pain Painful uterine contraction

DIGNOSTIC CRITERIA

1. GESTATIONAL AGE : 24-37 WEEKS2. UTERINE CONTRACATION: ATLEAST 3

CONTRACTIONS IN 30 MINUTES3. CERVICAL CHANGE: CHANGE IN

CERVICAL DIALTATION OR 2CM DILATED CERVIX

DIFFERNTIAL DIAGNOSIS

UTIRED DEGERATION OF FIBROIDPLACENTAL ABRUPTIONCONSTIPATIONGASTROENTERITIS

DIAGNOSTIC APPROACH

HXEXAMINATIONSINVESTIGATIONS

FBC CRP MID STREAM URINE SAMPLE U/S TVS FETAL FIBRONECTIN

PREVENTION

Rx of BV

Cervical Cerclage

Selective Reduction of pregnancy numbers

Progesterone ?

PREDICITON

Cervical length TVS improves diagnostic accuracy Normal length 35 mm In asymptomatic women with singleton pregnancy

Cervix <15 mm long : risk of delivering before 32 weeks is 4%

Cervix <5 mm long: risk of delivering before 32 weeks is 78%

In symptomatic woman with singleton pregnancy Cervix <15mm long : risk of delivering within 7 days is

50% Cervix >15 mm long: risk of delivery within 7 days is

<1%

cont

Fetal Fibronectin(fFn)- glue like protein at choriodecidual interface fFN test offers rapid assessment of risk in

symptomatic women with minimal cervical dilatation, fFN is protein not usually present in cervicovaginal

secretions at 22-36weeks fFN positive test indicates that women is likely to

deliver fFN predicts preterm birth within 7 – 10 days of

testing Implying disruption of choriodecidual interface

TOCOLYTIC AGENTS AND STEROIDS

Used to prevent labour and deliveryMay prolong pregnancy but not more than 72

hours Useful for fetal lung maturity by maternal IM steroids Transportation of mother to a facility with neonatal

intensive care

IMPORTANT TOCOLYTIC DRUNGS

TOCOLYTIC DRUGS SIDE EFFECTS

MAGNESIUM SULFATECompetitive inhibitors of calciumOverdose treated by IV ca gluconate

Resp depressionMuscle weaknessPulmonary edema

Beta- Adrenergic agonistTerbutaline

HTN and tachycardiaHypokalemiaHyperglycemia

cont

Calcium channel BlockerDec. intracellular Calciume.g nifidipine ,

HypotensionMyocardial depressionTachycardia

Prostaglandin synthetase inhibitorDec. smooth muscle contractilitye.g. Indomethacin

Fetal complications like oligohydramnios, premature closure of ductus and necritising enterocolitis have restricted their use.

MATERNAL STEROIDS

Reduces the rates of respiratory distress, intraventricular hemorrhage and neonatal death

Given as IM injection two doses 12-24 hrs apart.

Maximum benefit is seen after 48 hours.

MANAGEMENT OF PRETERM LABOUR

Confirm labour using three criteria listed above.

Rule out contraindications of tocolysisAdminister IV lineStart MgSO4 tocolysis with 5g IV for 20 min,

then 2g/hAdminster maternal IM betamethasone to

stimulate type II pneumocyte

Clear plan about Mode of delivery Monitoring in labour Presence of pediatrician In antibiotics in labour

PRETERM PRELABOUR OF MEMBRANES (PPROM)

Rupture of fetal membranes occurring before 37 wks of gestation.

It complicates about 3 % of pregnancies and contributes to one third of preterm births

RISK FACTORS

Ascending infection of lower genital tract-most common

Multiple pregnancyPolyhydramniosAntepartum hemorrhagePlacental abruptionCervical weaknessIdiopathic

Diagnosis of PPROM

History of sudden escape of watery amnoitic fluid. Oligohydramnios on US Pooling of amniotic fluid in posterior vagina

A sterile speculum examination confirms that the fluid is coming through the os.

Nitrazine test: turns blue from yellow if amniotic fluid leak.

Fern test Ultrasound examination shows oligohydramnios Amnisure test(immunochromatographic method)

detects trace amounts of placental microglobulin (PAMG-1)

Differential diagnosis

It needs to be differentiated from stress urinary incontinence

and profuse normal vaginal discharge. UTI Vaginal Infection

Management of PPROM

Correct and prompt diagnosis is imperative for optimum management.

PPROM remote from term: Conservative management is advisable, provided acute cord complications like prolapse and compression, placental abruption and fetal distress have been excluded. Oligohydramnios is not an indication. Antibiotics: help to prolong latency and improve

perinatal outcomes. Corticosteroids: should be given to patients between 24

and 34 weeks of gestation.

PPROM nearer to term(34-36 wks):

It is preferable to induce labour unless fetal lung maturity or gestational age is doubtful

Serial transabdominal amnioinfusions in<26 wks pregnancies with PPROM and severe oligohydramnios in selected women reduce the risk of pulmonary hypoplasia and improve neonatal survival.

POST-TERM PREGNANCY

Any pregnancy that exceeds 42 weeks from the first day of last menstrual period in women with regular 28 day cycles

Aka Postdate pregnancy and prolonged pregnancy

INCIDENCE

The generally quoted incidence of PT pregnancy is 10%

Incidence is decreasing b/c of better estimation of duration of gestation and timely induction of labour.

RISK FACTORS

Past history of prolonged pregnancyFamily historyRace (White>black)AnencephalyCongenital adrenal hyperplasiaExtra uterine pregnancy

COMPLICATION

FETAL COMPLICATION Macrosomia Syndrome Dysmaturity Syndrome

MATERNAL COMPLICATION Anxiety Prolonged labour C-section

Fetal Complications

Macrosomia Syndrome Occurs when placental function is maintained(80%

cases) Results in healthy but large fetus Amniotic fluid is normal Inc risk of C-section b/c of prolonged and arrested

labour Shoulder dystocia

Dysmaturity syndrome When placental function deteriorates (20% cases) Placental insufficiency results in reduction of

metabolic and respiratory support to fetus Amniotic fluid is decreased Inc risk of C-section b/c of non reassuring fetal heart

rate patterns Oligohydramnios results in umbilical cord

compression

MATERNAL COMPLICATIONS

Anxiety Is commonly seen postdate pregnancy b/c of worry of

inc. in gestation period from the EDDProlonged labour

Chances increases significantly and also the risk of instrumental delivery

C-section Risk of C-section is also greatly increased

MANAGEMENT

It depends on the Confirmation of gestational age Favorability of cervix

CONFIRAMTION OF GESTATIONAL AGE

In a booked case confirmation of gestational age is easily determined

In an unbooked case , diagnosis of post term pregnancy poses a major challenge.

DETERMINATION OF GESTATIONAL AGE

HISTORY LMP EARLY U/S FAMILY HISTORY HX OF NTDs

EXAMINATION SFH BISHOP SCORING

INVESTIGATIONS

U/SNSTAFI After confirmation of gestational age

management plan is decided

CONSERVATIVE MANAGEMENT

50% women going beyond 42 weeks of gestation experience spontaneous labour in 4-5 days

Poor bishop scoreGood fetal health + adequate placental

function

INDUCTION OF LABOUR

1. Favorable cervix2. Oligohydramnios3. Fetal macrosomia4. Non reactive NST

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