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PRETERM LABOUR
- 1. MRS. SONY SARAP.J ASSO. PROFESSOR MSC (N),OBSTETRICS AND GYNECOLOGICAL NURSING GANGA COLLEGE OF NURSING COIMBATORE
- 3. CONTENT OVERVIEW Introduction Definition Incidence Classification Causes Risk factor Mechanism Symptoms Diagnostictest Prevention Management Prognosis
- 4. INTRODUCTION • Preterm laboris one of the leading cause of perinatal morbidity and mortality. • Preterm delivery effects almost 23% pregnancies in developing countries like India
- 5. DEFINITIONS Pre term labouris defined as onset of labour prior to the completion of 37 weeks (259 days) of gestation and after the attainment of period of viability. (22 weeks & 500 gms by WHO)
- 6. INCIDENCE Incidence varies from5-15% • Cause unidentified in up to 50% of PTB • Majority of women with risk factors will not have PTB • Many women who have a PTB have no risk factors • 8.7% of singleton births • 66% of multiple births Frequency of preterm birth by gestational age • < 28 weeks : 0.82 % • < 32 weeks: 2.2 % • 33-36 weeks: 8.9 % • < 37 weeks: 11.2
- 7. CLASSIFICATIONS PRETERM LABOUR Extreme preterm Early Preterm Late Preterm < 28 weeks Cerclage/ progesterone /Tocolysis 28- < 32 weeks Progesterone/ Tocolysis 32 - < 37 weeks Tocolysis
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- 9. RISK FACTORS FORPTB Clinical Factors in preterm Labor Maternal Low socio economic status Age <18 years or >40 years Low pregnancy weight Smoking Substance abuse Multiparity Past Obstetric History Previous history of preterm delivery Previous history of second trimester abortion Uterine Factors Uterine volume increased: Polyhydramnios, Multifetal gestation Uterine anomalies Incompetent cervix Trauma Infection
- 10. RISK SCREENING History • Comprehensivehistory review including maternal characteristics and previous medical/pregnancy history Counselling • Psychosocial needs, smoking, lifestyle, chronic disease • Involve a multidisciplinary team and refer when needed/appropriate Bacterial vaginosis • Offer screening and treatment to women with symptoms of BV and/or history of PTB Bacteri -uria • Offer routine ward test urine screening and treatment to women Transvaginal cervical length • If history of PTB: recommend serial TVCL screening from 14–24 weeks • If low risk of PTB: consider a single TVCL measurement during mid- trimester USS
- 11. MECHANISM OF PRETERMLABOR CAUSES MECHANISM • Stress • Premature activation of physiological effectors Activation of maternal-fetal HPA-axis • CRH → Fetal adrenal androgens • Placental estrogen and progesterone • Inflammation and infection • Pro-inflammatory cytokines • Fetal inflammatory response syndrome • Ischemia or hemorrhage • Thrombin activation • Pathological Uterine distension • Increased gap junction along with contraction associated protiens and upregulation of prostaglandins and oxytocin receptors
- 12. painful or painlessuterine contractions SYMPTOMS Lower abdominal pain or menstrual like cramping Pain in lower back Blood stained vaginal discharge Sensation of pelvic or vaginal pressure
- 13. SIGNS • Palpable uterinecontractions • Engagement of presenting part • Cervical effacement & dilatation • Show (may be blood stained) • Bulging membranes • Rupture of membranes
- 14. Pelvic exam Lab tests Ultrasound-fetal well being, cervical length & placental localization, Uterine monitoring DIAGNOSTIC TEST
- 15. DIAGNOSTIC TEST contd... Pelvicexam • Dilatation(≥2cm) & Effacement (80%)of the cervix • Length of cervix ≤2.5cm • Funnelling of internal OS • Pelvic pressure, backache or vaginal discharge or bleeding. Uterine monitoring • Regular uterine contractions with or without pain (at least one in every 10 mins.)
- 16. Lab tests • Fullblood count • Routine urine -analysis,culture & senstivity • Cervicovaginal Swab- culture,fibronectin • Serum electrolytes & glucose levels- when tocolytic agents are to be used DIAGNOSTIC TEST contd...
