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Preterm Labor by Yinka Oyelese

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  • its really help me to finish my task about preterm labor espesially for the pathway..
    thank you so much ^_^
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  • amazing work
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  • 1. Preterm Birth Yinka Oyelese, MD, MRCOG Associate Professor, Maternal Fetal Medicine UTHSC
  • 2. Preterm birth rates in the United States < 37 weeks 12.9% %
  • 3. Preterm birth in the US One preterm birth every minute!
  • 4. To put it in perspective…..
    • One preterm birth each minute
    • 60 preterm births by the time this talk is over
    • Healthy people 2010 objective is to reduce rate to 7.6%
  • 5. Preterm birth
    • 75-80% of all perinatal mortality
    • 50% of all long term neurodevelopmental morbidity
    • Tremendous financial, emotional burden on society
  • 6.
    • Infants born preterm are at increased risk of:
    • Respiratory Distress syndrome
    • Chronic lung disease
    • Intraventricular hemorrhage
    • Necrotizing enterocolitis
    • Retinopathy of prematurity
    • Severe brain injury
    Newborn morbidity
  • 7. 50% of long term major morbidity among non-anomalous fetuses:
    • Cerebral palsy
    • Mental retardation
    • Blindness
    • Deafness
    • Sensory deficits
    • Developmental delay
    Long term consequences
  • 8.  
  • 9. Costs affect insurance rates, taxes, and PAY CHECKS!
  • 10. Sources of preterm birth, United States 2000 Ananth et al, Obstet Gynecol, 2006 Overall (%) Singletons (%) Twins (%) Spontaneous 60 69 44 Medically indicated 40 31 56
  • 11. Preterm births in the United States
  • 12. Spontaneous PTB Medically indicated PTB Preterm PROM
  • 13. SPB Source of Preterm Birth Tucker et al. Obstet Gynecol 1991 Spontaneous 30-50% Preterm PROM 30-40% Indicated 20-30%
  • 14. Medically indicated Spontaneous Overall SROM
  • 15. Preterm Birth Changes between 1989-00, US Whites Blacks All PTB 14% 15% Spont PTB 3% 27% Med-ind 55% 32% PNM 30% 25%
  • 16. Preterm Birth Trends Whites (%) Blacks (%) 89 00 Δ % 89 00 Δ % Total PTB 8.3 9.4 14 18.5 16.2 -15 pPROM 1.1 0.8 -23 2.3 1.5 -37 Med-ind 2.3 3.6 55 4.1 5.6 32 Spt labor 4.9 5.0 3 12.1 9.1 -27
  • 17. Indicated Preterm Birth Tucker et al. 1991 Meis et al. 1986 Singletons Twins Preeclampsia 43% 44% FGR/fet dist 37% 33% Abruption 7% 9% Fetal death 7% 7%
  • 18. Ananth and Vintzileos AJOG 2006 Ischemic Placental Disease Among… Ischemic placental disease present in Term births 1 in 10 births Preterm births 1 in 4 births Indicated preterm births ≥ 1 in 2 births
  • 19.  
  • 20. Etiologies Stress Infection Bleeding Uterine overdistension
  • 21.
    • Preterm birth is a “syndrome”
    • Inflammation/Infection (~40%)
    • Maternal/fetal stress (~25%)
    • Uteroplacental ischemia (~25%)
      • Thrombophilia, decidual hemorrhage, abruption
    • Abnormal uterine distension (~10%)
  • 22. Some pathways through which preterm birth may occur
  • 23. Some pathways through which preterm birth may occur
  • 24. Risk factors
    • Prior preterm birth
    • Poor socio-economic status
    • Black race
    • Low education
    • Smoking
    • Bleeding
    • Assisted reproduction
    • Multiple gestation
    • Genital tract infections
    • Periodontal disease
    • Cervical surgery
    • Pregnancy termination
    • Uterine anomalies
  • 25. Preterm babies are more likely to have preterm births as adults Porter et al. Obstet Gynecol 1997;90:63-67
    • 1405 preterm mothers
    • 2781 term mothers
  • 26. Maternal and Paternal Influences
    • 77,452 boys and girls in Norway who later became parents
    • Gestational age of the child at birth increased
      • 0.58 days for each additional week in the father’s GA
      • 1.22 days for each additional week in the mother’s GA
    Lie et al. Obstet Gynecol 2006
  • 27. Recurrence of preterm birth
  • 28. Recurrence of preterm birth
  • 29.  
