910939 premature labor and delivery

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  • 1. Premature LaborPremature Labor and Deliveryand Delivery Honor M. WolfeHonor M. Wolfe Associate ProfessorAssociate Professor Maternal Fetal MedicineMaternal Fetal Medicine

2. Objectives:Objectives: To review theTo review the Definition, frequency and consequence ofDefinition, frequency and consequence of preterm deliverypreterm delivery Modifiable and non modifiable risks forModifiable and non modifiable risks for Preterm deliveryPreterm delivery Pathogenesis of Preterm deliveryPathogenesis of Preterm delivery Prediction of Preterm deliveryPrediction of Preterm delivery Management of Preterm laborManagement of Preterm labor 3. Preterm Labor: DefinitionPreterm Labor: Definition Regular uterine contractions With Cervical change or > 2 cm dilation or > 80% effacement 4. Preterm DeliveryPreterm Delivery - Preterm birth:< 37completed weeks- Preterm birth:< 37completed weeks - Very Preterm birth: < 32 weeks- Very Preterm birth: < 32 weeks - Extremely Preterm birth: < 28 weeks- Extremely Preterm birth: < 28 weeks 5. Incidence/DefinitionsIncidence/Definitions 12.5% USA (2004)12.5% USA (2004) 2% < 32 weeks2% < 32 weeks Fetal growthFetal growth Small for gestational age < 10Small for gestational age < 10thth % for GA% for GA Birthweight:Birthweight: Low BWTLow BWT < 2500 grams< 2500 grams Very low BWTVery low BWT < 1500 grams< 1500 grams Extremely low BWT < 1000 gramsExtremely low BWT < 1000 grams 6. IncidenceIncidence 13% Rise in PTB since 199213% Rise in PTB since 1992 Multiple gestation (20% increase)Multiple gestation (20% increase) 50 % twins, 90% triplets born preterm50 % twins, 90% triplets born preterm Changes in Obstetric managementChanges in Obstetric management Ultrasound, inductionUltrasound, induction Sociodemographic factorsSociodemographic factors AMA!AMA! No improvement with physician interventions!No improvement with physician interventions! 7. Leading Causes of Neonatal Death (USA) NeonatalNeonatal deathsdeaths Percentage ofPercentage of neonatal deathsneonatal deaths Disorders related to prematurity and low birthDisorders related to prematurity and low birth weightweight 4,3184,318 23.023.0 Congenital malformations, chromosomalCongenital malformations, chromosomal abnormalitiesabnormalities 4,1444,144 22.122.1 Maternal complicationsMaternal complications 1,3941,394 7.47.4 Placenta, cord, and membrane complicationsPlacenta, cord, and membrane complications 1,0491,049 5.65.6 Respiratory distressRespiratory distress 929929 4.94.9 Bacterial sepsisBacterial sepsis 737737 3.93.9 Intrauterine hypoxia and birth asphyxiaIntrauterine hypoxia and birth asphyxia 589589 3.13.1 Neonatal hemorrhageNeonatal hemorrhage 563563 3.03.0 AtelectasisAtelectasis 483483 2.62.6 Necrotizing enterocolitisNecrotizing enterocolitis 313313 1.71.7 Neonatal deaths: death within 28 days of birth . Data adapted from: the Centers for Disease Control and Prevention, 2000. 8. SignificanceSignificance Infant mortalityInfant mortality Over 50% of infant deaths occur among theOver 50% of infant deaths occur among the 1.5% infants < 1500 grams1.5% infants < 1500 grams 70 % of infant deaths occur among the 7.7% of70 % of infant deaths occur among the 7.7% of infants < 2500 gramsinfants < 2500 grams MorbidityMorbidity 60%: 26 weeks60%: 26 weeks 30%: 30 weeks30%: 30 weeks 9. Risk Factors for Preterm Birth Non-modifiableNon-modifiable Prior preterm birthPrior preterm birth African-American raceAfrican-American race Age 40 yearsAge 40 years Poor nutrition/low prepregnancy weightPoor nutrition/low prepregnancy weight Low socioeconomic statusLow socioeconomic status Cervical injury or anomalyCervical injury or anomaly Uterine anomaly or fibroidUterine anomaly or fibroid Premature cervical dilatation (>2 cm) orPremature cervical dilatation (>2 cm) or effacement (>80 percent)effacement (>80 percent) Over distended uterus (multiple pregnancy,Over distended uterus (multiple pregnancy, polyhydramnios)polyhydramnios) ? Vaginal bleeding? Vaginal bleeding ? Excessive uterine activity? Excessive uterine activity ModifiableModifiable Cigarette smokingCigarette smoking Substance abuseSubstance abuse Absent prenatal careAbsent prenatal care Short interpregnancy intervalsShort interpregnancy intervals AnemiaAnemia Bacteriuria/urinary tract infectionBacteriuria/urinary tract infection Genital infectionGenital infection ? Strenuous work? Strenuous work ? High personal stress? High personal stress 10. Risk factors for preterm birthRisk factors for preterm birth StressStress Single womenSingle women Low socioeconomic statusLow socioeconomic status AnxietyAnxiety DepressionDepression Life events (divorce, separation, death)Life events (divorce, separation, death) Abdominal surgery during pregnancyAbdominal surgery during pregnancy Occupational fatigueOccupational fatigue Upright