divya- recent guidlines inmanagement of preterm labour
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Department of Obst. & GynaeG.R. MEDICAL COLLEGE, GWALIOR
SEMINAR PRESENTATION
MANAGEMENT OF PRETERM LABOUR
Chairperson Prof. Dr. (Mrs.) V. AgrawalProf. & HOD of Obst. & GynaeG.R. Medical College Gwalior
GuideProf . & Dr J BindalDepartment of Obst. & GynaeG.R. Medical College Gwalior
Presented by Dr. Divya Kakrani
IIIrd Year R.S.O. Obst. & Gynae
DEFINITION PREERM BIRTH-
CAUSES & OUTCOME
PREDICTION ANTECEDENT
FACTORS PREVENTION TREATMENT
MANAGEMENT OF PRETERM LABOUR
DEFINITION
Preterm labor is the presence of contractions of sufficient strength and frequency to effect progressive effacement and dilation of the cervix between 20 and 37 weeks' gestation
Contraction of four in 20 min, or 8in 60 min plus progressive change in cervix Cervical dialatation greater than 1cm Cervical effacement of 80% or greater
@Such explicit criteria do not appear in more recent guidelines (ACOG 2008)
ACOG CRITERIA to document PRETERM LABOUR
MORBIDITY IN PRETERM INFANTS
LATE PRETERM INFANTS34-36 WKS
(71.2% of all preterm births)
SMALL PRETERM INFANTS<34WKS
LONG TERM SEQUELAE PRESENT
26 WKS OR 750GM –current threshold Not appropriate to initiate resusitation in
MGA <23 wks
THRESHOLD OF VIABLITY
Induced labour or prelabour caesarian- for maternal and foetal indications
Spontaneous unexplained preterm labour with intact membranes
Idiopathic preterm premature rupture of membranes(PROM)
Twins and high order births Drugs like cocaine or methamphetamine Uterine and cervical causes-fibroid uterus,
abnormal shape of uterus,thin cervix
CAUSES OF PRETERM DELIVERY
Causes for preterm birth
Large for gestational age Preeclampsia Fetal distress IUGR Placental abruption Others-chronic hypertension, placenta
previa, unexplained bleeding, diabetes, renal disease, Rh incompatiblity and congenital malformations
MEDICAL AND OBSTRETIC INDICATIONS
PROGESTERONE WITHDRAWL-reversal of estrogen progesterone ratio. Serum progesterone conc do not fall
OXYTOCIN INITIATION- serum conc doesn’t change, so unlikely cause
INFLAMMATORY DECIDUAL REACTION
SPONTANEOUS PRETERM LABOUR
INFECTION- Microbes involved are-
-ureaplasma urealyticum -mycoplasma hominis -nisseria gonorrhoea -group B streptococci -trichomonas vaginalis
Rupture of membranes prior to 37 wks
PROM AND PPROM
Can preterm labor be predicted?
Prediction of preterm labor
1. Risk markers2. Home uterine activity monitoring
(HUAM)3. Salivary estriol
4. Screening for bacterial vaginosis (BV)5. Screening for fetal fibronectin (fFN)6. Cervical ultrasonography (cervical
length assessment
A previous history of preterm labor is the strongest risk marker
Risk markers
Other risk markers include multiple pregnancy Cigarette smoking, cervical incompetence or
uterine anomalies, uterine over-distension (polyhydraminos,
macrosomia, fibroids), previous cervical surgery , using smokeless
tobacco , bleeding in early pregnancy , bacterial
vaginosis, poor socioeconomic or educational status, and young or advanced
maternal age. Antiphospholipid syndrome
Risk markers
HUAM is based on the principle of tocodynamometry
Telemetric recording of uterine contractions and transmission to a monitoring center and daily feed back from healthcare practitioner
Not useful so not recommended in routine practice (ACOG 1995)
Home uterine activity monitoring (HUAM)
Premature activation of HPA axis in preterm labor may increase the serum and salivary levels of estriol in the mother.
Very poor sensitivity and specificity and has a very high false positive rate
Diurnal variation of the maternal salivary estriol level
Administration of betamethasone to effect surfactant production may suppress maternal salivary estriol levels
Salivary estriol
- Normal hydrogen peroxide producing , lactobacilli predominant vaginal flora is replaced by anaerobes –Gardenella vaginalis , mobiluncus sp , mycoplasma hominis.
