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Preterm labor an update
Preterm labor is defined as contractions and cervical changes before 37 weeks of gestation and is the leading cause of neonatal morbidity and mortality. It has many potential causes including infection, cervical issues, hormonal factors, uterine overdistension, and unknown etiologies. Risk factors include previous preterm births, infections, short cervical length, and medical conditions. Prevention strategies encompass progesterone supplementation, cervical cerclage, infection treatment, and bedrest. Diagnosis involves examining for contractions and cervical changes while monitoring is used to assess risk of imminent preterm delivery. Treatment focuses on stopping contractions with tocolytics if not yet at delivery while improving neonatal outcomes with corticosteroids if delivery is imminent.
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Preterm labor an update
- 2. Preterm Labor: AnUpdate Mahmoud Zakherah Prof Obstetrics and Gynecology Assiut University ,Egypt Mszakhera@gmail.com 2019
- 3. Magnitude of theProblem •Preterm birth is the leading cause of perinatal and neonatal morbidity and mortality. •Preterm birth, defined as spontaneous or iatrogenic delivery before 37 weeks gestation. •preterm labor is a multifactorial and complex syndrome. • incidence 12.5%
- 4. Definitions •Preterm Birth (delivery) •Before37 weeks •Preterm Labor •Contractions and cervical change before 37 weeks
- 5. Definition •Preterm labor isthe presence of contractions of sufficient strength and frequency to effect progressive effacement and dilation of the cervix between 28 and 37 weeks' gestation
- 6. • Preterm (orpremature) infant • Before 37 completed weeks of gestation • Late preterm infant (a recently identified category) • between 34 and 36 weeks gestation • Moderately preterm infant • between 32 and 36 completed weeks of gestation • Very preterm infant • before 32 completed weeks of gestation Definitions
- 7. Definitions •Low birthweight (LBW) •infant who weighs less than 2,500 grams at delivery •Very low birthweight (VLBW) • infant who weighs less than 1,500 grams at delivery •Extremely low birthweight (ELBW) • infant who weighs less than 1,000 grams at delivery Source: Iams JD, Creasy RK. Preterm labor and delivery, Chapter 34. In: Maternal-Fetal Medicine: Principles and Practice, 5th ed., 2004.
- 8. Preterm Labor: OneSyndrome, Many Causes
- 9. Pathophysiology •Myometrial contractility •Cervical ripeningdilatation •Decidual membrane activation
- 10. Preterm labor 1- spontaneousintact membranes 50% 2-Preterm ROM 30% 3-Iatrogenic Clinically indicated fetal or maternal 20%
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- 12.
- 13. Complications of PretermDelivery Neonatal ▪ Respiratory distress syndrome (RDS) ▪ Intraventricular hemorrhage (IVH) & periventricular leukomalacia (PVL) ▪ Necrotizing enterocolitis (NEC) ▪ Patent ductus arteriosus (PDA) ▪ Infection ▪ Metabolic abnormalities ▪ Nutritional deficiencies Long term ▪ Cerebral palsy ▪ Sensory deficits ▪ Incomplete catch-up growth ▪ School difficulties ▪ Behavioral problems ▪ Chronic lung disease Short term ▪ Feeding and growth difficulties ▪ Infection ▪ Neurodevelopmen tal difficulties ▪ Retinopathy ▪ Transient dystonia Source: Iams JD, Creasy RK. Preterm labor and delivery, Chapter 34. In: Maternal-Fetal Medicine: Principles and Practice, 5th ed., 2004.
- 14. Complications of PretermDelivery •Respiratory distress syndrome •Hypothermia •Hypoglycemia •Necrotizing enterocolitis •Jaundice •Sepsis
- 15.
- 16. Prediction ❑Assessment of riskfactors ❑Vaginal examination to assess the cervical status ❑Ultrasound visualization of cervical length ❑Detection of fetal fibronectin in cervicovaginal secretions
- 17. Prediction ❑CRH Elevated CRHis implicated in preterm labor associated with stress, infection and hemorrhage. ❑AFP and HCG ❑AMH
- 18. Risk Factors Risk Factorsfor Spontaneous Preterm Birth
- 19. Nonmodifiable Risk Factors •Prior preterm birth • Cervical injury or anomaly • Uterine anomaly • Age < 18 years or> 40 years • Excessive uterine activity (?) • Poor nutrition • Low prepregnancy weight • Low socioeconomic status •Overdistended uterus (twins, polyhydramnios) •Poor prenatal care •Vaginal bleeding
- 20. Potentially Modifiable RiskFactors •Cigarette smoking • lower genital tract infections • (including bacterial vaginosis, Neisseria Chlamydia trachomatis, Group B Streptococcus and Trichomonas vaginalis) • Illicit drug use • Anemia • A Bacteriuria/UTI • Gingival disease • High personal stress (?) • Strenuous work/work • Environment (?)