postureUpright posture Use of industrial machinesUse of industrial machines Physical exertionPhysical exertion Mental or environmental stressMental or environmental stress Excessive or impaired uterine distentionExcessive or impaired uterine distention Multiple gestationMultiple gestation PolyhydramniosPolyhydramnios Uterine anomaly or fibroidsUterine anomaly or fibroids DiethystilbesterolDiethystilbesterol Cervical factorsCervical factors History of second trimester abortionHistory of second trimester abortion History of cervical surgeryHistory of cervical surgery Premature cervical dilatation orPremature cervical dilatation or effacementeffacement InfectionInfection Sexually transmitted infectionsSexually transmitted infections PyelonephritisPyelonephritis Systemic infectionSystemic infection BacteriuriaBacteriuria Periodontal diseasePeriodontal disease Placental pathologyPlacental pathology Placenta previaPlacenta previa AbruptionAbruption Vaginal bleedingVaginal bleeding 11. Risk factors for preterm birthRisk factors for preterm birth MiscellaneousMiscellaneous Previous preterm deliveryPrevious preterm delivery Substance abuseSubstance abuse SmokingSmoking Maternal age (40)Maternal age (40) African-American raceAfrican-American race Poor nutrition and low body mass indexPoor nutrition and low body mass index Inadequate prenatal careInadequate prenatal care Anemia (hemoglobin 35 28%28% 28%28% 27%27% 7%7% 27. Clinical Diagnosis Preterm LaborClinical Diagnosis Preterm Labor Clinical CriteriaClinical Criteria Persistent Ctx 4 q 20 min or 8 q 60 minPersistent Ctx 4 q 20 min or 8 q 60 min Cervical change/80% effacement/> 2cm dil.Cervical change/80% effacement/> 2cm dil. Among the most common admission DxAmong the most common admission Dx Inexact diagnosis: PTL is not PTDInexact diagnosis: PTL is not PTD 30% PTL resolves spontaneously30% PTL resolves spontaneously 50% of hospitalized PTL deliver @ term50% of hospitalized PTL deliver @ term 28. Management of Preterm LaborManagement of Preterm Labor Bedrest, hydration, sedationBedrest, hydration, sedation NO evidence to support in the literatureNO evidence to support in the literature 29. Beta adrenergic receptor agonistsBeta adrenergic receptor agonists (terbutaline)(terbutaline) MechanismMechanism Interferes w/ myosin light chain kinaseInterferes w/ myosin light chain kinase Inhibits actin myosin interactionInhibits actin myosin interaction EfficacyEfficacy ? 48 hours. No change in perinatal outcome? 48 hours. No change in perinatal outcome Side EffectsSide Effects Tachycardia, palpitations,hypotension,SOB, pulmonaryTachycardia, palpitations,hypotension,SOB, pulmonary edema, hyperglycemiaedema, hyperglycemia ContraindicationsContraindications Maternal cardiac disease, uncontrolled diabetes andMaternal cardiac disease, uncontrolled diabetes and hyperthyroidismhyperthyroidism 30. Magnesium SulfateMagnesium Sulfate Mechanism of ActionMechanism of Action Competes with Calcium at plasma memb (?)Competes with Calcium at plasma memb (?) EfficacyEfficacy UnprovenUnproven Side EffectsSide Effects Diaphoresis, flushing, pulmonary edemaDiaphoresis, flushing, pulmonary edema ContraindicationsContraindications Myasthesthenia gravis, renal failureMyasthesthenia gravis, renal failure 31. Calcium Channel BlockersCalcium Channel Blockers Mechanism of ActionMechanism of Action Directly block influx of Ca thru cell membraneDirectly block influx of Ca thru cell membrane EfficacyEfficacy UnprovenUnproven Side EffectsSide Effects Nausea, flushing, HA, palpitationsNausea, flushing, HA, palpitations ContraindicationsContraindications Caution: LV dysfunction, CHFCaution: LV dysfunction, CHF 32. Cyclooxygenase InhibitorsCyclooxygenase Inhibitors Mechanism of ActionMechanism of Action Decrease prostaglandin productionDecrease prostaglandin production EfficacyEfficacy UnprovenUnproven Side EffectsSide Effects Nausea, GI reflux, spasm fetal DA, oligoNausea, GI reflux, spasm fetal DA, oligo ContraindicationsContraindications Platelet or hepatic dysfunction, GI ulcerPlatelet or hepatic dysfunction, GI ulcer Renal dysfunction, asthmaRenal dysfunction, asthma 33. Antenatal SteroidsAntenatal Steroids Recommended for:Recommended for: Preterm labor 24 34 weeksPreterm labor 24 34 weeks PPROM 24 32 weeksPPROM 24 32 weeks Reduction in:Reduction in: Mortality, IVH, NEC, RDSMortality, IVH, NEC, RDS Mechanism of action:Mechanism of action: Enhanced maturation lungsEnhanced maturation lungs Biochemical maturationBiochemical maturation 34. Antenatal SteroidsAntenatal Steroids Dosage:Dosage: Dexamethasone 6 mg q 12 hDexamethasone 6 mg q 12 h Betamethasone 12.5 mg q 24 hBetamethasone 12.5 mg q 24 h Repeated doses - NORepeated doses - NO Effect:Effect: Within several hoursWithin several hours Max @ 48 hoursMax @ 48 hours 35. Progesterone for History of PTBProgesterone for History of PTB 17 alpha OH Progesterone17 alpha