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Preterm Labour


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Preterm Labour

Preterm Labour

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  • 1. PROF. ABOUBAKR ELNASHAR BENHA UNIVERSITY HOSPITAL, EGYPT Elnashar53@hotmail.Com Preterm Labour Aboubakr Elnashar
  • 2. Introduction Definition Incidence Neonatal outcome Aetiology Risk factors Management of asymptomatic high-risk women Before pregnancy During pregnancy Prevention Prediction Management of symptomatic women Assessment Therapy Contents Aboubakr Elnashar
  • 3. INTRODUCTION Definition Incidence Neonatal outcome Aetiology Risk factors Aboubakr Elnashar
  • 4. DEFINITION Deliveries between 24+0 and 36+6 w. Documented regular UC ≥6/h AND At least one of the following: Rupture of membranes Cervical change (Cervix 2 cm dilated or 80% effaced) Aboubakr Elnashar
  • 5. Clinical subtypes 1. Indicated: 1/3 for maternal or fetal reasons 2. Spontaneous: 2/3 PTL PPROM Aboubakr Elnashar
  • 6. Subcategories: 1. mildly preterm: 32+0 to 36+6 w (incidence 55%) 2. moderately preterm: 28+0 to 31+6 w (incidence 0.7%) 3. extremely preterm: 24+0 to 27+6 w (incidence 0.4%). 24--Extreme--28--Moderate—32--Mild--37 Aboubakr Elnashar
  • 7. Incidence 5 -18% UK: 6.6% USA: 12% {differing aetiological, socioeconomic and cultural factors}. Aboubakr Elnashar
  • 8. NEONATAL OUTCOMES Mortality: leading cause of newborn deaths (WHO, 2012) 2nd leading cause of death (after pneumonia) in children under 5 y. Aboubakr Elnashar
  • 9. Morbidity 1. Neuro developmental impairment, disability and handicap: especially within the 24-26-w 50% of the survivors at 23-25 w were impaired, half with severe disability. 2. Educational difficulties. 3. Social behaviour and criminality, as well as subsequent influences on adult health. Aboubakr Elnashar
  • 10. AETIOLOGY I. Infection Subclinical infection of the choriodecidual space and amniotic fluid II. Vascular 1. Spontaneous prematurity has been associated with an increase in membrane haemosiderin deposits, thought to reflect decidual haemorrhages. 2. The link between placental abruption and either uterine activity or PPROM is well recognized. Aboubakr Elnashar
  • 11. III. Uterine overdistension 1. Multiple pregnancy Median gestation at delivery for twins: 35 w for triplets 33 w. ART responsible for 35% of twin 77% of triplets 2. Polyhydramnios Fetal anomalies Atresias of the GIT, are the most common cause of polyhydramnios: PTL. Aboubakr Elnashar
  • 12. IV. Cervical incompetence Difficult diagnosis Even a careful review of the clinical events: PTL does not necessarily show correlation with the aetiology. Aboubakr Elnashar
  • 13. V. Intercurrent illness 1. Serious infection: Pyelonephritis, appendicitis and pneumonia {direct blood-borne spread of infection to the uterine cavity or indirectly to chemical triggers, such as endotoxins or cytokines}. 2. Other medical complications cholestasis of pregnancy 3. Any surgical procedures {mechanisms remain obscure.} Aboubakr Elnashar
  • 14. Often multifactorial No risk factors in 50% PTL is a “syndrome” •Inflammation/Infection (40%) •Maternal/fetal stress (25%) •Uteroplacental ischemia (25%) •Thrombophilia, decidual hemorrhage, abruption •Abnormal uterine distension (10%) Aboubakr Elnashar
  • 15. RISK GROUPS I. Major risk factors 1. Previous PTL. After 1 PTL: risk 20%. After 2 PTL: risk 40% 2· Uterine overdistension. Multiple pregnancies Polyhydramnios Aboubakr Elnashar
  • 16. 3. Uterine abnormalities. Cone biopsy LLETZ. Surgical cervical dilatation 4. Malformed uterus {cervical weakness}, although recent evidence suggests that abnormalities of uterine vascularity may also playa role. Aboubakr Elnashar