- Chronic stress n frequent douching predispose
- antibiotics not helpful in preventing PTL
#NUGENT SCORE- relative concentrations of above mentioned phenotypes are studied in a gram stained smear
BACTERIAL VAGINOSIS
Fishy odour when mixed with 10% KOH AMINE TEST / WHIP TEST. pH of vaginal discharge more than 4.5 Presence of clue cells on smear. Treatment does not alter preterm birth Screening routinely not recommended
(ACOG 2001)
Screening for bacterial vaginosis (BV)
Basement membrane protein produced by the hepatocytes , fibroblasts , endothelial cells , fetal amnion and functions as an ‘adhesion binder’.
attachment of the placenta and membranes to the uterine decidua
Present in maternal blood and amniotic fluid Normally detectable in cervical secretions until
16-20 weeks of gestation. After 24 weeks (>50 ng/ml ) of gestation may
indicate disruption of the normal adhesion between chorioamnion and the underlying decidua.
Screening for fetal fibronectin (fFN)
Mean cervical length at 24 wks is approx 35mm
Women with progressively shorter cervix predisposed to PTL.
Funneling of cervix if present increases risk
CERVICAL CHANGES
THREATENED ABORTIONS LIFESTYLE FACTORS-smoking , inadequate
maternal wt gain , illicit drug usage WORK DURING PREGNANCY- only long and hard
physical labour are associated GENETIC FACTORS PERIODONTAL DISEASE-chronic anaerobic
inflammation of gums, BIRTH DEFECTS INTERVAL BETWEEN PREGNANCIES- smaller intervals
more associated PRIOR PRETERM BIRTHS
ANTECEDANTS AND CONTRIBUTING FACTORS
PROGESTERONE Weekly im injections reduce PTL. Daily 100mg progesterone suppositories
reduce PTL in women with prior PTL or circlage or uterine malformation.
Vaginal progesterone gel not useful in women with prior PTL
Efficacy in nulliparous with short cervix is under way.
PREVENTION OF PRETERM BIRTH
Prophylactic use of 17 hydroxy progesterone caproate to prevent preterm labor revealed a significant decrease in preterm birth .
However, it has not successfully inhibited active preterm labor.
17 Hydroxy -Progesterone Caproate
PRECONCEPTIONAL n DURING PREGNANCY-decreasing work hours’standing <6hr per day
Vitamin supplementation-calcium supp decreases PTL
Smoking cessation Self monitoring of vaginal pH and yoghurt
treatment
PREVENTION
Cervical circlage For cervical insufficiency which complicates
0.1-2% of all pregnancies and is responsible for 20% of late 2nd trimester losses
Prophylactic circlage – 12-14wks. Not much fruitful.
Rescue circlage – when cvx changes already detected
Efficacy seen in women with prior PTL
Treatment Inhibition of labor Corticosteroid Antibiotics Others.
Inhibition Of LaborBed rest :DVTHydration &sedation
Tocolytics
Hydration Intravenous hydration does not seem to be beneficial, even during the period of evaluation soon after admission,
Women with evidence of dehydration may, however, benefit from the intervention.
Is Tocolysis Better Than No Tocolysis For Preterm Labour?
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
Choice Of Tocolytic Drug
B –Sympathomimetic (Ritodrine)Magnesium sulphateIndomethacin Nifedipineatosiban
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.
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.
MgSO4 Terbutaline Indocin Nifedipine
Class Β-agonist Cox inhibitors CCB
Action Competes for Ca
↑ cAMP↓ intracellular
Ca
↓ PGD production
Block Ca influx
Side Effect Pulm edema, ? ↑ ped M&M
Tachy, ↓BP, palp, ↓K,
pulm edema
N/V, gastritis, narrowing of
DA, oligo
↓BP, reflex tachy, ? ↓ of blood flow
Efficacy Not very good!
No ↓ of PTB @ 7 days, sx
relief
Appears to be more
effective than placebo
↓ # of women giving birth at
7 days
Magnesium Sulfate
Magnesium sulphate is ineffective
at delaying birth or preventing
preterm birth, and its use is
associated with an increased
mortality for the infant.
@ Neuroprotective for foetus-decreses
chances of cerebral palsy
Nitric Oxide DonorsThere is insufficient evidence to
support the routine
administration of nitric oxide
donors (nitroglycerin )in the
treatment of preterm labor.
Side effect- Maternal
hypotension
Indomethacin Indomethacin can be used as a second-line tocolytic agent in early gestational age preterm labors.