- 17. TRANSVAGINAL CERVICAL LENGTH(TVCL) • Risk of PTL increases with a shorter cervical length • If history of PTL: recommend serial TVCL screening from 14–24 weeks • If low risk of PTL: consider a single TVCL measurement during mid-trimester USS • Consider therapeutic interventions when TVCL is < 25 mm DIAGNOSTIC TEST contd...
- 18. FETAL FIBRONECTIN TESTING Sample: from the posterior fornix of the vagina Indications: • Symptomatic preterm labour 24 - 36 weeks • Intact membranes and Cervical dilatation less than 3 cm Contraindications: • Ruptured membranes • Vaginal bleeding & Cervical cerclage in situ Relative Contraindications: • After the use of lubricants or disinfectants • Within 24 hours of coitus or vaginal examination DIAGNOSTIC TEST contd...
- 19. Fibronectin • A proteinthat binds the fetal membranes to decidua. • Normally found in cervicovaginal discharge before 22 wks & again after 37wks of pregnancy presence of fibronectin in cervicovaginal discharge b/w 24 wks & 34 wks • Predicts pre-term labour DIAGNOSTIC TEST contd...
- 20. MANAGEMENT OF PRETERMLABOUR Management Preventive Definitive
- 21. PREVENTION • Seek regularprenatal care & Consider pregnancy spacing • Eat a healthy diet & Avoid risky substances • Be cautious when using assisted reproductive technology • Taking preventive medications , who has short cervix (Progesterone) • Restricting sexual activity & Limiting certain physical activities. • Manage chronic conditions such as DM, Increased BP.
- 22. PREVENTION contd... Primary Care: •To reduce the incidence of preterm labour by reducing the high risk factors(e.g. infection etc.) Secondary Care: • Includes screening tests for early detection & prophylactic treatment (e.g. tocolytics) Tertiary care: • To reduce the perinatal morbidity & mortality after the diagnosis (e.g. use of corticosteroids)
- 23. CERVICAL CERCLAGE • Considercervical cerclage for women with a history of: – One or more prior spontaneous PTL and/or second- trimester loss related to painless/painful cervical dilation and in the absence of labour or placental abruption or – Prior cerclage due to painless cervical dilation in second trimester or Cervical incompetence
- 24. • Cerclage maybe indicated if TVCL is less than 25 mm before 24 weeks if: – Preterm prelabour rupture of membranes (PPROM) in a previous pregnancy – A history of cervical trauma/surgery – Prior spontaneous PTB before 34 weeks gestation and Current pregnancy singleton CERVICAL CERCLAGE
- 25. PROGESTERONE THERAPY Reduces riskof PTL in women with a history of spontaneous PTL and/or short cervix, Consider for: • Singleton pregnancy from 16–24 weeks with a history of prior spontaneous PTB • Asymptomatic women with incidentally diagnosed short cervix in the second trimester • Not recommended for use in multiple pregnancies
- 26. MANAGEMENT OF PRETERMLABOR • Bed rest and hospitalization. • In utero transfer • Sedation • Hydration • Corticosteroids to induce fetal lung maturation • Treatment of infection with antibiotics • Inhibition of uterine contractions with tocolysis
- 27. DEFINITIVE Corticosteroid Administration – Singledose antenatal corticosteroids to women between 24-34 weeks with High risk of preterm birth – Ante-natal corticosteroid should be given to all women whom an elective caesarean section planned prior to 38weeks. (level 2)
- 28. • Tocolytic therapymay offer some short-term benefit in the management of preterm labor. Aim of tocolysis : Suppress uterine contractions and delay preterm delivery to allow in-utero transfer to an appropriate level facility . 2-allow for the administration of corticosteroids and MAG SULF for neuroprotection TOCOLYSIS :
