preterm labour nice guideline november 2015
TRANSCRIPT
Preterm labour NICE guideline
November 2015
Aboubakr Elnashar Benha university, Egypt
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Definitions
I. Prevention
II. Diagnosis
III. Treatment
1. Tocolysis
2. Corticosteroids
3. Mg sulfate
4. Foetal monitoring
5. Mode of birth
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DEFINITIONS
Symptoms of PTL
Before 37+0 w
symptoms that might be indicative of PTL(such
as abdominal pain), but
no clinical assessment (including speculum or
digital vaginal examination) has taken place.
Suspected PTL
symptoms of PTL and
clinical assessment (including a speculum or
digital vaginal examination) that confirms the
possibility of PTL but rules out established
labour.
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Diagnosed PTL
suspected PTL and
positive diagnostic test for PTL.
Established PTL
Progressive cervical dilatation from 4 cm with
regular contractions.
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Rescue' cervical cerclage
Cervical cerclage performed as an emergency
procedure in a woman with premature cervical
dilatation and often with exposed fetal
membranes.
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I. PREVENTION
Offer a choice of
prophylactic vaginal progesterone OR
prophylactic cervical cerclage
history of spontaneous PTB or mid-trimester loss
between 16+0 and 34+0 w and
TVS carried out between 16+0 and 24+0 w:
cervical length ≤25 mm. Discuss the benefits and risks of prophylactic progesterone and cervical cerclage with the woman and take her preferences into account.
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Offer prophylactic vaginal progesterone
No history of SPTB or mid-trimester loss in
whom TVS carried out between 16+0 and 24+0
w: cervical length ≤25 mm.
Consider prophylactic cervical cerclage
TVS carried out between 16+0 and 24+0 w:
cervical length of less than 25 mm and who have
either:
had P-PROM in a previous pregnancy or
history of cervical trauma.
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Rescue' cervical cerclage
Contraindications:
signs of infection
active vaginal bleeding
uterine contractions.
Indications:
between 16+0 and 27+6 w
with a dilated cervix and exposed,
unruptured fetal membranes Take into account
gestational age (being aware that the benefits are likely to be greater for earlier gestations) extent of cervical dilatation discuss with a consultant obstetrician and consultant paediatrician.
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Explain to women:
Risks of the procedure
Aims to delay the birth: increase the likelihood
of the baby surviving and of reducing serious
neonatal morbidity.
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II. Diagnosis
Clinical assessment
History taking
Observations
Speculum examination (followed by a digital vaginal examination if the extent
of cervical dilatation cannot be assessed).
Measuring cervical length using TVS most accurate way to diagnose PTL when used alone
for women over 30 w.
Fibronectin: useful if cervical length measurement not available or
not acceptable
not as good a diagnostic tool as cervical length.
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Suspected PTL and 29+6 w or less:
tt for PTL
Suspected PTL and 30+0 w or more:
TVS measurement of cervical length as a diagnostic
test to determine likelihood of birth within 48 h:
if cervical length is more than 15 mm unlikely that she is in PTL
think about alternative diagnoses
discuss with her the benefits and risks of going home
compared with continued monitoring and tt in hospital
advise her that if she does decide to go home, she
should return if symptoms suggestive of PTL persist or
recur
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if cervical length is 15 mm or less
view the woman as being in diagnosed PTL:
offer tt
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fetal fibronectin testing
diagnostic test to determine likelihood of birth
within 48 h
for
women who are 30+0 w or more
TVS measurement of cervical length is
indicated but is not available or not acceptable
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if fetal fibronectin testing is negative (concentration
50 ng/ml or less):
unlikely that she is in PTL
think about alternative diagnoses
discuss with her the benefits and risks of going
home compared with continued monitoring and tt
in hospital
advise her that if she does decide to go home,
she should return if symptoms suggestive of
preterm labour persist or recur
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if fetal fibronectin testing is positive (concentration
more than 50 ng/ml)
diagnosed PTL: offer tt
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Suspected PTL
30+0 w or more
does not have TVS measurement of cervical length
or fetal fibronectin testing to exclude preterm labour:
offer treatment consistent with her being in
diagnosed PTL
Do not use TVS measurement of cervical length
and fetal fibronectin testing in combination to
diagnose PTL
Ultrasound scans should be performed by
healthcare professionals with training in, and
experience of, transvaginal ultrasound
measurement of cervical length.
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III. TREATMENT
1. Tocolysis
Calcium blockers
most clinical and cost-effective tocolytic
Oxytocin receptor blockers
effective for some other outcomes
not the most effective option overall.
Prostaglandin inhibitors
produce a protective effect for delaying birth
by more than 48 hours.
long-term consequences of tocolytics for both
babies and their mothers:
limited data
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Take into account :
whether the woman is in suspected or
diagnosed PTL
other clinical features:
bleeding or infection which may suggest that
stopping labour is contraindicated
gestational age at presentation
likely benefit of maternal corticosteroids
availability of neonatal care (need for transfer
to another unit)
preference of the woman.
