Premature Labour


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SALSO Series - Premature Labour

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Premature Labour

  2. 2. DEFINITION <ul><li>Regular, painful uterine contractions accompanied by effacement and dilatation of the cervix after 20 and before 37 completed weeks of pregnancy. </li></ul>
  3. 3. <ul><li>5 -10 % of all deliveries </li></ul><ul><li>85% of all neonatal deaths </li></ul><ul><li>High morbidity and mortality </li></ul>
  4. 4. COMPLICATIONS OF PREMATURE BABY <ul><li>Respiratory distress syndrome </li></ul><ul><li>Intraventricular haemorrhage </li></ul><ul><li>Necrotizing enterocolitis </li></ul><ul><li>ROP </li></ul><ul><li>Neonatal jaundice </li></ul><ul><li>Failure to thrive </li></ul><ul><li>Cerebral palsy </li></ul>
  5. 5. <ul><li>Aetiology : </li></ul><ul><li>Usually not apparent and may be multifactorial. </li></ul><ul><li>There are a number of associations : </li></ul><ul><ul><ul><li>Demographic & socio-economic factors </li></ul></ul></ul><ul><ul><ul><li>Reproductive history </li></ul></ul></ul><ul><ul><ul><li>Uterine factors </li></ul></ul></ul><ul><ul><ul><li>Infections </li></ul></ul></ul><ul><li>Demographic & socio-economic factors : </li></ul><ul><ul><li>Extremes of maternal age ( < than 17 & > 35 yrs ) </li></ul></ul><ul><ul><li>Low socio-economic class </li></ul></ul><ul><ul><li>Unmarried </li></ul></ul><ul><ul><li>Low prepregnancy weigth ( BMI < 19 ) </li></ul></ul><ul><ul><li>Smoking , cocaine abuse </li></ul></ul><ul><ul><li>anemia </li></ul></ul>
  6. 6. <ul><li>Reproductive Hx : </li></ul><ul><ul><li>Previous history of spontaneous pretern labour or second trimester miscarriage, particularly > 1 episode have increased risk. </li></ul></ul><ul><ul><li>2 nd trimester induced abortion ( Henriet and Kaminski 2001 ) </li></ul></ul><ul><li>Overall 10 % of cases have this history </li></ul><ul><li>Uterine factors : </li></ul><ul><ul><li>Congenital Uterine abnormalities & fibroids </li></ul></ul><ul><ul><li>Cervical weakness </li></ul></ul><ul><ul><li>Uterine overdistension : multiple pregnancy, polyhydramnios. </li></ul></ul>
  7. 7. <ul><li>Infection : </li></ul><ul><li>It is suggested Bacterial vaginosis is an important cause of PTL. </li></ul><ul><ul><li>Penn and Steer 98 : treatment with metronidazole reducese the incidence of PTL in colonized women by 50 % </li></ul></ul><ul><li>Infectious aetiology is more likely in cases of prelabour rupture of membrane. </li></ul><ul><li>Other proposed organism ( no conclusive evidence ) includes : </li></ul><ul><ul><li>Ureaplasma urealyticum, Chlamydia tracomatis, Tricomonas vaginalis, GBS, Mycoplasma hominis and Neissseria gonorrhoea. </li></ul></ul>
  8. 8. CAUSES <ul><li>Multiple pregnancy </li></ul><ul><li>APH </li></ul><ul><li>IUGR </li></ul><ul><li>Cervical incompetence </li></ul><ul><li>Chorioamnionitis </li></ul><ul><li>Abnormal baby </li></ul><ul><li>Congenital uterine anomaly </li></ul><ul><li>Polyhydramnios </li></ul><ul><li>Infections </li></ul><ul><li>Iatrogenic </li></ul><ul><li>idiopathic </li></ul>
  9. 9. PREDICTION OF RISK <ul><li>No scoring system </li></ul><ul><li>Strongest association is with previous preterm delivery </li></ul><ul><li>? Social factor, cervical assessment, uterine contraction monitoring, fetal fibronectin </li></ul>
  10. 10. PREVENTION ? <ul><li>?Cervical cerclage </li></ul><ul><li>?antibiotics </li></ul>
  11. 11. MANAGEMENT <ul><li>DEPENDS ON SIX MAIN FACTORS </li></ul><ul><ul><li>State of membrane </li></ul></ul><ul><ul><li>Dilatation of cervix </li></ul></ul><ul><ul><li>Gestational age </li></ul></ul><ul><ul><li>Cause of preterm labour </li></ul></ul><ul><ul><li>Availability of neonatal intensive care facilities </li></ul></ul><ul><ul><li>Steroids therapy </li></ul></ul>
