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PRETERM LABOR

PRETERM LABOR. Associate Prof essor Iolanda Elena Blidaru , M D , PhD. PRETERM LABOR. Delivery between 24 (20) & 37 weeks gestation Different from Low birthweight ( LBW ) LBW < 2500gm Very LBW < 1500gm Extremely LBW < 1000gm Major cause of fetal, perinatal & Infant death

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PRETERM LABOR

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  1. PRETERM LABOR Associate Professor Iolanda Elena Blidaru,MD, PhD Managrement of Preterm Labour

  2. PRETERM LABOR • Delivery between 24(20) & 37 weeks gestation • Different from Low birthweight (LBW) • LBW<2500gm • Very LBW < 1500gm • Extremely LBW < 1000gm • Major cause of fetal, perinatal & Infant death • High cost of survival Managrement of Preterm Labour

  3. PRETERM LABOR Incidence : 6- 10% • Spontaneous : 40-50% • PROM : 25-40% • Obstetrically indicated : 20-25% Managrement of Preterm Labour

  4. PRETERM LABOR Most mortality and morbidity is experienced by babies born before 34 weeks. Managrement of Preterm Labour

  5. PRETERM LABOR Major Fetal Risks Of Preterm Delivery • Death • Respiratory distress syndrome • Hypothermia • Hypoglycemia • Necrotising enterocolitis • Jaundice • Infection • Retinopathy of prematurity Managrement of Preterm Labour

  6. PRETERM LABOR ETIOLOGY(I) • Amnionic fluid infection • Cervical incompetence • Placenta praevia • Placental abruption • Uterine anomalies, fibroids • Polyhydramnios Managrement of Preterm Labour

  7. PRETERM LABOR ETIOLOGY(II) • Hypertension • Fetal anomalies • Immunological • Trauma or surgery • IDIOPATHIC - Cause undetectable Managrement of Preterm Labour

  8. PRETERM LABOR CLASSIFICATION Complications of pregnancy that mandate delivery (fetal / maternal risk) Spontaneous preterm labor with intact membranes – true / false labour Preterm / premature rupture of membranes (PROM) Managrement of Preterm Labour

  9. Prediction • Assessment of risk factors • Vaginal examination to assess the cervical status • Ultrasound visualization of cervical length and dilatation • Detection of biological markers Managrement of Preterm Labour

  10. Assessment of risk factors Managrement of Preterm Labour

  11. RISK FACTORS OF PRETERM LABOR • Risk assessment - Papiernik • There is strong evidence that intrauterine infection plays a role in preterm labor. • Bacterial vaginosis increases the risk of preterm delivery >2-fold . Managrement of Preterm Labour

  12. RISK FACTORS OF PRETERM LABOR (I) • Poor socioeconomic/ education/ hygiene/ nutritional status • Young (<16 y.)or advanced age (>35y.) • Nuliparity or grand multiparity • Short stature or low weight (BMI < 19.0) • Medical or surgical illness in pregnancy • Antiphospholipid syndrome Managrement of Preterm Labour

  13. RISK FACTORS OF PRETERM LABOR(II) • Previous preterm delivery: risk 20- 40% • Obstetric complications:hypertension in pregnancy, antepartum hemorrhage, infection, polyhydramnios, fetal abnormalities. • Cigarette smoking: risk 20-30% • Multiple pregnancy: risk >50% • Cervical incompetence • Uterine abnormalities Managrement of Preterm Labour

  14. RISK FACTORS OF PRETERM LABOR (III) • Cervical effacement and/or dilatation > 20weeks • Pelvic pressure • Low back pain • Uterine contraction Managrement of Preterm Labour

  15. 2. Vaginal examination to assess the cervical status Managrement of Preterm Labour

  16. Digital examination is the traditional method used to detect cervical maturation, but quantifying these changes is often difficult. Managrement of Preterm Labour

  17. 3. Ultrasound assessment of cervical length and dilatation Vaginal ultrasonography → a more objective examination of the cervix(≈ 35mm). Managrement of Preterm Labour