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Consider Nifedipine
between 24+0 and 25+6 w
intact membranes
suspected PTL
Offer nifedipine:
26+0 and 33+6 w
intact membranes
suspected or diagnosed PTL
If nifedipine is contraindicated:
oxytocin receptor antagonists for tocolysis.
Do not offer betamimetics for tocolysis.
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2. Corticosteroids
Discuss with woman:
23+0 and 23+6 w
suspected or established PTL
having a planned preterm birth or
have PPROM
Consider
between 24+0 and 25+6 w
in suspected or established PTL
having a planned preterm birth or
have P-PROM.
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Offer
between 26+0 and 33+6 w
in suspected, diagnosed or established PTL
having a planned preterm birth or
have P-PROM.
Consider
between 34+0 and 35+6 w
in suspected, diagnosed or established PTL
having a planned preterm birth or
have P-PROM.
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Do not routinely offer repeat courses of maternal
corticosteroids, but take into account:
the interval since the end of last course
gestational age
the likelihood of birth within 48 hs.
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3. Mg sulfate
for neuroprotection of the baby
between 24+0 and 29+6 w who are:
in established PTLor
having a planned preterm birth within 24 h.
Consider
30+0 and 33+6 w who are:
in established PTL or
having a planned preterm birth within 24 h.
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4 g IV bolus over 15 min, followed by IV infusion
of 1 g/h until the birth or for 24 h (whichever is
sooner).
Monitor
clinical signs of magnesium toxicity/4 h by
recording pulse, blood pressure, respiratory rate
and deep tendon (for example, patellar)
reflexes.
If a woman has or develops oliguria or other
signs of renal failure:
monitor more frequently for magnesium toxicity
think about reducing the dose of magnesium
sulfate.
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4. Foetal monitoring
Explain to the woman
different fetal monitoring options
Normal CTG
Reassuring
indicates that the baby is coping well with
labour,
Abnormal
does not necessarily indicate that fetal
hypoxia or acidosis is present.
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absence of evidence that using CTG improves
the outcomes of PTL for the woman or the baby
compared with intermittent auscultation.
Offer women in established PTL but with no other
risk factors a choice of FHR monitoring using
either:
CTG using external ultrasound or
intermittent auscultation.
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CTG and intermittent auscultation
Discuss with women in suspected, diagnosed
or established PTL:
the purpose of fetal monitoring and what it
involves
the clinical decisions it informs at different
gestational ages
if appropriate, the option not to monitor FHR
(for example, at the threshold of viability).
Involve a senior obstetrician
in discussions about whether and how to
monitor the FHR for women who are between
23+0 and 25+6 w
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Fetal scalp electrode
Do not use a fetal scalp electrode for FHR
monitoring if the woman is less than 34+0 w
unless all of the following apply:
it is not possible to monitor FHR using either
external CTG
or intermittent auscultation
it has been discussed with a senior obstetrician
the benefits are likely to outweigh the potential
risks the alternatives (immediate birth,
intermittent ultrasound and no monitoring) have
been discussed with the woman and are
unacceptable to her.
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Discuss with the woman the possible use of a
fetal scalp electrode between 34+0 and 36+6 wee
if it is not possible to monitor the fetal heart rate
using either external cardiotocography or
intermittent auscultation.
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Fetal blood sampling
Do not carry out fetal blood sampling if the
woman is less than 34+0 w.
Discuss with the woman the possible use of
fetal blood sampling between 34+0 and 36+6 w
if the benefits are likely to outweigh the
potential risks.
When offering fetal blood sampling, discuss
this with the woman and advise her that if a
blood sample cannot be obtained CS is likely.
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5. Mode of birth
Discuss the general benefits and risks of CS
and vaginal birth with women in suspected,
diagnosed or established PTL and women with
P-PROM
Explain to women in suspected, diagnosed or
established PTL and women with P-PROM
about the benefits and risks of CS that are
specific to gestational age.
highlight the difficulties associated with
performing CS for PTL, especially the
increased likelihood of a vertical uterine incision
and the implications of this for future
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Explain to women in suspected, diagnosed or
established preterm labour that there are no
known benefits or harms for the baby from CS, but
the evidence is very limited.
Consider CS for women presenting in
suspected, diagnosed or
established PTL between 26+0 and 36+6 w with
breech presentation.
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Timing of cord clamping for preterm babies (born
vaginally or by CS
If a preterm baby needs to be moved away
from the mother for resuscitation, or
there is significant maternal bleeding:
consider milking the cord and
clamp the cord as soon as possible.
if the mother and baby are stable.
Wait at least 30 seconds, but no longer than 3
minutes, before clamping the cord
Position the baby at or below the level of the
placenta before clamping the cord.
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