- 29. Indications of Tocolytics AcutePreterm Labor Completing a course of corticosteroids or in utero transfer Reduce the proportion of births occurring within 7 days Maintenance - Acute Preterm labor Both oral and parenteral may be for maintenance therapy beyond 48–72 hours Prophylaxis of Preterm Labor in women who are at high risk for Preterm labor
- 30. Contraindications : • Gestation> 34 weeks & Labour is too advanced • In utero fetal death & Lethal fetal anomalies • Suspected fetal compromise & Placental abruption • Suspected intra-uterine infection • Maternal hypotension: BP < 90 mmHg systolic Relative contraindications : • Pre-eclampsia & Multiple pregnancy • Placenta praevia & Rupture of membrane TOCOLYSIS :
- 31. TOCOLYTIC DRUGS CLASS EXAMPLES Betaagonists Isoxsuprine, Ritodrine, Terbutaline Oxytocin Antagonist Atosiban Nitric oxide donors GTN Calcium Channel Blockers Nifedipine Others Magnesium Sulphate
- 32. REGIMENS FOR TOCOLYSIS 1.Calcium channel blockers • 1st line tocolytic agent in developing countries • Nifedipine 20 mg oral followed by 10 mg, 4-6 hourly until uterine contractions cease followed by 10 mg 8 hourly for about a week 2. Ritodrine hydrochloride • IV therapy (100 mg in 500 ml 5% Dextrose). Starting with 0.05 mg/mt (5 drops/mt) to a maximum of 0.30 mgmt (30 drops/mt) and continued for 48 hours. • Currently ritodrine is not much preferred due to risk of complications like pulmonary edema, hypotension etc
- 33. REGIMENS FOR TOCOLYSIS 3.Isoxsuprine • IV therapy at rate of 60 microgram (8 drops/mt) in 500 ml 5% dextrose. • Isoxsuprine 10 mg IM every 4-6 hours initially followed by maintenance dose of 60-80 mg daily (orally or IM). Side effects same as Ritodrine. 4. Terbutaline • IV therapy bolus of 250 microgram followed by 10-50 microgram/mt until labour stops. •Maintenance of 2.5-5 mg orally may be given 4-6 times a day • Side effects same as Ritodrine.
- 34. REGIMENS FOR TOCOLYSIS 5.Magnesium sulphate • Safe drug with limited tocolytic efficacy • Loading dose of 4-6 g over 20-30 mts followed by infusion of 1-2 g/hr. •Evidence suggests that if used between 24 and 32 weeks, for atleast 12 hours, it has tocolytic and neuroprotective role by decreasing incidence of cerebral palsy. 4. Indomethacin • Indomethacin in dose of 50 mg loading dose orally followed by 25-50 mg 6 hourly is effective. • Some studies reported side effects of fetal abnormalities like patent ductus arteriosus, necrotizing enterocolitis and even death whereas other studies have not reported any side effects.
- 35. MANAGEMENT-FIRST STAGE • Patientis put to bed to prevent PROM • To ensure adequate fetal oxygenation • Strong sedative avoided • Epidural analgesia is of choice • Labour should be watched by intensive clinical monitoring • In case of delay, caesarean section should be performed
- 36. MANAGEMENT-SECOND STAGE • Thebirth should be gentle &slow to avoid rapid compression & decompression of head • Episiotomy may be done under local anesthesia to minimize head compression if there is perineal resistance • The cord is to be clamped immediately at birth to prevent Hypervolemia & Hyperbilirubinemia • To shift the baby to intensive neonatal care unit under care of neonatologist
- 37. PROGNOSIS Results in highPerinatal mortality & Perinatal morbidity • With intensive neonatal care unit, survival rate of the baby weighing b/w 1000 to 1500 gm is more than 90% • With use of surfactant, survival rate of infants born at 26wks is about 80%
- 38. REFERENCES • D.C.Dutta,”Textbook ofObstetrics including Perinatology and Contraception". Seventh Edition. • J.B. Sharma, “Midwifery & Gynaecological Nursing” Avichal Publishing company:1st edition • Jacob, Annamma (2009). A Comprehensive Textbook of Midwifery.Second Edition. New Delhi: Jaypee Brothers Medical Publishers.