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Preterm labor pain

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preterm labor pain chapter for medical students

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Preterm labor pain

  1. 1. Preterm Labor Saeed esmailian Kerman University of Medical Sciences
  2. 2. DefinitionDefinition regular uterine contractions by progressive cervical dilation and/or effacement at less than 37 weeks
  3. 3. Significance  Preterm birth is the leading direct cause of neonatal death (death in the first 28 days of life).  It is responsible for 27 percent of neonatal deaths worldwide, comprising over one million deaths annually  The risk of neonatal mortality decreases as gestational age at birth increases, but the relationship is nonlinear (figure 1  preterm birth is the second most common cause of-death (after pneumonia) in children younger than 5 years.
  4. 4. Survival in Premature Infants survival chance is directly proportional to the maturity 26 wks – 80% 27 wks – 90% 28-31 wks – 90 to 95% 32-33 wks – 95% 34-36 wks – approaches term survival rates
  5. 5. Complications of PrematurityComplications of Prematurity  RDS  IVH  Feeding difficulties/NEC  Apnea  PDA  Infection  Jaundice  Hypothermia  Neurobehavioral  ROP  Anemia
  6. 6. Prevalence  Worldwide 11 percent (range 5 percent [parts of Europe] to 18 percent [parts of Africa]), 15 million children each year (range 12 to 18 million)  United States in 2011, 11.73 percent
  7. 7. RiskRisk factorsfactors
  8. 8. Signs and symptomsSigns and symptoms 1. Painful or painless uterine contractions 2. Menstrual-like cramping 3. Mild, irregular contractions 4. Low back ache 5. pressure sensation in the vagina 6.6. Vaginal dischargeVaginal discharge of mucus, which may be clear, pink, or slightly bloody (ie, mucus plug, bloody show)
  9. 9. Diagnostic critiriaDiagnostic critiria Uterine contractionUterine contraction 4 in 20 mins 8 in 60 mins with cervical change Cervical dilatation > 1 cm Cervical effacement > 80%
  10. 10. Initial evaluation  Maternal vital signs: (temperature, blood pressure, heart rate, respiratory rate)  Fetal monitoring:  fetal heart rate and contraction (frequency /duration /intensity)  Uterine contractions are evaluated continuously using a contraction monitor, palpation, and the patient’s subjective assessment.  patient’s past and present obstetrical and medical history and GA   Examination of the uterus firmness, tenderness, fetal size, and fetal position.
  11. 11. Initial evaluation  Speculum examination using a wet non-lubricated speculum  cervical dilation and effacement  uterine bleeding (abruptio placenta or placenta previa)  fetal membranes, ( intact or ruptured)  fetal fibronectin (fFN).  bactrial culture (B streptococcal,gonorrhea and chlamydia)
  12. 12. Fetal Fibronectin  Fetal Fibronectin (fFN)- it is a glue like protein binding choriodecidual membrane  Present in vaginal secretions between 23-34 weeks and signifies onset of labor  Bedside test can be done – if negative it rules out preterm labor in next two weeks  P/V examination gives false positive result for 24 hours Between 24-32 weeks fFN – 25ng/ml + cervical length of 25 mm shows significant risk
  13. 13. Initial evaluation  Ultrasound examination  Assess amniotic fluid index.  Determine (+/ - 3 weeks) gestational age.  Transvaginal scan for cervical length.  Normal cervical length = 35 mm  Significant cervical length = 25 mm  Funnelling of membrane
  14. 14. Management 1.  BBetamethasone  (24- 34w)etamethasone  (24- 34w) 2.2. Tocolytic drugs (before 34w)Tocolytic drugs (before 34w) for up to 48 hours 3.3. AntibioticsAntibiotics ( GBS chemoprophylaxis, Appropriate antibiotics to women with positive urine culture results)  Bed rest (+)  Hydration (-)  Emergency cerclage (+)
  15. 15. Glucocorticoid  BetamethasoneBetamethasone 12mg IM stat and 24 hours later Effective: 24 hours after initial dose Effect up to 7 days Adverse effect:  Pulmonary edema  Infection  Difficult glucose control in DM women
  16. 16. Tocolytic drugsTocolytic drugs
  17. 17. Magnesium SulfateMagnesium Sulfate Calcium antagonist Cleared almost by renal excretion 4 g loading dose 2 g/hr continuous dose Therapeutic range:  4~7 mEq/L  1 mEq/L = 1.2 mg/dl = 0.5 mmol/L Deep tendon reflex disappear  10 mEq/L Respiratory arrest  12 mEq/L
  18. 18. Beta-Adrenergic Agonist  RitodrineRitodrine  Beta-adrenergic receptor desensitization  Side effect:  Pulmonary edema  Hyperglycemia  Arrhythmia
  19. 19. Prostaglandin Inhibitors (Nsaid(  IndomethacinIndomethacin < 48 hours < 30-32 weeks' gestation) Not > 200mg/day.  Side effect:  Oligohydramnios (reversible)
  20. 20. Prostaglandin Inhibitors (Nsaid( Capsule 25mg oral Amp 50mg Rectal Supp 100 mg 50 mg Loading dose Then 25-50mg /6hs
  21. 21. Calcium Channel Blockers  Nifedipine (adalat)Nifedipine (adalat) Higher delaying of delivery for >48 H. Lower risk of RDS &Neonatal jundice. Lower admission to NICU Fewer maternal adverse effects  Side effect:  Hypotension  Decrease uteroplacental perfusion
  22. 22. Dose: 20mg initial 10-20 mg /4-6 h Available forms Adalate capsule : 10mg Adalate retard Tablet: 20 mg
  23. 23. Atosiban  Nonapeptide oxytocin analogue  Competitive antagonist of oxytocin-induced contractions  Side effect:  Nausea, vomiting, headache, dizziness, money loss  18000 NTD/day
  24. 24. Reffrences
  25. 25. thanks

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