- 21. Risk Factors ofpreterm Syndrome Uterine Overdistension Vascular Infection Cervical pathology Hormonal Immunological © VR RR MM Unknown
- 22. Risk factors • Previouspreterm labor or premature birth risk 20- 40% the most significant risk factor • Uterine overdistension ( Polyhydramnios- multiple pregnancy): risk >50% • Uterus, cervix or placental anomalies (Cervical incompetence- Uterine anomalies ) • infections, particularly of the amniotic fluid and lower genital tract Bacterial Vaginosis ( even periodontal disease)
- 23. Risk factors •Chronic diseases, hypertensionand diabetes •Stress •Cigarette smoking: risk 20-30% •Bleeding during pregnancy APH - even 1st trimester •Short interval between pregnancies less than 6 months
- 25. The Preterm ParturitionSyndrome Uterine Overdistension Vascular Infection Cervical Disease Hormonal Immunological © VR RR MM Unknown
- 26. Infections Subclinical •Asymptomatic bacteria •Bacterial vaginosis •Vaginal douchingand vaginal infections are associated with preterm labor Clinical •Pyelonephritis •Chorioamnionitis Proinflammatory mediators such as cytokines and matrix metalloproteinases
- 27. The Preterm ParturitionSyndrome Uterine Overdistension Vascular Infection Cervical Disease Hormonal Immunological © VR RR MM Unknown
- 28. Progesterone in PregnancyMaintenance • Myometrial quiescence • Down-regulate gap junction formation • Inhibit cervical ripening
- 29. The Preterm ParturitionSyndrome Uterine Overdistension Vascular Infection Cervical Disease Hormonal Immunological © VR RR MM Unknown
- 30. •Multiple gestation •Polyhydramnios •stretching ofmyometrium induces formation of gap junctions, upregulation of oxytocin receptors and production of prostaglandins Uterine Overdistension
- 31. Uterine factors • Cervicalinsufficiency • Contractions • Anomalies • Distention
- 33.
- 34. Prevention •Primary prevention IdentifyHigh risk groups PROG •Secondary prevention Tocolysis steroids antibiotics ▪Tertiary preventions Minimize complications IU transfer
- 35. Prevention •Regular prenatal care •Lifestyle Eat a healthy diet-stress reduction PUFA •Rest pelvic –body ??? •Pregnancy spacing. •Be cautious when using assisted reproductive technology (ART). . Multiple pregnancies carry a higher risk of preterm labor.
- 36. Prevention Bedrest Effects •Muscle atrophy •Boneloss occurs •Pulmonary •Cardiovascular changes •Financial
- 37. Prevention •Cervix ultrasound cerclage •Myometrialcontractions Monitoring tocolysis •Membrane decidual activation Fibronectin antibiotics
- 38.
- 39. Transvaginal Cervical length •Normal3-4cm and no funnelling •Measuring cervical length using transvaginal ultrasonography is a useful tool to predict the risk of preterm birth in low- and high-risk pregnancies. • At 18-22 weeks • CL <25 mm
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- 41. How short istoo short Cervical Length RR of PTD <35mm 2.35 <30mm 3.79 <26mm 6.19 <22mm 9.49 <13mm 13.99
- 42. Fetal Fibronectin •Trophoblast Glue Glycoproteinsecreted by fetal membranes. • Promotes cellular adhesion at uterine-placental and decidual-fetal membrane interfaces • Not detectable after 20 weeks until PROM •Before collection: • Intact membranes? • CVX <3cm? • GA 24-34 wks? • No Intercourse-bleeding last 24 hrs?