  • 30. Average length of gestation by plurality
  • 31.
    • Over 80% of patients who present with regular painful contractions go on to deliver at term
    • Most interventions do not prevent preterm birth and are potentially harmful
    • How then do we determine who will actually deliver preterm (isn’t THAT the question?)
  • 32. More than 1/2 of patients who deliver preterm have no risk factors More than 2/3 of patients with traditional risk factors do not deliver preterm Most important traditional risk factor is preterm delivery in a prior pregnancy
  • 33. Fetal fibronectin
  • 34.  
  • 35. Fetal fibronectin
  • 36.  
  • 37.  
  • 38.  
  • 39.  
  • 40. Cervical Length as Predictor of SPB
    • The risk of SPB is increased in women with short cervix. Abnormal cervical length < 25 mm (10%ile) (Iams JD & NICHD MFMU Network, 1996)
    • The shorter the cervix, the higher is the risk for SPB
    Conspiracy?
  • 41.  
  • 42.  
  • 43.  
  • 44. Transvaginal sonographic cervical assessment
  • 45. Interventions that have been used
    • Bed rest
    • Intravenous hydration
  • 46. Are there any therapeutic interventions to prevent SPTB?
  • 47. Types of Cervical Cerclage
    • History-indicated
    • Physical exam-indicated
    • Ultrasound-indicated
  • 48. The Use of Cervical Cerclage for a Short Cervix ( Ultrasound-Indicated Cerclage ) 4 RCT’s
    • Rust-2000 Unselected No benefit
    • Althuisius-2001 High-risk Benefit*
    • To-2004 Unselected No benefit
    • Berghella-2004 Unselected No benefit
    AUTHOR-YEAR POPULATION OUTCOME * REDUCTION OF PREMATURITY, MORTALITY & MORBIDITY
  • 49. Multicenter RCT on the Use of Cervical Cerclage in High Risk Pregnancies (Report of the MRC/RCOB, Br J Obstet Gynaecol 1993; 100:516)
    • Benefit observed in 1:25 cases
    • Cerclage is beneficial only in women with a history of > 3 second trimester losses/preterm births
    History-Indicated Cerclage
  • 50. Cerclage for dilated cervix with membranes at or beyond the external os Althusius et al, Am J Obstet Gynecol 2003 Cerclage & Indomethacin (n=13) Bedrest alone (n=10) Prolongation (weeks) 7.7 3.0 Neonatal survival 56% 28% Preterm birth <34 weeks 54% 100% Composite neonatal morbidity 62% 100%
  • 51. Management of Cervical Insufficiency and Bulging Fetal Membranes (at 18-26 weeks) (Daskalakis et al Obstet Gynecol 2006;107:219)
    • Prolongation (wks) 8.8 3.1
    • Mean BW (g) 2,101 739
    • Live birth 86% 41%
    • Neon survival 96% 57%
    • PTB <32 wks 31% 94%
    • NICU admission 28% 86%
    Cerclage (n=29) No Cerclage (n=17) Physical Exam-Indicated Cerclage
  • 52. Use of Cerclage for Prevention of SPB in Women With Prior SPB. A Meta-analysis of 4 RCTs (Berghella V, Odibo A, To M, Rust O and Althiusius S) Obstet Gynecol 2005;106:181
    • 4 RCTs (n=208 women with prior SPB)
    • SPB <35 weeks
    • No cerclage 39/101 (39%)
    • Cerclage (for CL <25 mm) 25/107 (22%)
    • RR=0.61 (95% CI=0.40, 0.92)
    • (Hx of prior 2 nd trim loss) RR=0.57 (95% CI=0.33, 0.99)
  • 53. Multicenter Randomized Trial of Cerclage For Preterm Birth Prevention In High-Risk Women With Shortened Mid-Trimester Cervical Length (Owen J, Abst #4, Am J Obstet Gynecol Suppl Dec 2008) Reduction in PTB < 35 wks in cerclage patients OR (95% CI) If CL < 15 mm 0.23 (0.08, 0.66) If CL 16-24 mm 0.84 (0.49, 1.40) P=0.05 CONCLUSION: Cerclage will mostly benefit high-risk women with mid-trimester CL < 15 mm (77% reduction in PTB rate)
  • 54. Tocolytics
    •  -adrenergic agents
    • Magnesium sulfate
    • Prostaglandin synthetase inhibitors
    • Calcium channel blockers
    • Nitroglycerin
    • Oxytocin antagonists
  • 55. Magnesium sulfate! Good or evil?
