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PRETERM LABOR

DR. SHABNAM NAZ


MBBS, MCPS, FCPS

ASSISTANT PROFESSOR

OBGYN
SHAHEED MOHTARMA
BENAZIR BHUTTO
MEDICAL UNIVERSITY LARKANA

OBJECTIVES

Define PTL and describe their significance


List risk factors associated with PTL
Outline initial evaluation of PTL
Describe management of PTL
Discuss neonatal GBS prevention
strategies.

Preterm labor
Labor before 37 completed weeks of
gestation

TERMINOLOGY
Preterm birth:
24-36+6wks
Indicated preterm birth
Spontaneous preterm birth
(3contractions/10 min +cervical changes)
Preterm premature rupture of membrane
Premature ROM(1 hr or more before onset of labour)
PPROM(premature ROM before 37 wks)

Classification of preterm birth


Mildly preterm birth 32 - 36 weeks
Very preterm birth 28 - 31 weeks
Extremely preterm birth - 24 - 27 weeks

Incidence
Accounts for 85% of all perinatal mortality
and morbidity.
8-12% of all deliveries are preterm.
71.2%
34-36 weeks
13%
32-33 weeks
10%
28-31 weeks
6% <28 weeks

Survival in Premature Infants


survival chance is directly proportional to the maturity

26 wks
80%
27 wks
90%
28-31 wks 90 to 95%
32-33 wks 95%
34-36 wks
approaches term
survival rates

Complications of Prematurity

RDS
IVH
Feeding difficulties/NEC
Apnea
PDA
Infection
Jaundice
Hypothermia
Neurobehavioral
ROP
Anemia

Pathogenesis
Premature activation of maternal or fetal
HPA axis
Decidual hemorrhage
Inflammation/infection
Pathological uterine distention

Mechanisms For Preterm Labor

Penyebab Persalinan Preterm

Can preterm labor be


predicted?

Prediction
1.
2.
3.
4.

Assessment of risk factors


Vaginal examination to assess the cervical status
Ultrasound visualization of cervical length and dilatation
Detection of fetal fibronectin in cervicovaginal secretions

Risk factors for preterm birth


Risk factors

Relative risk

2-Vaginal examination

Digital examination is the traditional


method used to detect cervical
maturation, but quantifying these
changes is often difficult.

3-Vaginal U/S
Vaginal Ultrasonography allows a

more objective approach to


examination of the cervix.

Sonographic Cervical Length

80-100% of women who


deliver early have cervix
<30mm
50% delivery rate within one
week have cervix < 15 mm or
less

Fetal Fibronectin

Fetal Fibronectin (fFN)- it is a glue like protein binding


choriodecidual membrane
Present in vaginal secretions between 23-34 weeks
and signifies onset of labor
Bedside test can be done if negative it rules out
preterm labor in next two weeks
P/V examination gives false positive result for 24 hours

Between 24-32 weeks


fFN 25ng/ml + cervical length of 25 mm
shows significant risk

Prevention of
preterm labor

Prevention of PTB
Reduce/eliminate risk factors, if possible
Not proven to be effective: bedrest, home
uterine monitoring, prophylactic tocolytics,
prophylactic antibiotics, abstinence.
Supplemental progesterone
Women with previous spontaneous preterm delivery
at less than 34 weeks gestation
Weekly 17OHprogesterone IM or daily vaginal
progesterone suppositories
Start at 16-20 wks gestation, continue through 36
weeks

Treatment Of Vaginosis
Treatment of asymptomatic abnormal vaginal flora
and bacterial vaginosis with vaginal

clindamycin or oral metronidazole early


in the 2nd trimester significantly reduces the rate
of late miscarriage and spontaneous preterm
birth.

DIAGNOSIS
OF
PRETERM LABOR

Diagnosis
Three criteria to document PTL(20-37wks)
1-Regular uterine contractions occur at 4/20 min. or

8/60 min. Plus: progressive change in the cervix.


2- Cervical dilatation > 1 cm
3- Effacement >80%.

Four Questions:
Is the patient in labor?
Are the membranes ruptured?
Is the fetus preterm?
What risk factors are present?

PATIENT HISTORY

Detailed history of labor.


History of fluid leakage.
Dating of pregnancy.
Review history for risk factors.
History of other medical problems.
Assessment of social history and home
support.

PHYSICAL EXAMINATION

Maternal vitals: signs of infection.


General physical exam.
Fetal heart rate pattern.
Fetal size and presentation.
No digitals cervical exam if membrane
rupture suspected.

STERILE SPECULUM
EXAMINATION
Assess for membrane rupture:
Pooling of fluid in vagina.
Nitrazine and fern test.
Assess cervix visually.
Obtain cervical cultures.
Obtain wet prep for vaginitis, if no ROM.
Obtain GBS culture of outer vagina and
rectum.

