Preterm labor by audace

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Preterm labor by audace

  1. 1. Audace NIYIGENA Intern in Gynecology & ObstetricsIn Butare University Teaching Hospital Supervised by Dr Ntwali NDIZEYE
  2. 2. Objectives Define preterm labor Discuss epidemiology Review risk factors Diagnosis Review complication Discuss Management
  3. 3. Case study M.E 19y Admitted on 19th Jan. 2013 Transferred from Nyanza DH  Nifedipine 20mg bid  Dexametasone 12mg 2times Symptoms  Periodic pelvic pain and back pain for 2 days  No bleeding, no fluid gush G.O  G1P0  Lmp 12th Jull. 2012 GA 27W2D
  4. 4. Case study cnt Mhx:  No hx of STI  No diseases on pregnancy  No asthmatic  HIV neg  No alcohol  No tobacco  No trauma Low socio economic status
  5. 5. Case study cnt P/E  HEENT: no pallor, no oedema, no jaundice  Chest: good symmetric chest expansion, lung clear, S1 & S2 well audible without added sound  Abdomen & pelvic:  Gravid uterus FH: 24cm  Bcf: 148b/m  Cephalic presentation  2 contractions/10m  Cervix dilatation 4cm  Effacement 100%  Engagement 1/5 Diagnosis: Preterm labor
  6. 6. Case study cnt Spontaneous rupture of membrane at 13h15’ 14h45’  Eutocic delivery of preterm baby  APGAR 3, weight:900gr  Transferred in neonatology (but died in the evening)
  7. 7. Define preterm labor
  8. 8.  Term pregnancy - 37 to 42 weeks gestation Preterm pregnancy 24 to 37 weeks gestation Preterm labor is occurrence of uterine contractions between 24 to 37 weeks of gestation( amenorrhea) Preterm labor is the presence of contractions of sufficient strength and frequency to effect progressive effacement and dilation of the cervix between 20 and 37 weeks gestation (WHO) Gynecology and obstetrics clinical protocols & treatment guidelines
  9. 9. Epidemiology
  10. 10. Preterm Birth 12 % of deliveries/yr are preterm 71.2% 34-36 weeks 13% 32-33 weeks 10% 28-31 weeks 6% <28 weeks
  11. 11. Preterm Birth Spontaneous preterm labor 30-50% Multiple gestation 10-30% PPROM 5-40% Preeclampsia/eclampsia 12% Antepartum bleeding 6-9% Fetal growth restriction 2-4% Other 8-9%
  12. 12. Survival in Premature Infants  23 wks – 17%  24 wks – 39%  25 wks – 50%  26 wks – 80%  27 wks – 90%  28-31 wks – 90 to 95%  32-33 wks – 95%  34-36 wks – approaches term survival ratesSources: march of Dimes, Quint Boenker Preemie Survival Foundation
  13. 13. Review risk factors
  14. 14. Risk Factors for PTD Previous PTB Multiple gestation  Maternal age extremes Increased uterine size  Anemia (Polyhydramnios, twins)  Low BMI < 20 Uterine abnormalities  cervical incompetency Maternal Infections  Severe stressors Placental pathology  Short inter-pregnancy Maternal trauma interval Smoking (Substance abuse)
  15. 15. Diagnosis
  16. 16. Signs and Symptoms Pelvic and Back pain Uterine contractions Cervix dilatation and effacement
  17. 17. Investigations FBC Vaginal swab for lab analysis Urine analysis Maternal and fetal screening for infections Obstetric Ultrasound
  18. 18. Review complication
  19. 19. Complications of Prematurity RDS IVH Feeding difficulties/NEC Apnea PDA Infection Jaundice Hypothermia Neurobehavioral ROP Anemia
  20. 20. Management
  21. 21. Goals of Treatment of PTL Halt contractions temporary by tocolysing Allow 48 hr+ for steroids to be given Allow for transport to delivery location with NICU capability
  22. 22. Steroids Reduce incidence of RDS, IVH, NEC, sepsis, and mortality by about 50% Dexamethasone 6 mg IM 12 hr x 4 (cervix dilatation < 4cm) Dexamethasone 12mg IM 12 hr x 2 ( cervix dilatation > 4 cm) (Gynecology and obstetrics clinical protocols & treatment guidelines)
  23. 23. Tocolysis  Beta agonists ( terbutaline, salbutamol)  Magnesium sulfate  Indomethacin  Atosiban  Nifedipine
  24. 24. TocolysisRisk/benefit ratio of various treatments Beta agonists (salbutamol, terbutaline)  Tachycardia, hypotension, tremor, palpitations, chest discomfort, hypokalemia, hyperglycemia Magnesium sulfate  Nausea, flushing, fatigue, diaphoresis, loss of DTRs, respiratory depression, cardiac arrest Indomethacin  Maternal GI SE, premature closure of ductus, oligohydramnios Atosiban  Possible increase in fetal/neonatal morbidity/mortality; not available in US CAUTION we should avoid combining tocolytics (Green-top guideline no:1b feb 2011)
  25. 25. Tocolysis Nifedipine  Low cost  Oral  Low incidence of side effects (hypotension, dizziness, flushing)Often considered first lineDose:  20mg start dose and 10-20 mg 3 to 4 times dailyTotal ≥ 60mg appears to be associated with increase of 3 to 4 fold the bad event of headache and hypotensionCaution: be careful when use in multiple pregnancy, rupture of membrane, sepsis, diabet mellitus and cardiac disease.(Source: the royal Australian and new Zealand college of obstetrics and gynecology C-obs 15)
  26. 26. Management after Tocolysis If maternal and fetal conditions are stable, can be managed at home Avoid excessive physical activity; most advocate pelvic rest Continued tocolytics have not shown definite benefit
  27. 27. Prevention of PTB Reduce/eliminate risk factors, if possible Not proven to be effective: bedrest, home uterine monitoring, prophylactic tocolytics, prophylactic antibiotics, abstinence
  28. 28. To retain Preterm labor is the presence of sufficient uterine contractions to effect progressive cervix changes between 20 and 37 weeks of gestation Various strategies that have been used to prevent or treat preterm labor, havent proven effective. Tocolysis should be considered only for 2 days-  for corticosteroids action,  gain time for transfer to a tertiary center .
  29. 29. References UpToDate19.3 2009 offline march of Dimes, Quint Boenker Preemie Survival Foundation Gynecology and obstetrics clinical protocols & treatment guidelines Sept.2012 the royal Australian and new Zealand college of obstetrics and gynecology C-obs 15 Green-top guideline no:1b Feb.2011
  30. 30. Thanks

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