  • 56. Contraindications to Tocolysis
    • Conditions where delivery is indicated such as
    • Severe preeclampsia/hypertension
    • Fetal non-reassuring status
    • Maternal non-reassuring status
    • Significant hemorrhage
    • Maternal cardiac disease
    • Gestational age >36 weeks (? >34 weeks)
    • Infection/ chorioamnionitis
    • Fetal demise or lethal anomaly
  • 57. Goals of tocolysis
    • To allow steroid administration
    • To allow transport or to facilitate delivery under safer circumstances
    • To prolong gestation in very preterm pregnancies
  • 58. Calcium channel blockers
    • Inhibit calcium entry into cells
    • Nifedipine most commonly used
    • Rapidly absorbed after oral adminstration
    • Peak concentration in 15-90 minutes
    • Half life of 81 minutes
    • Duration of action of single dose 6 hours
    • Good contraction suppression and few side effects
    • 12 reported trials show reduced deliveries within 7 days (RR 0.76; CI 0.60, 0.97)
    • Reduced deliveries before 34 weeks (RR 0.83, CI 0.69, 0.99)
    • Reduced fetal RDS, IVH, NEC, jaundice, when compared with other tocolytics
    • Fewer women stop treatment due to side effects
  • 59. Calcium channel blockers
    • Side effects:
    • Hypotension
    • Headaches
    • Dizziness
    • Nausea
    • No significant fetal effects
    • Administration
    • 10 -20 mg every 4-6 hours
  • 60. Cyclooxgenase inhibitors
    • Inhibit prostaglandin synthesis
    • Vary in activity/potency
    • Indomethacin most widely used
    • Powerful tocolytic
    • Crosses placenta
    • Associated with reduction in births before 37 weeks, increased gestational age, birth weight
    • Maternal side effects:
    • GI disturbances
    • Bleeding
    • Thrombocytopenia
    • Asthma
    • Renal injury
  • 61. Cyclooxgenase inhibitors
    • Fetal side effects:
    • Oligohydramnios
    • Premature closure of ductus arteriosus
    • These complications are rare
    • Generally not recommended beyond 37 weeks
    • NEC
    • Treatment protocol
    • 50 mg loading
    • 25-50 mg every 6 hours
    • Assess AFI, ductus if using for prolonged periods
    • Stop treatment if delivery is imminent
  • 62. Steroids
    • Reduce risk of :
    • Respiratory distress syndrome
    • Intraventricular hemorrhage
    • Necrotizing enterocolitis
  • 63. Progesterone
  • 64. Progesterone for the reduction of risk of preterm birth
  • 65. Reduction of SPTBs By Progesterone Administration Among Asymptomatic High Risk Women
    • 60% reduction for births < 37 weeks-daily 100mg progesterone vaginal suppositories (da Fonseca et al, Am J Obstet Gynecol 2003;188:419)
    • 34% reduction for births < 37 weeks-weekly IM injections of 17-P (Meis PJ & NICHD MFMU Network, N Engl J Med 2003;348:2379)
    CL unknown (was not reported) in the above two studies
  • 66. Prevention of Recurrent Preterm Delivery by Progesterone Vaginal Gel-A R-DB-PC Trial ( O’Brien et al Ultrasound Obstet Gynecol 2007;30:687 DeFranco et al Ultrasound Obstet Gynecol 2007;30:697)
    • N=659 women with Hx of SPTB
    • No reduction in PTB at < 32 weeks
    • (SECONDARY ANALYSIS)
    • Women with CL <28 mm had
    • a) less PTBs (0% vs, 30%); and
    • b) less NICU admissions (16% vs. 52 %)
    Daily vag prog gel (90mg) starting at 18-23 weeks
  • 67.
    • It is possible that progesterone administration in women with history of SPTB may benefit only those with a short cervix in the current pregnancy
    Speculation
  • 68. Use of Progesterone to Reduce Preterm Birth (ACOG Committee Opinion, Number 419, October 2008)
    • It should be offered to women with a singleton pregnancy and a history of spontaneous preterm birth < 37 weeks gestation
    • Progesterone supplementation for asymptomatic women with an incidentally identified very short cervical length (< 15 mm) may be considered; however, routine cervical length screening is not recommended