preterm labor. preterm termination of pregnancy abortion: …22 week of gestation abortion: …22...

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  • Preterm labor

  • Preterm termination of pregnancyAbortion: 22 week of gestation

    Premature labor [PTL]:23 36 week of gestation

  • Preterm labor [PTL]Spontaneous

    Iatrogenic (result of therapeutic intervention)

  • Preterm labor : definitionRegular uterine contractions

    Cervical effacement

    Cervical dilation

  • The earlier treatment the better results!

  • The earlier the gestational age the worse neonatal outcomes!

  • Consequences of PTLPreterm birthPerinatal death

    Neonatal complications:- Respiratory Distress Syndrome [RDS]Intraventricular hemorrhageNecrotizing enterocolitisSepsisSeizures

  • Consequences of PTLLong-term morbidity:

    Bronchopulmonary dysplasiaCerebral palsyDevelopmental abnormalities

  • Etiology of PTLIdiopathic!Infections: local / generalizedExcessive uterine enlargement (hydramnios, multiple gestation)Fetal congenital anomaliesIncompetent cervixPremature rupture of membranes [PROM]DehydrationUterine anatomical malformations Maternal smoking!

  • Symptoms and signs of PTLUterine contractionsAbdominal / pelvic pressureLow backacheMenstrual-like crampsChanges in vaginal discharge: volume, consistence, blood content

  • Prevention of PTL?Patient education to recognize signs and symptoms of PTLRisk scoring programs

    Unfortunately:the frequency of PTL is stable

  • Evaluation of a patient in PTLStatus of the cervix (dilation and effacement):SpeculumDigital examination2. Cervical culture3. Contractions: Electronic fetal monitoring (frequency and duration)Abdominal palpation (intensity)

  • Evaluation of a patient in PTLUltrasound examination: gestational age of the fetus, fetal presentation, AFI, placental location

    Vaginal bleeding: volume, fresh / dark blood (placenta previa? abruptio placentae?)

    Urine: analysis, culture (infections)

  • Management of PTLTo delay delivery (until fetal maturity)

    Therapy of PTL itselfDetection and treatment of disorders leading to PTL

  • TocolysisDef.: the suppression of uterine contractions by pharmacologic treatmentOne patient = one form of tocolysisAdditions: if previous treatment is not effectiveStart: 20 34 weeks of gestationRemember to stop therapy! (36 weeks)Still controversial: do tocolytics prolong pregnancy?

  • Intravenous hydration1. Compound electrolyte solution: 1000 ml / 12 hours

    2. After 12 hours: reevaluation Calcium-channel blockers (nifedidpine)Quit therapy

  • Calcium-channel blockers: nifedipineLoading dose: 3 x 10 mg in: 0` - 30 ` - 60`Then: 4 x 20 mg p.o. (every 6 hours)

    Potentiates effects of MgSO4 (hypotension! respiratory depression!)

  • -adrenergic agents: fenoterol1 mg in 500 ml 0.9% NaClKeep the inflow: 2.5 3.0 ug/min for 6 hoursChanges of inflow - dependent on resultMax. 48 hoursControl: HR, blood pressure, glucose levels, ions In effective inhibition of uterine contractions: convert to nifedipine

  • Magnesium sulfate (MgSO4)Loading dose: 4 g in 20 ml 0.9% NaCl i.v.1st day: 8 g in 500 ml of compound electrolyte solution i.v. every 12 hours (twice a day)2nd day: 6 g in 500 ml of compound electrolyte solution i.v. every 12 hours

    Total dose: 30 32 g of MgSO4 Control: magnesium levels!

  • Prostaglandin synthetase inhibitors: indomethacin Only in non- effectiveness of previously described tocolytics Between 28 and 32 weeks of gestation60 mg i.m. every 12 hoursMax. dose: 300 mgUltrasound control: AFI, ductus arteriosus blood flow (doppler)

  • SteroidsTo enhance fetal pulmonary maturity24 34 weeks of gestationBetamethasone 2 x 12 mg i.m. with 12 hours intervalCaution: steroids promote infections!Control: CRP, glucose levels

  • General contraindications to tocolysisAdvanced labor (cervical dilation > 4 cm)Mature fetus (>34 weeks of gestation)Severely anomalous fetusIntrauterine fetal deathSignificant vaginal bleedingPossibility of the adverse effects of tocolysisAny complications contraindicating delay in delivery