ADDITIONAL TESTS
CBC, Urinalysis.

Evaluate for maternal infection.

Amniocentesis.

Assess fetal lung matunity.

Ultrasound

Assess amniotic fluid index.


Determine (+/ - 3 weeks) gestational
age.
Transvaginal scan for cervical length.
Normal cervical length = 35 mm
Significant cervical length = 25 mm
Funnelling of membrane

Cervioovaginal swab for fetal


fibronection.

MANAGEMENT
OF
PRETERM LABOR

MANAGEMENT OF PRETERM
LABOUR
Prophylactic management
Management in labour
Management after
delivery

Prophylactic
Management
Good antenatal care.
All diseases should be controlled well.
In multiple pregnancy rest and
sedatives very
important
In incompetent Cx. Circlage stitches.
Diabetic treatment.
Tocolytic therapy

Management of Acute
Preterm Labour
Sedation and hydaration
Bed rest and hydration are commonly
recommended,
but
without
proven
efficacy. (risk of DVT in bed rest).

Probable role of hydration decrease


secretion of ADH + oxytocin from post
pitutary

Steroids
Antibiotics
Tocolysis

Role of Steroids
Single course of antenatal steroids b/w 24 and
34 wks of gestation with intact membranes and
24-32 wks in PPROM reduces the risk of
RDS,IVH, NEC, Sepsis and neonatal mortality
by 50%.
Dose
Betamethasone 12mg i/m B.D for 24 hrs.
Dexamethasone 6 mg i/m every 6 hours for 24
hours.

MOA of steroids.

1. Stimulates type II pneumocyctes to produce surfactant.


2. Structural development of lungs
3. Accelerated maturation of fetal intestines (Prevent NEC).
effect on myocardium (Prevent IVH)
Repeated Dose increased sepsis in PPROM.
Restricted fetal body and brain growth .
Adrenal Suppresssion.
Increase risk of NND

TRH, Vitamine K , Phenobarbitone


The use of thyrotropin-releasing hormone (TRH), vitamin
K and phenobarbitone to improve neonatal outcome has
been studied in randomized trials, but has not been
shown to be beneficial.

Role of Antibiotics
(Oracle Trail)
Administration of antibiotics to the mother
do not delay delivery.
Only positive health benefit is a reduction
in maternal infection rates.

TOCOLYSIS

Is Tocolysis Better Than No Tocolysis For


Preterm Labor?
It is reasonable not to use tocolytic drugs, as there is no
clear evidence that they improve outcome. However,
tocolysis should be considered if the few days gained
would be put to good use, such as
completing a course of corticosteroids,

or in utero transfer

Tocolytics
There is no reliable data to suggest tocolytics agent is
able to delay the delivery for longer than 48 hours.
No single agent has a clear therapatic advantage.
Maintenance tocolysis beyond 48 hours is not
recommended, it has not been shown to delay delivery
and is associated with Significant adverse effect.

Tocolytics
Recent meta analysis suggest that
maintenance tocolytic with nifedipine
may be beneficial.
Concurrent use of tocolytics has no more
effective than single agent alone and has
more S.E so not recommended.

Most authorities do not recommend use of


tocolytics at or after 34 weeks' .
There is no consensus on a lower
gestational age limit for the use of tocolytic
agents.

CANDIDATES FOR TOCOLYSIS

No contraindications to drug.
Fetus currently healthy.
Clear diagnosis of preterm labor.
Cervix < 4cm dilatation.
Gestational age between 24 -34 weeks.

Contraindication of Tocolysis
Severe pregnancy induced
hypertension
Uncontrolled diabetes mellitus
Placental abruption
Cardio-pulmoary diseases
Multiple gestation
Maternal hyperthyroidism
Rhesus iso-immunisation
Sickle cell disease.
Severe anaemia.

Choice Of Tocolytic Drug


B Sympathomimetic
(Ritodrine)
Magnesium sulphate
Indomethacin = Indocid

Nifedipine = Adalate retard


Atosiban= Tractocile

Choice Of Tocolytic Drug

If a tocolytic drug is used, ritodrine no longer seems the


best choice.

Atosiban or nifedipine appear preferable


as they have fewer adverse effects and seem to have
comparable effectiveness.

B -Sympathomimetic Agents.

Use of beta-agonists should be restricted to the


management of preterm labor between 20 and 35
completed weeks, including women with ruptured
membranes.
(Grade A)

Side Effects of B -Sympathomimetic


Agents.
Maternal: pulmonary edema, myocardial
ischemia, arrhythmia, and even maternal
death.
Fetal : arrhythmia, cardiac septal
hypertrophy , hydrops, pulmonary edema,
and cardiac failure. hypoglycemia,
periventricular-intraventricular
hemorrhage, and fetal and neonatal death.