  • 17. 5. Fibroids Controversial considering their frequency, their influence is probably minimal in the absence of cervical involvement. 6. Factors in current pregnancy. intercurrent illness Surgery recurrent vaginal bleeding. Aboubakr Elnashar
  • 18. II. Minor risk factors A. Modifiable. Smoking low BMI interpregnancy interval <1y. B. Not modified Maternal age (teenage) Parity (nulliparous or grandmultiparous) Ethnicity (black women) Socioeconomic deprivation Unemployment low levels of education. Aboubakr Elnashar
  • 19. MANAGEMENT OF ASYMPTOMATIC HIGH-RISK WOMEN Before pregnancy During pregnancy Prevention Prediction Aboubakr Elnashar
  • 20. I. Before pregnancy 1. Assessment and the events leading to their PTL reviewed. 2. Management Plan for any subsequent pregnancy Aboubakr Elnashar
  • 21. II. During pregnancy A. Prediction 1. Assessment of risk factors 2. Early dating scan 3. TVS: cervical length & dilatation 4. Foetal fibronectin in cervicovaginal secretions 5. Salivary oestriol, home uterine-activity monitoring and measurement of plasma metabolites: not effective in routine clinical practice Aboubakr Elnashar
  • 22. 1. Assessment of risk factors: Scoring systems e.g. Creasy score Based on risk factors e.g. PreviousPTD Bleedingin pregnancy, UTI Higherorderpregnancies BMI<20 kg/m2, Stress(family illness,mortality,disruption,violence,or financial) Do not identify the majority of women Limited clinical use. have not proved helpful. Aboubakr Elnashar
  • 23. 2. Early dating scan {To time subsequent investigations. Ensures precise gestational age} Aboubakr Elnashar
  • 24. 3. Cervical ultrasound The risk of PTL is inversely related to cervical length [C} Not TAS: {full bladder: false lengthening and can obliterate gross funneling}. TVS: more accurate than digital measurements In asymptomatic women 11-20 mm: 4% risk 10 mm: 15% risk <10 mm: dramatic increase in risk Recommended high risk asymptomatic at 22-24 w Not for routine screening Aboubakr Elnashar
  • 25. 4. Cervlcovaginal fibronectin testing Done after 23 w {high prior to this gestation, rarely present in vaginal secretions between 23 and 34 w}. fFN: glue-like ‘ protein binding the choriodecidual membranes. Any disruption at the choriodecidual interface: fFN release positive/ negative result. Aboubakr Elnashar
  • 26. Steps: No Digital examination or lubricating jelly or Endocervical swabbing The swab should be rotated in the posterior fornix for 15-20 secs The test result should be read within 15 min False-positive results Sexual intercourse within 24 h. Vaginal bleeding. Aboubakr Elnashar
  • 27. Interpretation Positive at 24 w: 46% will deliver before 30 w: no proven treatment: several groups are studying the potential role of antibiotics. Negative: risk of PTL 1%: High negative predictive value to either withhold treatments or optimize their timing. Aboubakr Elnashar
  • 28. B. Prevention Before pregnancy: 1. Smoking cessation. 2. Dietician referral for women with a low BM. 4. Prevent multiple pregnancy 5. Leaving 12 months between pregnancies During pregnancy 1. Detection and tt of vaginal and intra­uterine infection 2. Cervical cerclage 3. Progesterone 4. Life style modification Aboubakr Elnashar
  • 29. 1. Diagnosis and treatment of vaginal and intra­uterine infection a. Bacterial vaginosis {associated with an increased risk of PTL} Diagnosis: A vaginal swab is rolled on to a glass slide Gram staining and microscopy: Nugent scoring. Treatment: Oral metronidazole: 5-7 days at standard doses lowers the risk of PTL, by 60% [A} {BV may reflect chronic intrauterine infection} Vaginal clindamycin cream in BV-positive women : an increase in PTL {topical therapy adequately treats vaginosis, but fails to affect pre-existing intrauterine infection}Aboubakr Elnashar
