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Preterm Labor

Preterm Labor. Ayesha Shaikh PGY3 Emory Family Medicine 06.17.10. Case!. One innocent Emory Family Medicine resident! Age unknown! G4P1A2 at 25.5 wks GA, presented in didactics on one pleasant morning of Feb 2010.

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Preterm Labor

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  1. Preterm Labor Ayesha Shaikh PGY3 Emory Family Medicine 06.17.10

  2. Case! • One innocent Emory Family Medicine resident! • Age unknown! • G4P1A2 at 25.5 wks GA, presented in didactics on one pleasant morning of Feb 2010. • Later seen by perinatology for Antiphospholipid syndrome.Asymptomatic otherwise! • Transvaginal ultrasound shows cervical funneling and shortening to 0.5 cm. Immediately put on bed rest, Steroids administered and 3 days later admitted in hospital for PRETERM LABOR!

  3. Defination • Preterm Birth • Before 37 weeks • Preterm Labor • Contractions and cervical change before 37 weeks

  4. Why care? • Incidence • ~12% of births in US • ~2% before 32 weeks • Significance • 2nd leading cause of infant mortality • Infant mortality rates are function of gestational age at birth and increase significantly before 32 weeks gestation • 35% of all US health care spending goes to care for preterm infants • Among 26wk survivors – 60% disability • Among 31wk survivors – 30% disability

  5. Where do premies come from? • 50% due to PTL • 25% due to PPROM • 25% iatrogenic

  6. Causes of preterm birth 30-50% 8-9% 10-30% 2-4% 5-40% 12% 6-9%

  7. Today’s Focus • Spontaneous preterm labor with intact membranes

  8. Maternal Race, Interpregnancy interval, Prepregnancy BMI= 19 Pregnancy Hx: Previous preterm delivery Medical disorders Pregnancy characterisitcs: Infections Cocaine/heroine Cone biopsy/LEEP Abd surgery Multiple gestation Periodontal disease Shortened Cervix Tobacco Uterine anomalies Vaginal bleed Risk Factors

  9. Ethnic rates! • Rate of preterm birth in African-Americans is significantly higher- 18.4% • PTB in Hispanic Americans is only slightly increased (12.1%) over Caucasian population (11.7%)

  10. Cervical Length • Shortened Cervix is less than 3 cm or a funneling configuration at internal os in 2nd trimester transvaginal Ultrasound • Cervical effacement in normal pregnancy at 32 wks • A short cervix confers a higher risk of preterm delivery

  11. Cervical funneling

  12. Prevention of Preterm Delivery • Smoking cessation • Bacteriuria? • Periodontal disease? • Bacterial vaginosis? • Antenatal Progesterone?

  13. Bacterial vaginosis and PTL • Screening and treatment for prevention contraversial. • For history of preterm birth, screening reduces PPROM and LBW but not PTL. • USPSTF recommends AGAINST screening low risk patients.

  14. BV diagnosis • Amsel Criteria? • KOH amine odor, clue cells on saline prep, PH > 4.5, and a thin homogenous vaginal discharge • (need 3/4) • CDC Rx: Clindamycin 300mg PO BID x 7 days Flagyl 500 mg BID x 7 days Prefer Clindamycin!

  15. Antenatal progesterone • Prevents formation of cellular gap junctions and maintains uterine quiescence. • 250 mg IM/week from 16-20 weeks through 36 weeks gestation. • Lower risk of NE, IVH, and less need for supplemental oxygen • Twin pregnancies? • ACOG, limit use to women with a previous spontaneous birth at less than 37 weeks gestation.

  16. Assessment of PTL • What is the gestational age? • Are the membranes ruptured? • Is the patient in labor? • Is there an infection? • What is the likelihood that the patient will deliver prematurely?

  17. Rupture of membranes? • Sterile speculum exam and FFN • Nitrazine test accuracy of 97% • Ferning has accuracy of 84-100% • False positive Nitrazine test in presence of bleed, semen, urine, vaginal infections and Ferning in presence of cervical mucus. • Oligohydroamnios is suggestive of but not diagnostic of ROM. Confirm with Amnioinfusion of indigo carmine.

  18. Assessment • What is the gestational age? • Are the membranes ruptured? • Is the patient in labor? • Is there an infection? • What is the likelihood that the patient will deliver prematurely?

  19. Infection • Evaluate UA for Bacteruria and Pyelpnephritis • Rectovaginal culture for GBS • Screen for GC and Chlamydia if not done earlier • Evaluation for BV and trichomoniasis and • Treatment does not effect pregnancy duration

  20. Assessment • What is the gestational age? • Are the membranes ruptured? • Is the patient in labor? • Is there an infection? • What is the likelihood that the patient will deliver prematurely?