  12. 12. STEROIDS THERAPY <ul><li>Corticosteroids given to the mother between 24 and 36 weeks can induce pulmonary surfactant in the lungs of the immature fetus and prevent respiratory distress syndrome </li></ul><ul><li>IM Dexamethasone 6mg stat and repeat 12 hours later for 2 days </li></ul>
  13. 13. TOCOLYIS <ul><li>In 50 % of patients contractions will stop spontaneously and pregnancy will continue till term </li></ul><ul><li>Aim </li></ul><ul><ul><li>Awaiting steroids therapy </li></ul></ul><ul><ul><li>In utero transfer </li></ul></ul>
  14. 14. DRUGS FOR TOCOLYSIS <ul><li> SYMPATHOMIMETIC </li></ul><ul><ul><li>Salbutamol, ritodrine </li></ul></ul><ul><li>NITRATES </li></ul><ul><li>CALCIUM CHANNEL BLOCKER </li></ul><ul><ul><li>Nifedipine </li></ul></ul><ul><li>OXYTOCIN ANTAGONIST </li></ul>
  15. 15. CONTRAINDICATIONS TO TOCOLYSIS <ul><li>APH </li></ul><ul><li>Severe PE </li></ul><ul><li>Maternal condition hazardous if pregnancy prolonged </li></ul><ul><li>Contraindications to drugs </li></ul><ul><ul><li>Salbutamol – heart disease, thyrotoxicosis, </li></ul></ul>
  16. 16. MODE OF DELIVERY <ul><li>Cephalic – aim for vaginal delivery </li></ul><ul><li>Breech / malpresentation – CS </li></ul><ul><li>BUT IN EXTREME PREMATURITY, TO DECIDE ON CASE TO CASE BASIS… </li></ul>
  17. 17. CLINICAL REVIEW <ul><li>Confirm diagnosis </li></ul><ul><li>Reassessment after 2 -4 hours if unsure </li></ul><ul><li>Confirm dates </li></ul><ul><li>Assess dilatation, membrane </li></ul><ul><li>EFW </li></ul><ul><li>U/S - fetal abnormality, liqour,number </li></ul><ul><li>Determine fetal wellbeing </li></ul>
  18. 18. MANAGEMENT <ul><li>If PPROM, allow labour </li></ul><ul><li>If > 34 weeks or EFW > 2 kg, allow labour </li></ul><ul><li>If < 34 weeks, consider tocolysis to allow steroids to work </li></ul><ul><li>If failed supression, completed steroid and in centre with adequate neonatal support, allow labour </li></ul>
  19. 19. DELIVERY <ul><li>Inform superior </li></ul><ul><li>Paediatrician to standby </li></ul><ul><li>Nursery informed (ventilator) </li></ul>
  20. 20. <ul><li>Introduction : </li></ul><ul><li>Ruptured of amniotic membrane usually coincide with onset of labour. </li></ul><ul><li>Can be devided into : </li></ul><ul><ul><li>Preterm Prelabour Rupture Of Membrane : when membrane ruptures before 37 weeks </li></ul></ul><ul><ul><li>Term Prelabour Rupture Of Membrane : when it occurs after 37 weeks. </li></ul></ul>
  21. 21. <ul><li>Aetiology : </li></ul><ul><li>In most cases , there is no obvious cause. </li></ul><ul><li>The role of bacterial colonization & infection of the vagina & cervix is suspected, but unclear.Infections such as bacteria vaginosis, ureaplasma etc may alter vaginal pH or produce substance that weaken the membrane, like proteases. </li></ul><ul><li>Increased intraamniotic pressure associated with multiple pregnancy/polyhydramnios may be implicated. </li></ul><ul><li>Potential traumatic procedures such as amniocentesis and ECV are rare causes </li></ul><ul><li>Cervical incompetence : it exposes the membrane to vaginal flora & this together with lack of support at internal os may lead to rupture of membrane – rare cause. </li></ul>
  22. 22. <ul><li>Diagnosis : </li></ul><ul><li>By history & examination </li></ul><ul><li>History : </li></ul><ul><li>Sudden uncontrolled loss of clear fluid from vagina </li></ul><ul><li>Important particularly if rupture has occurred some hrs previously & most of the fluid has escaped from the vagina. </li></ul><ul><li>In one study : history is erroneous in up to 1/3 of cases. </li></ul>
  23. 23. <ul><li>Examination : </li></ul><ul><li>Speculum examination : </li></ul><ul><ul><li>Identification of amniotic fluid pooled in posterior fornix. ( HVS should be taken for bacteriological study ) </li></ul></ul><ul><li>Nitrazine test : </li></ul><ul><ul><li>Most widely use test to differentiate amniotic fluid and other fluid. </li></ul></ul><ul><ul><li>Yellow --- dark blue </li></ul></ul><ul><ul><li>False positive ( 15 % ): presence of blood, semen or infection </li></ul></ul><ul><li>Litmus test : pink ---blue </li></ul>