  • 30. b. Asymptomatic bacteriuria {increased risk of pyelonephritis in women presenting with asymptomatic bacteriuria.} Screening Antibiotic treatment [A]. Aboubakr Elnashar
  • 31. c. Group B streptococcal colonization (GBS) {Preterm infants are more susceptible to early-onset GBS infection, acquired during passage through the birth canal}. evidence that it is one of the major causal organisms behind spontaneous prematurity: weak} Screening High risk group combined low vaginal/rectal swab Intrapartum prophylaxis {1. antenatal antibiotics have not been shown to lower perinatal transmission. 2. prophylactic treatment of GBS: increase in neonatal infections with penicillin-resistant Escherichia coli. 3. antibiotics have the potential for harm}. Aboubakr Elnashar
  • 32. d. Other organisms Chlamydia trachomatis, Neisseria gonococcus and Trichomonas vaginalis have been associated with preterm delivery: a causal link has not been established. Treatment of chlamydia: No decrease PTL prevent perinatal transmission. Treatment of chlamydia and gonococcus include contact tracing and treatment of the partner. Aboubakr Elnashar
  • 33. 2. Cervical cerclage Indication 1. 3 or more previous PTL and/or 2nd T losses. 2. History of one or more spontaneous mid-trimester losses or preterm births +TVS: cervix is 25 mm or less Aboubakr Elnashar
  • 34. 3. Progesterone supplementation Indications: (ACOG 2008) 1. Singleton (not multiple) pregnancy and a history of PTL < 37 w 2. Asymptomatic women with an incidentally identified very short cervical length (< 15 mm) Effect reduce the incidence of PTL by 50% Aboubakr Elnashar
  • 35. Forms and Dose I. Vaginally: •Gel (Crinone 8%, 90 mg/day), •Capsules (Uterogestan 200 mg twice daily) •Suppositories (cyclogest 200 mg daily, prontogest 200 mg daily) from 22 - 34 w II. IM: •17-alpha-hydroxyprogesterone caproate weekly of 250-1000 mg, from 16-37 w •Prontogest100 mg= Gestone Aboubakr Elnashar
  • 36. 4. Lifestyle modification 1. Stop smoking [C].  Hospitalization for bed rest: an increase in PTL [A].  Sexual abstinence and/or psychological support: should not be recommended as a universal or general measure in high-risk women. Aboubakr Elnashar
  • 37. MANAGEMENT OF SYMPTOMATIC WOMEN Assessment: A. Maternal B. Foetal Therapy 1. Corticosteroids 2. Tocolytics 3. Antibiotics 4. Emergency cerclage 5. In Utero transfer 6. Mode of delivery 7. Anathesia Aboubakr Elnashar
  • 38. I. Assessment A. Maternal Objective: chance of delivery within the next 7 d. 1. Low risk: Observation and review. 2. High risk: Treatment Aboubakr Elnashar
  • 39.  History Risk factors Current symptoms •low backache or cramping: often cyclical. •Vague complaints: pelvic pressure or increased discharge: common. •Vaginal bleeding: should be taken seriously. UC+ closed cx + bleeding UC+ 2 cm cx dil Risk of delivery within 7 days Aboubakr Elnashar
  • 40. Examination Abdominal examination uterine tenderness, suggesting abruption or chorioamnionitis. Speculum examination Pooling of amniotic fluid, blood and/or abnormal discharge . Visual assessment of cervical dilatation: accurate as digital examination findings. Aboubakr Elnashar
  • 41. limit digital examinations speculum assessment is inconclusive {1. stimulate prostaglandin 2. introduce organisms into the cervical canal 3. Reduce latent interval before labour}. Repeat vaginal examination in 1-4 h (guided by the severity of the symptoms) in the absence of secondary tests. Aboubakr Elnashar