Magnesium Sulphate
Magnesium sulphate is ineffective at delaying birth or

preventing preterm birth, and its use is associated with an


increased mortality for the infant.

Nitric Oxide Donors


There is insufficient evidence to support the routine
administration of nitric oxide donors
(nitroglycerin patch )in the treatment of preterm labor.

Indomethacin
Compared with ritodrine there is insufficient evidence for any
differential effect on delay in delivery, but indomethacin
does seem to have fewer maternal adverse effects than the
beta-agonists

Fetal risk: (Common with high dose and prolonged exposure)


Premature closure of the ductus arteriosus.
Renal and cerebral vasoconstriction.
Necrotising enterocolitis

Indomethacin
Indomethacin therapy for
< 48 hours
< 30-32 weeks' gestation)
Not > 200mg/day.
appears to be a relatively safe and effective tocolytic agent
Indomethacin can be used as a second-line tocolytic agent
in early gestational age preterm labors.

Indomethacin
Indomethacin may be a first-line tocolytic in:

Associated polyhydramnios:
( to have renal effects of indomethacin)
Capsule
Amp

25mg oral
50mg

Rectal Supp

100 mg

50 mg Loading dose
Then 25-50mg /6hs

Atosiban: Tractocil
Atosiban, a synthetic peptide, is a competitive antagonist of oxytocin at
uterine oxytocin receptors.

Atosiban - compared with beta-agonists- has:


Little difference in the effect of these agents on delayed
delivery
Fewer maternal adverse effects than beta-agonists, such as

chest pain, palpitations , tachycardia , hypotension ,


dyspnoea ,vomiting , and headache.

Nifedipine
Nifedipine- compared with ritodrine - has:
Higher delaying of delivery for >48 H.
Lower risk of RDS &Neonatal jundice.
Lower admission to NICU
Fewer maternal adverse effects

When tocolysis is indicated for women in preterm labor, calcium channel


blockers are preferable to other tocolytic agents compared, mainly
betamimetics.
Further research should address the effects of different dosage regimens
and formulations

Nifedipine
Dose:
20mg initial
10-20 mg /4-6 h
Available forms
Adalate capsule

: 10mg

Adalate retard Tablet: 20 mg

Group B Streptococci (GBS) Prophylaxis


All patients in preterm labor are considered at high risk for neonatal GBS
sepsis and should receive prophylactic antibiotics regardless of culture
status.

ACOG Advises Screening All Pregnant Women for Group B Strep.


The goal of this strategy is to prevent neonatal sepsis, and not to prevent
preterm birth.
All patients in preterm labor are considered at high risk for neonatal GBS
sepsis and should receive prophylactic antibiotics regardless of culture
status.

Management after Tocolysis


If maternal and fetal conditions are stable, can be
managed at home
Avoid excessive physical activity; most advocate pelvic
rest

Delivery of Preterm Fetus


Every effort for in utero transfer to an
tertiary care obstetric unit linked with NICU

Mode of Delivery
If the presentation is Cephalic and normal fetal heart rate
pattern Vaginal Delivery
No evidence of routine C-section
No evidence for elective forceps delivery.
Episiotomy rarely required
If abnormal F.H.R pattern C-section
( Hypoxia pelivemtricular leucomalacia)

Preterm Breech
(Obstetric Dilemma)
Mode of delivery of preterm breech will need to be made
on a case to case by obstetrician at that time.
C-section in preterm breech already in vagina may be
more traumatic then vaginal delivery

Summary
Oral metronidazole significantly lowers the risk of
preterm birth, by 60% in high risk women positive
for bacterial vaginosis.
Asymptomatic bacteriuria carries an increased risk
of preterm birth, the risk is reduced by appropriated
antibiotic treatment.
Mothers at risk of preterm delivery should be
screened for GBS colonization. If positive, intra
partum antibiotics should be offered.

When based on historical factors alone, cervical


cerclage improves outcomes only in women with
three or more previous very early deliveries.

Hospitalization for bed rest leads to an increase in


preterm births .

Tocolytics have no significant benefit on perinatal


mortality or the prolongation of pregnancy to term, but do
reduce the number of women delivering within 48 hours
by 40 percent.

continue

A single course of maternal steroids given b/w 28 and 34


wks gestation and received within 7 days of delivery
results in markedly improved neonatal outcomes.
There is no evidence of benefit and some evidence of
harm associated with the use of antibiotics in
uncomplicated preterm labor with intact membrane

Thanks