Indomethacin Indomethacin therapy for < 48 hours < 30-32 weeks' gestation)Not > 200mg/day.appears to be a relatively safe and effective tocolytic agent
Indomethacin Indomethacin may be a first-line tocolytic in:
Associated polyhydramnios :
( to have renal effects of indomethacin)
Indomethacin Capsule 25mg oral Amp 50mg Rectal Supp 100 mg
50 mg Loading dose
Then 25-50mg /6hs
Indomethacin Fetal risk:Premature closure of the ductus.Renal and cerebral vasoconstriction.
Necrotising enterocolitis Common with high dose and prolonged exposure.
Atosiban: TractocilAtosiban, a synthetic
peptide, is a competitive
antagonist of oxytocin at uterine oxytocin
receptors.
Atosiban: TractocilAtosiban - 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.
NifedipineNifedipine- compared with ritodrine -
has:
Higher delaying of delivery for >48
H.
Lower risk of RDS &Neonatal jundice.
Lower admission to NN ICU
Fewer maternal adverse effects
Nifedipine20mg initial
10-20 mg /4-6 h
Epilate capsule :10mg
Epilate retard Tablet: 20 mg
NifedipineWhen 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
General contraindications Acute fetal distress (except intrauterine
resuscitation) Chorioamnionitis Eclampsia or severe preeclampsia Fetal demise (singleton) Fetal maturity Maternal hemodynamic instability
Contraindications to Tocolysis for Treatment of Preterm Labor
Beta-mimetic agents Maternal cardiac rhythm disturbance or other
cardiac disease Poorly controlled diabetes, thyrotoxicosis or
hypertension
Magnesium sulfate Hypocalcemia Myasthenia gravis Renal failure
Contraindications for specific tocolytic agents
Indomethacin (Indocin) Asthma Coronary artery disease Gastrointestinal bleeding (active or past history) Oligohydramnios Renal failure Suspected fetal cardiac or renal anomaly
Nifedipine (Adalat, Procardia)
Maternal liver disease
Beta-adrenergic agents Hyperglycemia Hypokalemia Hypotension Pulmonary edema Cardiac insufficiency Arrhythmias Myocardial ischemia Maternal death
Potential Complications of Tocolytic Agents
Magnesium sulfate Pulmonary edema Respiratory depressionCardiac arrestMaternal tetany Profound muscular paralysis Profound hypotension
Indomethacin (Indocin) HepatitisRenal failure Gastrointestinal bleeding
Nifedipine (Adalat, Procardia) Transient hypotension
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. .
Maintenance Tocolysis Is Not Recommended For Routine Practice in threatened PTL.
CorticosteroidsThe optimal treatment-delivery
interval for administration of
antenatal corticosteroids is
after 24 hours but < 7 days
after the start of treatment.
Decreses RDS , IVH.
CorticosteroidsTwo 12 mg doses of betamethasone
given IM 24 hours apart, Or
Four 6 mg doses of dexamethasone
given IM 12 hours apart (I-A).
There is no proof of efficacy for any
other regimen.
Antibiotics There is no evidence of clear overall benefit from prophylactic antibiotics for preterm labour with intact membranes on neonatal outcomes.
Screening for GB Strep.
ACOG Advises Screening All Pregnant Women for Group B Strep.
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.
Group B Streptococci (GBS) Prophylaxis
The goal of this strategy is to prevent neonatal sepsis, and not to prevent preterm birth.
Prophylactic Vitamin K Or Phenobarbital
Have not been shown to significantly prevent periventricular haemorrhages in preterm infants.
ConclusionsVarious strategies that have been used to prevent or treat preterm labor, haven't proven effective.
Tocolysis should be considered only for 2 days- if needed - for corticosteroids thereby , or in utero transfer to a tertiary center .
ConclusionsIf a tocolytic drug is
used, ritodrine no
longer seems the best
choice.
ConclusionsOther drugs with fewer adverse effects
and comparable effectiveness are now
recommended
Atosiban or nifedipine have been
recommended by RCOG
Indomethacin may be used as a 2nd
line tocolytic or if there is
polyhydramnous
ConclusionsMaintenance tocolytic therapy has no proven effect.
It cannot be recommended for routine practice.
PSCHYCOSOCIAL SUPPORT AND COUNCILLING FOR
NEXT PREGNANCY
CARBON MONOOXIDE HUMAN GONADOTROPIN
NEWER DEVELOPMENTS
Thank YouThank You
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