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Preterm labor

Preterm labor. Outpatient considerations Joseph Breuner 2/14/06. Teaching points. Examine the cervix in 2 nd /3 rd tri patients with symptoms differentiate high risk from low risk consider using fetal fibronectin and cervical length from your clinic. Preterm birth.

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Preterm labor

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  1. Preterm labor Outpatient considerations Joseph Breuner 2/14/06

  2. Teaching points • Examine the cervix in 2nd/3rd tri patients with symptoms • differentiate high risk from low risk • consider using fetal fibronectin and cervical length from your clinic

  3. Preterm birth • Definition: WHO birth between 20 and 37 wks • US incidence 11%, europe 5-7% • has not declined over 40 yrs

  4. Preterm birth • leading cause of neonatal mortality • 60-80% of deaths of infants without congenital anomalies

  5. Preterm labor • Definition: regular contractions and cervical change prior to 37 wks • accounts for 40-50% of preterm birth • 40% of preterm birth is PPROM • 15-20% obstetrically indicated inductions

  6. Preterm labor • 4 basic causes • infection • bleeding/abruption/thrombophilia • incompetent cervix • Multiple gestation • Note that the first two are also most common causes of PPROM

  7. Preterm labor • Infection • Clinical chorio complicates 2-5% of all pregnancies, but 25% of preterm births • Histological chorio in 10% of term births but 32% of preterm births • Goldenberg, robert, the management of preterm labor. J Obstet Gynecol 2002: 100:1020-37

  8. Preterm labor • Infection • Watts et al: of women in preterm labor, positive amniotic fluid cultures found in 19% despite no clinical signs of chorioamnionitis • Goldenberg, robert, the management of preterm labor. J Obstet Gynecol 2002: 100:1020-37

  9. Preterm labor • Infection • Proportionately more important at early gestational ages • Chorioamnion colonization associated with 83% of very early spontaneous preterm births, but much less important 28-32 or 32-37 wks • Goldenberg, robert, the management of preterm labor. J Obstet Gynecol 2002: 100:1020-37

  10. Preterm labor • Bleeding/abruption/thrombophilia • 1st tri hematoma by US increases RR of preterm birth to 2.3—nagy, et al • Inherited thrombophilias markedly increase risk of maternal thromboembolism and 2nd/3rd tri loss, but not 1st tri loss-lockwood, et al

  11. Preterm labor • ACOG practice bulletin 2003 clinical considerations and recommendations

  12. Preterm labor • Recommendations based on good and consistent scientific evidence (level A) • There are no clear ‘first-line’ tocolytic drugs to manage preterm labor. Clinical circumstances and physician preferences should dictate treatment • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  13. Preterm labor • Recommendations based on good and consistent scientific evidence (level A) • Antibiotics do not appear to prolong gestation and should be reserved for group B streptococcal prophylaxis in patients in whom delivery is imminent • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  14. Preterm labor • Recommendations based on good and consistent scientific evidence (level A) • Neither maintenance treatment with tocolytic drugs nor repeated acute tocolysis improve perinatal outcome; neither should be undertaken as a general practice. • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  15. Preterm labor • Recommendations based on good and consistent scientific evidence (level A) • Tocolytic drugs may prolong pregnancy for 2-7 days, which may allow for administration of steroids to improve fetal lung maturity and the consideration of maternal transport to a tertiary care facility. • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  16. Preterm labor • Recommendations based on limited or inconsistent scientific evidence (level B) • Cervical ultrasound examination and fetal fibronectin testing have good negative predictive value; thus, either approach or both combined may be helpful in determining which patients do not need tocolysis • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  17. Preterm labor • Recommendations based on limited or inconsistent scientific evidence (level B) • Amniocentesis may be used in women in preterm labor to assess fetal lung maturity and intraamniotic infection. • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  18. Preterm labor • Recommendations based on limited or inconsistent scientific evidence (level B) • Bed rest, hydration, and pelvic rest do not appear to improve the rate of preterm birth and should not be routinely recommended. • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  19. Preterm labor • Clinical considerations • Who are appropriate candidates for intervention? • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  20. Preterm labor • Clinical considerations • Are there tests that can help identify patients at risk for progressing to preterm birth? • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  21. Recurrence risk of spontaneous preterm birth at <35wks according to cervical length and fetal fibronectin in women with a prior preterm birth

  22. Prediction at 22-24 wks of spontaneous preterm birth rates before 35 wks gestation, iams et al

  23. Preterm labor • Clinical considerations • Does tocolytic therapy improve neonatal outcome? • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  24. Is there a clear ‘first-line’ tocolytic drug? Acog practice bulletin, no. 43, may 2003, management of preterm labor Preterm labor

  25. Preterm labor • Clinical considerations • Is there a role for adjunctive antibiotics? • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  26. Preterm labor • Clinical considerations • Is preventive treatment efficacious? • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  27. Preterm labor • Clinical considerations • Should women with preterm contractions without cervical change be treated? • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  28. Preterm labor • Clinical considerations • Should women with multiple gestations be treated differently? • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  29. Preterm labor • Clinical considerations • Is there a role for maintenance treatment after completing acute treatment? • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  30. Preterm labor • Clinical considerations • Is tocolysis warranted for recurrent preterm labor? • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  31. Preterm labor • Clinical considerations • Is there a role for amniocentesis? • Acog practice bulletin, no. 43, may 2003, management of preterm labor

  32. Teaching points • Examine the cervix in 2nd/3rd tri patients with symptoms • differentiate high risk from low risk • consider using fetal fibronectin and cervical length from your clinic

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