  21. Determine likelihood of true labor • Labor: regular uterine contractions at least 6/hr, • With descent of fetal presenting part, • Progressive dilation at least 3 cm • Effacement of cervix to 80% • Rupture of membranes or vaginal bleed However patients present with incomplete picture

  22. Determine likelihood of true labor • FFN: Superior to cervical dil and contraction in symptomatic women NPV 99% and PPV 13-30% NOT if done vag exam, intercourse, endovaginal ultrasound within past 24 hours. Confounders: vag bleed, ROM, Abnormal vag flora, vaginal lubricants • Cervical Ultrasound: determine cervical length Most deliveries within 7 days if length less than 1 cm. • FFN+Cervical US is more accurate tha either test done alone

  23. Management • Steroids! • BMTZ 12mg IM Q24 x 2 doses • DexMTZ 6 mg IM Q24 x 4 doses • Antibiotic prophylaxis for GBS • PCN, Cefoxetin, Clinda, Vanc • Tocolysis • PNV/Colace/FeSO4/SCDs

  24. Management • GBS prophylaxis: for culture + GBS, GBS bacteruria and prior newborn infected with GBS • Dose: PenG 5 mu bolus IV ->2.5 muQ4 hr till delivery Ampicillin 2 gm bolus ->I gm Q4 till delivery • Penicillin allergy Clindamycin 900mg IV Q 8 hrs till delivery Or Erythromycin 500 mg Q 6 hrs till delivery Vanc 1gm Q12 hrs till delivery

  25. Tocolysis • Lacks robust outcome-based research support • Buy time to administer steroids. • General contraindication: fetal distress, Chorioamnionitis, and maternal instability

  26. Indomethacin: CI: maternal hepatic or renal impairment, oligohydroamnios, PUD SE: constriction of ductus arteriosis- DO NOT use after 32 wks GA IVH, NE, hyperbili. Magnesium Sulfate: CI: Mysthenia Gravis SE: flushing, lethargy HA, diplopia, dry mouth, pulmonary edema, newborn: hypotonia, respiratory depression Tocolytics

  27. Nifedipine: CI: maternal hypotension SE: flushing, HA, diziness, nausea, transient hypotension No fetal SE noted Terbutaline: CI: heart disease, poorly controlled DM, thyrotoxicosis, SE: cardiac arrythmias, pulmonary edema, MI, hypotension, tachycardia, Hyperglycemia, hypokalemia, tremor, nervousness, palpitations, nausea, vomiting Fetal: tachycardia, hypoglycemia, hyperbili, IVH Tocolytics

  28. Nifedipine: CI: maternal hypotension SE: flushing, HA, diziness, nausea, transient hypotension No fetal SE noted Terbutaline: CI: heart disease, poorly controlled DM, thyrotoxicosis, SE: cardiac arrythmias, pulmonary edema, MI, hypotension, tachycardia, Hyperglycemia, hypokalemia, tremor, nervousness, palpitations, nausea, vomiting Fetal: tachycardia, hypoglycemia, hyperbili, IVH Tocolytics

  29. Indomethacin: Loading 50 mg rectal or 100 mg oral, maintenance 25-50 mg oral Q4 hrs for 48 hrs MagSO4: 4-6 g bolusIV over 20 min, then 1-2 gm /hr( max 3 g/hr) Nifedipine: 30 gm loading dose orally, then 10 -20 mg every four to six hours Terbutaline: 0.25 mg SC every 20 to 30 minutesfor four hou to six doses. 5 mg PO every 4 hours. TERBUTLAINE PUMP! Tocolytic Doses

  30. Delivery of the Preterm Infant • Level III NICU for care of preterm infant. • Fetal injury due to Acidosis, anoxia. • Perform continuous electronic fetal monitoring. • The immaturity of fetus and Tolcolytic adverse effects complicate fetal surveillance. Does prophylactic episiotomy, forceps delivery, or c-section improve neonatal outcome? • Common retained placenta. Send cord acid-base studies.

  31. Coming back to the Innocent EFM Resident!

  32. Subsequent Transvaginal US 0.5 cm short cervix ---> finger tip inone week! It is snowfall week of Feb 2010. Dose #1 Betamethasone IM at OB office Dose #2 Betamethasone IM self administered at home. OUCH!

  33. OUCH! OUCH!… OUCH! • Terbutaline pump catheter in thighs, change Q 3 days • Lovenox injection on pregnant belly, Q daily • Weekly Progesterone injection in the buttock • Two rounds of Betamethasone injection in Deltoids

  34. Also! • Failed Nifedipine due to hypotension • Unable to tolerate Terbutaline PO • Terbutalin pump and Q 4 hrs tachycardia, missing beats and nervousness lasting 90 min each episode.

  35. Ended up! • Epidural induced hypotension • Nubaine induced Vomitings • C section related intra-op bleed needing blood transfusion TWICE. • AND…

  36. Yes ! It is lunch hour!I know!I am done!

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