  • 42. Investigation 1. Cervical length measurement In symptomatic women: Accepted safe length is 3 cm Cx length > 3cm: No risk of PTL Cx length <2cm: 70% will deliver PT Aboubakr Elnashar
  • 43. 2. Bedside fibronectin testing :rapid assessment of risk in symptomatic women who do not have advanced dilatation. Igreater predictive value than digital examination. 30% of women with a positive fibronectin test delivered within 7 days, compared with only 10% of women who were 2-3 cm dilated. positive fibronectin test carries a risk of delivery within 28 days of up to 70%, regardless of initial cervical length. Combination testing refines the prediction of deliveries in the next 7 days. positive fibronectin test but a normal cervical length, only 5% will deliver within 1 w. However, if the cervix is also short when tested, the risk of delivery within 7 days climbs to 50% This is particularly useful, as many interventions (tocolytics, steroids and in- utero transfer) should be based on this end-point. Aboubakr Elnashar
  • 44. B. FETAL 1. CTG: During pregnancy: Maternal steroid therapy can suppress both fetal activity and heart rate variability. Interpretation: difficult  Applying criteria used at term is inappropriate. Baseline rate is more important than either decelerations or variability. During labour: Moderately PTL: no benefit from continuous as opposed to intermittent monitoring [B]  Severe PTL: Decisions regarding monitoring must be discussed with parents. Intervention on the basis of FHR monitoring may not be justifiable near the limits of viability. Aboubakr Elnashar
  • 45. 2. Umbilical artery Doppler AED or RED: a short-term return of end diastolic flow is commonly observed. When labour has started or is thought to be imminent 3. US a. Presentation {clinical palpation is unreliable} b. Fetal weight Aboubakr Elnashar
  • 46. II. THERAPY 1. Corticosteroids: RCOG,2011 When:  between 24 and 35 W  between 24 and 36 W (SFGA)  between 24 and 39 W (elective CS) Dose: Betamethasone: 12 mg given IM in two doses or Dexamethasone: 6 mg given IM in four doses Betamethasone Vs Dexamethasone: No difference improved neurological outcomes with betamethasone. Aboubakr Elnashar
  • 47. Effect: Significant reduction: RDS neonatal death intraventricular hge. Most effective: 24 h after last dose and up to 7 days Aboubakr Elnashar
  • 48. Single course Harmful effects of repeated doses: increased sepsis in PPROM restricted fetal body and brain growth adrenal suppression. increased risk of neonatal death seen when 3 or more courses of antenatal steroids Aboubakr Elnashar
  • 49. 2. Tocolytics: RCOG, 2011 Effect: prolongation of pregnancy for up to 7 days No significant effect on preterm birth No clear effect on perinatal or neonatal morbidity. Indication 1. Completing a course of corticosteroids 2. In utero transfer.  Maintenance therapy is not recommended. Aboubakr Elnashar
  • 50. Nifedipine Vs atosiban (Tractocil) comparable effectiveness in delaying birth for up to 7 days. Price is 1/10 Nifedipin Vs Beta-agonists or indomethacin improvement in neonatal outcome fewer maternal adverse effects less risk of rare serious adverse events. Aboubakr Elnashar
  • 51. Dose Nifedipine: Initial oral dose: 20 mg followed by 10–20 mg three to four times daily, adjusted according to uterine activity for up to 48 hours. A total dose above 60 mg appears to be associated with a three- to four-fold increase in adverse events. Atosiban Initial bolus dose of 6.75 mg over 1 minute, followed by an infusion of 18 mg/h for 3 h, then 6 mg/h for up to 45 h (to a maximum of 330 mg). Aboubakr Elnashar