  24. 24. <ul><li>A.Preterm Prelabour Rupture Of Membrane </li></ul><ul><li>Occurs in 30 –40 % of preterm labour . </li></ul><ul><li>Risk to the mother : </li></ul><ul><ul><ul><li>Preterm labour & delivery </li></ul></ul></ul><ul><ul><ul><li>Intrauterine infection </li></ul></ul></ul><ul><li>Risk to the baby : </li></ul><ul><ul><ul><li>Prematurity </li></ul></ul></ul><ul><ul><ul><li>Infection </li></ul></ul></ul><ul><ul><ul><li>Cord prolapse </li></ul></ul></ul><ul><ul><ul><li>Skeletal deformities </li></ul></ul></ul><ul><ul><ul><li>Pulmonary hypoplasia </li></ul></ul></ul><ul><ul><ul><li>Cord compression </li></ul></ul></ul><ul><ul><ul><li>Increased perinatal mortality </li></ul></ul></ul>
  25. 25. <ul><li>Management : </li></ul><ul><li>1.Transfer to tertiary center. </li></ul><ul><li>2.Watch for sign & symptoms of infection : </li></ul><ul><ul><li>Earliest sign : fetal tachycardia & low grade fever </li></ul></ul><ul><ul><li>Late sign : uterine tenderness & foul smelling discharge </li></ul></ul><ul><ul><li>Others : Leucocyte count & CRP ( these two level have not been found to have practical clinical application ) </li></ul></ul><ul><ul><li>In many women, one of the earliest sign of infection is the onset of labour itself. </li></ul></ul><ul><li>- In the presence of infection , rapid delivery is required . </li></ul>
  26. 26. <ul><li>3.Antibiotics : </li></ul><ul><li>Shown to prolonged pregnancy, reduce maternal infection & reduce neonatal morbidity ( kenyon et al 2001 ) </li></ul><ul><li>ORACLE I : Use of erythomycin was associated with prolongation of pregnancy, reduction in neonatal treatment with surfactant, decreased in oxygen dependant at 28 days and older, fewer major cerebral abnormalities on u/s before discharge, fewer positive blood culture. </li></ul>
  27. 27. <ul><li>4.Corticosteroid administration. </li></ul><ul><li>5.Tocolytics : </li></ul><ul><ul><li>In general tocolytic is not indicated or effective in pPROM. </li></ul></ul><ul><ul><li>However in cases of threatened preterm labour without sign of chorioamnionitis, it may be used for upto 48 hrs to allow corticosteroid to take effect or transfer to tertiary sare unit. </li></ul></ul><ul><ul><li>In most cases tocolysis is unsuccessful. </li></ul></ul><ul><li>In many cases, labour does not supervene and several weeks might be gained.During this period : </li></ul><ul><ul><li>Fetal growth by U/S : every 2 weeks </li></ul></ul><ul><ul><li>Amniotic fluid : asses twice/week </li></ul></ul><ul><ul><li>CTG Biophysical profile : weeky or more </li></ul></ul>
  28. 28. <ul><li>If the pregnancy is safely carried to 35 – 37 weeks of gestation, depending on the presence or absence of of oligohydramnios & other aspects of fetal growth, induction of labour may be and option. </li></ul>
  29. 29. <ul><li>TERM PRELABOUR RUPTURE OF MEMBRANE </li></ul><ul><li>Occurs in 6 – 20 % of all term birth. </li></ul><ul><li>In 80 % labour is established within 24 hrs & in 90 % within 48 hrs. </li></ul><ul><li>Remarkable constant 2 – 5 % will be undelivered after 72 hrs & almost same proportion will remain undelivered after 7 days. </li></ul><ul><li>In general Induction of labour is indicated . </li></ul><ul><li>Timing of IOL : </li></ul><ul><ul><li>May be delayed if the women wishes. </li></ul></ul><ul><ul><li>Some suggest to wait for 12 hrs as 50 % will be in labour by this time. </li></ul></ul><ul><ul><li>Most women prefer to wait for 24 hrs. </li></ul></ul><ul><li>Women should be informed about the option ( prompt or delayed induction ) and encourage to choose the option they prefer. </li></ul>
  30. 30. <ul><li>Antibiotics : </li></ul><ul><li>If the women is GBS positive or if the membrane has rupture > 24 hrs, penicillin prophylaxis should be given. </li></ul>