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Pre-term labour
Spontaneous onset of regular uterine contraction with or without rupture of membrane resulting in change in state of cervix before 37 weeks of gestation is pre-term labour. It may happen due to: Previous premature delivery or second trimester abortion Multiple pregnancies and polyhydramnios Uterine malformation Placenta abruption or chorioamnionitis Severe maternal infection in illness Genital tract infection like bacterial vaginosis Foetal death
Isoxsuprine (Duvadilan): It inhibits myometrial activity with cardiovascular effect. Dose is 80 mg in 500ml of Ringer lactate solution. Start with 15 drops/min and increase to 60 drops/min if no hypotension is there. Dose is tapered on inhibition of uterine activity to 10mg IM half hourly for five doses and then oral 10mg thrice daily for three days or till 37 weeks Ritodrine Hydrochloride: It inhibits myometrial activity, bronchial smooth muscle with mild cardiovascular activity. Dose-150mg in 500 ml normal saline 0.1mg/min I.V. Increase it to 0.3mg/min till the uterine contraction ceases and then give oral 10 mg 6 hourly Potential steroids if gestation age is between 27 and 36 weeks. It is given to prevent respiratory distress syndrome in pre-term infant. Betnesol 12 mg IM is given and repeated after12 hours Check the presentation of foetus and formulate a delivery plan accordingly In case of vertex presentation, labour is accelerated by ARM and oxytocin infusion but in breech presentation C-section is justified
Steps to manage
Advise bed rest Use of tocolysis to inhibit uterine contraction. Contraindications of tocolysis
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IUD Severe hypertension Chorioamnionitis Advanced labour APH Maternal diabetes Thyroid disease Intravenous beta-adrenergic agents are the usual first choice for the treatment of patients in established pre-term labour
Management
IV fluid Antibiotic Acceleration of labour by Oxytocin (Syntocinon) drip. Start with two units of Oxytocin (Syntocinon) in 500ml of dextrose with 10 drops/min and then slowly increase the drop and concentration of the drip depending on the uterine contraction FHS and progress of labour If the contraction is well established and there is no progress of labour, no cervical dilatation, descent of head and there are other features of obstructed labour like caput formation, difficulty in passing urine then prepare the patient for C-section
Intra-uterine death
It is death of the foetus after 28 weeks of gestation. To prevent intrauterine deaths high-risk cases, as given below, should be screened and treated early. Pre eclampsia APH Renal / hypertensive disease of mother Severe anaemia Syphilis / diabetes / RH negative Post maturity
Dilatation ( in cm)
Diagnosis is done on the basis of symptoms and signs and confirmation of diagnosis is done by ultrasound.
Symptoms
Duration ( in hrs)
Loss of foetal movement Dirty discharge per vagina
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Signs
No FHS by stethoscope/Doppler on repeated examination Spalding sign i.e. overlapping of sutures is found after seven days. It is the surest sign USG reveals no foetal heartbeat On per abdominal examination fundal height found to be less than what it should be due to amenorrhoea. It is usually found after four weeks of foetal death Confirm diagnosis only if clinical negative FHS is found after repeated test, over two weeks.
Syntocinon: Five hundred ml of Ringer lactate and Oxytocin (Syntocinon) are usually used for induction of labour. Dose is 10 units in first bottle and 15 units in second bottle for the first day of induction and if there is no response then again start Oxytocin (Syntocinon) drip on next day with 20 units in first bottle and 25 units in second bottle. Antibiotics should be started with induction to prevent infection Never do ARM If repeated induction fails than always exclude extra-uterine pregnancy
Investigations
Haemoglobin count, ABO RH typing TC, DC of WBC BT, CT Platelet count Blood sugar VDRL
Management
Expectant treatment Spontaneous expulsion occurs in two weeks in majority of cases. Do not do expectant treatment in APH, ruptured uterus, infection, psychological cases and where pregnancy is far from term. Active treatment by induction of labour Dianoprostone (Cerviprim gel): When cervix is unfavourable cerviprim gel can be given for induction of labour. Misoprostol (Misoprost): Second alternative is Misoprosot in the dosage of 100 microgram four hourly.
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Signs of coagulopathy
Prolonged BT, CT and PT Decreased platelet count
Management
Fresh blood transfusion with two units of blood Fresh frozen Plasma Platelet packs After correcting the coagulation only the induction for delivery of baby should be started
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Stillbirth
When a newborn weighing 1000gm or more shows no sign of life after 28 weeks, it is a case of stillbirth. This can be of two types: Macerated stillbirth is death of foetus before labour. This is also known as intra-uterine death. Fresh stillbirth is death of foetus during labour, also called intra-natal death.
However, for the purpose of treatment anaemia is divided into three types: Mild - 8 to 10gm% Moderate - 6 to 8gm% Severe - less than 6 gm% Before treatment the medical history of the patients need to be taken note of the factors which predispose to anaemia: Dietary history History of menorrhagia History of piles History of worms History of malaria History of UTI, respiratory tract infection, haemoglobinopathy
Causes of stillbirth
If the woman suffers from anaemia and hypertension then during labour placental insufficiency may arise leading to foetal death. Uterine cause-Abnormal uterine action in labour enhances foetal hypoxia due to placental insufficiency already existing during pregnancy. Umbilical cord accidents- Prolapse of cord in labour, cord compression by after coming head of breech, multiple turns around foetal neck are causes of foetal death. Foetal causes-Foetal hypoxia in labour and birth trauma are important causes.
Foetal complications Stillbirth Baby with low birth weight, pre-term, IUGR Increased neo-natal death Anaemia in baby
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Management
Advise diet containing eggs, meat, liver, peas, green leafy vegetables and fruits Treatment of piles In case of worms give two to three tablets of pyrantel Pamoate in second trimester In mild case of anaemia oral tablets of ferrous sulphate are to be taken twice daily. If the rise of haemoglobin does not occur after one month then it is a case of non-responsive anaemia. If there is concurrent vitamin B complex deficiency then 10 injections of B complex should be given every alternate day In cases where Hb% is 6-8 gm% and also in cases of non-responsive mild anaemia give parenteral iron
Indications
Non-responsive anaemia Poor compliance Oral iron intolerance
Postnatal care is important and the patient should be given iron and folic acid tablets for three months along with good nutritious diet. Contraception advice must be given.
Contraindications
Nephritis Cardio-respiratory diseases Allergy Inject iron sorbitol citric acid complex 75mg(Jectofer) IM on upper quadrant of buttock in Z shaped fashion on alternate days after sensitivity test for at least 10 injections. Never use total dose infusion iron.
Primary PPH
PPH is predicted in some high-risk pregnancies: Prolonged/obstructed labour Grand multipara
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