  18. Transvaginal sonogram in early pregnancy showing a normal cervix. Arrows point to the internal and external os

  19. Funneled and short cervix.

  20. 4. Detection of biological markers • Testing with biological markers (24-36 weeks): • Fetal Fibronectin (FFN) - in cervico-vaginal secretions (> 50ng/mL) • Salivary estriol (E3). Managrement of Preterm Labour

  21. DIAGNOSIS OF IMPENDING PRETERM DELIVERY (Active preterm labor) Managrement of Preterm Labour

  22. IMPENDING PRETERM DELIVERY (Active preterm labor) • 3 criteria for active preterm labour(20-36w): • uterinecontractions - 4 in 20 min. or 8 in 1 h. • + • cervical changes over time (effacement 80%)or • dilatation ≥ to 2 cm (at least 1) Managrement of Preterm Labour

  23. Prevention Managrement of Preterm Labour

  24. Prevention of Preterm Labor • Antenatal care • Self-monitoring of uterine activity at home: external tocodynamometer • Reduce work, smoking, stress, travel, sexual activity, bed rest, improve nutrition Managrement of Preterm Labour

  25. PREVENTION OF PRETERM LABOR Specific obstetric treatment • Bed rest (in hospital) • Cerclage of the cervix • Antibiotics: urinary infection (asymptomatic bacteriuria), local infection (bacterial vaginosis), occult infection • Progesterone Managrement of Preterm Labour

  26. Treatment ofactive preterm labor • Inhibition of uterine contractions • Corticosteroids • Antibiotics Managrement of Preterm Labour

  27. Treatment ofactive preterm labor • Inhibition of uterine contractions • Bed rest - hospitalisation • Hydration and sedation ? • Tocolytics • Corticotherapy, Antibiotics Managrement of Preterm Labour

  28. Choice Of Tocolytic Drug • Beta –Sympathomimetic agents (Ritodrine, Isoxsuprine, Terbutaline, Salbutamol) • Magnesium sulphate • Nonsteroidal anti-inflammatory drugs (Indomethacin) • Calcium channel blockers (Nifedipine) • Nitric Oxide Donors (Nitroglyerin) • Oxytocin receptor antagonist (Atosiban = Tractocile) Managrement of Preterm Labour

  29. Choice Of Tocolytic Drug Atosiban: Tractocil • a synthetic peptide, acts as a competitive antagonist of oxytocin at uterine oxytocin receptors. Managrement of Preterm Labour

  30. Choice Of Tocolytic Drug • Most authorities do not recommend use of tocolytics at or after 34 weeks'. • Tocolysis should be considered for completing a course of corticosteroids, or in utero transfer. Managrement of Preterm Labour

  31. Corticosteroids • Antenatal corticosteroids are associated with a significant reduction in rates of RDS, neonatal death and intraventricular hemorrhage. • The optimal interval between treatment and delivery is 24 hours. Managrement of Preterm Labour

  32. Treatment ofactive preterm labor • CORTICOSTEROIDS (GA = 24-34 weeks) • 2 doses of Betamethasone 12 mg i.m. at 24 hours interval • or • 4doses of Dexamethasone 6 mg i.m./i.v. at 12 hours interval Managrement of Preterm Labour

  33. Treatment ofactive preterm labor • ANTIBIOTICS • Ampicillin / Clindamycin / Erythromycin • Screen All Pregnant Women for GBS - All patients in preterm labor are considered at high risk. Managrement of Preterm Labour

  34. Intra Partum Managements of Preterm Labour Minimise Maternal Hypotension and Fetal hypoxia and acidosis < Respiratory Distress Syndrome • Routine use of prophylactic forceps & episiotomy ? • Postpartum uterine control • If Fetal distress - CS? • Below 28 weeks - NO CS • Below 32 weeks - ?  • Above 32 weeks - CS • Vertical uterine incision Managrement of Preterm Labour

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