- 43. Biochemical Markers forPreterm Labor •Salivary estriol Elevated before preterm birth •Partosure test simple and quick bed-side test PartoSure is a bedside test to detect the presence of placental alpha macroglobulin (PAMG-1) in the CVF •Lamellar Body Count
- 44. Prevention •Progesterone • Vaginal micronizedprogesterone???? 17 Hydroxy -Progesterone Caproate GD? Vaginal progesterone supp 200-400mg. •Treatment of infection •Cerclage History-Indicated Versus Ultrasound-Indicated Cerclage
- 45. Progesterone therapy •All pregnantwomen who have either a prior history indicating increased risk or current, asymptomatic cervical insufficiency should receive progesterone supplementation until the end of GW 34. Ekkehard Schleußner 2013
- 46. Progesterone therapy •17 Hydroxy-Progesterone Caproate GD? •Start weekly injections at 16 weeks and continue until 36 weeks •Painful Oily
- 47. •Women with singletongestations receiving weekly 17α-hydroxyprogesterone caproate for recurrent preterm birth prevention had a significantly higher incidence of abnormal glucose test results and GDM. • Eke, Ahizechukwu C et al 2019
- 48. Progesterone therapy Vaginal progesterone •Directeffect •Convenient • 200mg 400 mg •16-36 ws
- 49. Progesterone therapy •At best,progesterone supplementation prevents only one-third of recurrent preterm births, and the long-term benefits of progesterone supplementation are not yet clear. •The potential clinical benefits of progesterone supplementation appear large, whereas the risks seem small (Errol R Norwitz et all,2011)
- 50. Progesterone therapy •Cochrane reviewof prenatal administration of progesterone for preventing preterm birth in women considered to be at risk of preterm birth Dodd et al, Cochrane Database of Systematic Reviews 2013, Issue 7
- 51. The use ofprogesterone is associated with benefits in infant health following administration in women considered to be at increased risk of preterm birth due either to a prior preterm birth or where a short cervix has been identified on ultrasound examination,Dodd et al,2013
- 52.
- 53. Cerclage •Prophylactic •Emergency • Shiradkor cerclage •McDonald’s Cerclage • Cervical occlusion Mucus
- 54. Cervical pessary •There areongoing RCTs evaluating the effect of a cervical pessary in women at risk of preterm birth based on their obstetric history. • a flexible silicon ring designed to encircle and support the cervix
- 55.
- 56. Preterm Labor HomeCare Instructions WARNING SIGNS OF PRETERM LABOR
- 57. Diagnosis - symptoms •Pelvic pressure • Low, dull backache • Menstrual-like cramps • Change or increase in vaginal discharge • Uterine contractions every 10 minutes or more often, with or without pain • Intestinal cramping, with or without diarrhea
- 58. Diagnosis Examination ❑Pelvic exam. Digital cx ❑Ultrasound.Cx length ❑Uterine monitoring contractions Home Monitoring Lab tests ❑infections ❑ fetal fibronectin — a substance that acts like a glue between the fetal sac and the lining of the uterus
- 59. Treatment of pretermlabor
- 60. Treatment of pretermlabor •Stop contractions unless CI Tocolytics • Lung maturity corticosteroids •When to deliver •Where to deliver Intrauterine transfer
- 61. Tocolytics •Short term delay •IU transfer required • or need to give steroids
- 62. Tocolysis – inhibitmyometrial contractility for two days B –Sympathomimetic (Ritodrine-Terbutaline- Salbutamol ) Magnesium sulphate Hydration Indomethacin Nifedipine = Epilat Atosiban= Tractocile Oxytocin antagonist Intravenous Infusion
- 63. Magnesium sulfate •Neuroprotective • Reducethe risk cerebral palsy) for babies born before 32 weeks of gestation •Maintain levels of 5.5-7 mg/dl
- 64. INDOMETHACIN •Powerful Anti-inflammatory • Inhibitsprostaglandin synthesis • Readily crosses the placenta • Often used in conjunction with other tocolytic therapy (e.g., magnesium) • Effective in prolonging pregnancy 48-72 hours • Oligohydramnios Premature closure of DA
- 65. •Emergency cerclage •Rescue Cerclage •High failurerate •Corticosteroids • Between 24 and 34 Ws Betamethasone Two IM doses of 12.5 mg 24 hours apart Dexamethasone 6 mg IM x 4 doses 12 hours apart Reduce RDS by 50%, Decrease NEC and IVH Treatment of preterm labor
- 66. Summary and takehome message •Preterm labour is a serious problem •Prevention is the ultimate goal •Prediction is the main target in ANC
- 67. Summary and takehome message •Preterm Labor Patient Education •Warning Signs of Preterm Labor •CALL YOUR DOCTOR
- 68. Summary and takehome message •Progesterone with or without cerclage is very useful in cases with previous history of PL or short Cervix.
- 69. Summary and takehome message •Consider ▪ Steroids ▪ Tocolysis ▪ Antibiotics
- 70. Summary and takehome message Special care baby unit is essential at delivery
- 71. Summary and takehome message •The inferior physician waits until the disease is full blown before treating. •The mediocre physician treats the disease once it has become clinically manifest. •The superior physician prevents the disease.