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Preterm labor

Preterm labor. Preterm termination of pregnancy. Abortion: …22 week of gestation Premature labor [PT L ]: 23 – 36 week of gestation. Preterm labor [PTL]. Spontaneous Iatrogenic (result of therapeutic intervention). Preterm labor : definition. Regular uterine contractions

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Preterm labor

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  1. Preterm labor

  2. Preterm termination of pregnancy • Abortion: …22 week of gestation • Premature labor [PTL]: 23 – 36 week of gestation

  3. Pretermlabor [PTL] • Spontaneous • Iatrogenic (result of therapeutic intervention)

  4. Preterm labor : definition • Regular uterine contractions • Cervical effacement • Cervical dilation

  5. The earlier treatment the better results!

  6. The earlier the gestational age the worse neonatal outcomes!

  7. Consequences of PTL • Preterm birth • Perinatal death • Neonatal complications: - Respiratory Distress Syndrome [RDS] • Intraventricular hemorrhage • Necrotizing enterocolitis • Sepsis • Seizures

  8. Consequences of PTL • Long-term morbidity: • Bronchopulmonary dysplasia • Cerebral palsy • Developmental abnormalities

  9. Etiology of PTL • Idiopathic! • Infections: local / generalized • Excessive uterine enlargement (hydramnios, multiple gestation) • Fetal congenital anomalies • Incompetent cervix • Premature rupture of membranes [PROM] • Dehydration • Uterine anatomical malformations • Maternal smoking!

  10. Symptoms and signs of PTL • Uterine contractions • Abdominal / pelvic pressure • Low backache • Menstrual-like cramps • Changes in vaginal discharge: volume, consistence, blood content

  11. Prevention of PTL? • Patient education to recognize signs and symptoms of PTL • Risk scoring programs • Unfortunately: the frequency of PTL is stable

  12. Evaluation of a patient in PTL • Status of the cervix (dilation and effacement): • Speculum • Digital examination 2. Cervical culture 3. Contractions: • Electronic fetal monitoring (frequency and duration) • Abdominal palpation (intensity)

  13. Evaluation of a patient in PTL • Ultrasound 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)

  14. Management of PTL • To delay delivery (until fetal maturity) • Therapy of PTL itself • Detection and treatment of disorders leading to PTL

  15. Tocolysis • Def.: the suppression of uterine contractions by pharmacologic treatment • One patient = one form of tocolysis • Additions: if previous treatment is not effective • Start: 20 – 34 weeks of gestation • Remember to stop therapy! (36 weeks) • Still controversial: do tocolytics prolong pregnancy?

  16. Intravenous hydration 1. Compound electrolyte solution: 1000 ml / 12 hours 2. After 12 hours: reevaluation • Calcium-channel blockers (nifedidpine) • Quit therapy

  17. Calcium-channel blockers: nifedipine • Loading 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!)

  18. Β-adrenergic agents: fenoterol • 1 mg in 500 ml 0.9% NaCl • Keep the inflow: 2.5 – 3.0 ug/min for 6 hours • Changes of inflow - dependent on result • Max. 48 hours • Control: HR, blood pressure, glucose levels, ions • In effective inhibition of uterine contractions: convert to nifedipine

  19. 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!

  20. Prostaglandin synthetase inhibitors: indomethacin • Only in non- effectiveness of previously described tocolytics • Between 28 and 32 weeks of gestation • 60 mg i.m. every 12 hours • Max. dose: 300 mg • Ultrasound control: AFI, ductus arteriosus blood flow (doppler)

  21. Steroids • To enhance fetal pulmonary maturity • 24 – 34 weeks of gestation • Betamethasone 2 x 12 mg i.m. with 12 hours interval • Caution: steroids promote infections! • Control: CRP, glucose levels

  22. General contraindications to tocolysis • Advanced labor (cervical dilation > 4 cm) • Mature fetus (>34 weeks of gestation) • Severely anomalous fetus • Intrauterine fetal death • Significant vaginal bleeding • Possibility of the adverse effects of tocolysis • Any complications contraindicating delay in delivery

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