  • 52. Indomethacin: orally or rectally. 50 to 100 mg is followed at 8-hour intervals not to exceed a total 24-hour dose of 200 mg. or 50 mg Loading dose, then 25-50mg /6hs Serum concentrations usually peak 1 to 2 hours after oral administration, whereas levels after rectal administration peak slightly sooner. limited use to less than 72 h and only below 30 w {oligohydramnios, it is reversible} Aboubakr Elnashar
  • 53. 3. Antibiotics Uncomplicated PTL no evidence of benefit significant increase in the incidence of cerebral palsy. Preterm PROM significant advantages No increase in cerebral palsy in the long term Erthryomycin (250 mg qds for 10 d) Aboubakr Elnashar
  • 54. Thyrotropin-releasing hormone, vitamin. K or phenobarbitone RCT: not beneficial [B]. Aboubakr Elnashar
  • 55. 4. Emergency cervical cerclage Indication: mid-trimester minor symptoms (pelvic pressure, watery discharge membranes bulging into the tipper vagina. Contraindication: 1. symptomatic contractions 2. intrauterine infection: 10%of chorioamnionitis are clinically obvious  Reassess the cervical dilatation after several hours. This can be precisely and repeatedly measured using transperineal US. Aboubakr Elnashar
  • 56. 5. In-utero transfer To a unit with adequate neonatal facilities, where these are not available in the admitting unit improve outcome for babies. Aboubakr Elnashar
  • 57. 6. MODE OF DELIVERY  <26 W: Vaginal delivery {fetal morbidity and mortality, the difficulty in diagnosing intrapartum hypoxia/acidosis and the maternal risk} do not justify CS has not been shown to improve neonatal outcomes}.  {As gestation advances, both neonatal outcomes and the ability to diagnose fetal compromise improve, and intervention for fetal reasons becomes universally appropriate}. Aboubakr Elnashar
  • 58. Breech CS {an increased mortality and morbidity to the preterm breech born vaginally. recent similar studies that conclude the opposite}. Aboubakr Elnashar
  • 59. Type of CS Membranes ruptured: De Lee vertical lower segment {At the earliest gestations, the lower segment is poorly formed does not appear to carry any greater risk than a conventional transverse incision} [D]. Membranes intact: Transverse incision Aboubakr Elnashar
  • 60. 7. ANALGESIA  Epidural Benefits 1. Avoiding expulsive efforts before full dilatation or a precipitous delivery, a relaxed pelvic floor and perineum 2. Ability to proceed quickly to CS. Narcotics prolonged effects on a preterm infant with limited metabolic capacity. Aboubakr Elnashar
  • 61. SUMMARY Beneficial antenatal treatments for high-risk women include metronidazole for bacterial vaginosis antibiotics for asymptomatic bacteriuria cerclage for three or more 2nd T losses or PTL progesterone supplementation. Hospitalization for bed rest leads to an increase in preterm births. Aboubakr Elnashar
  • 62. Tocolytics have no significant benefit on perinatal mortality or the prolongation of pregnancy to term, but do reduce the number of women delivering within 48 hours by 40%. There is no evidence of benefit and some evidence of harm associated with the use of antibiotics in uncomplicated preterm labour with intact membranes. Aboubakr Elnashar
  • 63. In symptomatic women, the following factors are associated with a high risk of delivery within 7 days: cervical dilatation >3 cm, ruptured membranes or any vaginal bleeding.  A single course of maternal steroids given between 24 and 35 w and received within 7 days of delivery results in markedly improved neonatal outcomes. Aboubakr Elnashar
  • 64. After the diagnosis of preterm labour neonatology consultation, fetal monitoring, mode of delivery intrapartum antibiotics if a known GBS carrier. Aboubakr Elnashar
  • 65. Thank you Aboubakr Elnashar