Preterm labour د.علية شعيب

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    Preterm Labor:

    Dr : Alia Abdullah Shoib

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    Evidence Based Sources:

    PubMed

    Cochrean libraryRCOG Guidelines

    ACOG Issues Guidelines

    National Guideline Clearinghouse

    MOH Sing. Guideline

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    Definition

    Preterm labor is the presence of

    contractions of sufficient strength

    and frequency to effectprogressive effacement anddilation of the cervix between 20

    and 37 weeks' gestation

    WHO

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    Preterm Labor

    Incidence : 6- 10%

    Spontaneous : 40-50%

    PROM : 25-40%

    Obstetrically indicated : 20-25%

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    Preterm Labor

    Most mortality and

    morbidity is experienced

    by babies born before 34weeks.

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    Major Risks Of Preterm Delivery

    Death

    Respiratory distress syndrome

    Hypothermia

    Hypoglycaemia

    Necrotising enterocolitis

    Jaundice

    Infection

    Retinopathy of prematurity

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    Can pretermlabor bepredicted?

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    Prediction1. Assessment of risk factors

    2. Vaginal examination to assess the

    cervical status3. Ultrasound visualization of

    cervical length and dilatation

    4. Detection of foetal fibronectin incervicovaginal secretions

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    1-Risk FactorsWhile the exact cause of

    preterm labor is often

    unknown, there is strongevidence that intrauterine

    infection may play a role invery early preterm labor.

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    Bacterial Vaginosis Bacterial vaginosis increased the

    risk of preterm delivery >2-fold .

    Risks were higher for those

    screened at

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    Multiple pregnancy: risk >50%

    Previous preterm delivery: risk 20- 40%

    Cigarette smoking: risk 20-30%

    Cervical incompetenceUterine abnormalities

    Other Risk Factors

    1-Risk Factors

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    Young age of mother - less than 16 years of age.

    Lower socioeconomic class.

    Reduced body mass index (BMI) - BMI less than19.0.

    Antiphosphlipid syndrome.

    Obstetric complications, including hypertension inpregnancy,antepartum haemorrhage, infection,polyhydramnios, foetalabnormalities.

    Other Risk Factors

    1-Risk Factors

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    2-Vaginal examination

    Digital examination is the traditional

    method used to detect cervicalmaturation, but quantifying these

    changes is often difficult.

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    3-Vaginal U/S

    Vaginal ultrasonography

    allows a more objectiveapproach to examination

    of the cervix.

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    Outcome Sensitivity specificity

    Delivery

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    Prevention

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    Prevention of Preterm Labor

    Women at increased risk of

    preterm delivery may be

    identified by various risk

    factors in the obstetric

    history and treated.

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    17 Hydroxy -Progesterone Caproate

    Prophylactic use of 17 hydroxy

    progesterone caproate to prevent

    preterm labor revealed a significantdecrease in preterm birth .

    However, it has not successfully inhibited

    active preterm labor.

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    Treatment Of Vaginosis

    Treatment of asymptomatic abnormal

    vaginal flora and bacterial vaginosis

    with oral clindamycinearly in the2nd trimester significantly reduces

    the rate of late miscarriage andspontaneous preterm birth.

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    Diagnosis

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    3 criteriato document PTL(20-37w)

    1-Regular uterine contractions occur

    at 4/20 min. or 8/60 min. Plus:

    progressive change in the cervix.

    2- Cervical dilatation > 1 cm3- Effacement _ 80%.

    Diagnosis

    >

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    Vaginal U/S+ Fibronectin Test

    Suspected preterm labor with nocervical changes :

    Negative fetal fibronectin +

    Cervical length > 30 mm

    the likelihood of delivering in the next week

    is less than 1%.

    Thus most women with a negative test can

    safely be sent home without treatment.

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    TreatmentInhibition of labor

    Corticosteroid Antibiotics

    Others.

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    Inhibition Of Labor

    Bed rest :DVT

    Hydration &sedation

    Tocolytics

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    Most Efforts to PreventPreterm Labor Not Effective

    Until effective strategies are found, effortsshould be aimed at preventing newborncomplications by :

    Corticosteroids Antibiotics against group B strep

    Avoiding traumatic deliveries.

    Delivery in a center with experiencedresuscitation teams and neonatal intensivecare

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    Hydration Intravenous hydration does not seem

    to be beneficial, even during theperiod of evaluation soon after

    admission, Women with evidence of dehydration

    may, however, benefit from the

    intervention.

    Is Tocolysis Better Than No

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    Is Tocolysis Better Than NoTocolysis For Preterm Labour?

    It is reasonable not to use tocolytic

    drugs, as there is no clear evidence

    that they improve outcome. However,tocolysis should be considered if the

    few days gained would be put to good

    use, such as completing a course ofcorticosteroids, or in uterotransfer

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    Tocolytics

    Most authorities do notrecommend use of tocolytics

    at or after 34 weeks' .There is no consensus on a

    lower gestational age limit forthe use of tocolytic agents.

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    Choice Of Tocolytic Drug

    Nifedipine = Epilate

    Atosiban= Tractocile

    B Sympathomimetic(Ritodrine)

    Magnesium sulphateIndomethacin

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    Choice Of Tocolytic Drug

    If a tocolytic drug is used, ritodrine no

    longer seems the best choice.

    Atosiban or nifedipine appear

    preferable as they have fewer adverse

    effects and seem to have comparableeffectiveness.

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    B -Sympathomimetic Agents.

    Maternal: pulmonary edema, myocardialischemia, arrhythmia, and even maternaldeath.

    Fetal : arrhythmia, cardiac septalhypertrophy , hydrops, pulmonary edema,and cardiac failure. hypoglycemia,

    periventricular-intraventricularhemorrhage, and fetal and neonatal death..

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    Dose

    Side effect

    Magnesium Sulfate

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    Nitric Oxide Donors

    There is insufficient evidence to

    support the routine

    administration of nitric oxide

    donors (nitroglycerin )in the

    treatment of preterm labor.

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    IndomethacinCompared with ritodrine there isinsufficient evidence for any

    differential effect on delay indelivery, but indomethacin does

    seem to have fewer maternal

    adverse effects than the beta-agonists

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    IndomethacinFetal risk:

    Premature closure of the ductus.

    Renal and cerebral vasoconstriction.

    Necrotising enterocolitis

    Common with high dose andprolonged exposure.

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    IndomethacinIndomethacin therapy for

    < 48 hours

    < 30-32 weeks' gestation)

    Not > 200mg/day.

    appears to be a relatively safe andeffective tocolytic agent

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    Indomethacin

    Indomethacin can be

    used as a second-linetocolytic agent in early

    gestational age pretermlabors.

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    IndomethacinIndomethacin may be a first-line tocolytic in:

    Associated polyhydramnios :

    ( to have renal effects ofindomethacin)

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    IndomethacinCapsule 25mg oral

    Amp 50mg

    Rectal Supp 100 mg

    50 mg Loading dose

    Then 25-50mg /6hs

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    Atosiban: Tractocil

    Atosiban, a syntheticpeptide, is a competitive

    antagonist of oxytocin atuterine oxytocin

    receptors.

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    Atosiban: TractocilAtosiban - compared with beta-agonists-

    has:

    Little difference in the effect of these agents ondelayed delivery

    Fewer maternal adverse effects than beta-agonists,

    such as chest pain, palpitations , tachycardia ,hypotension , dyspnoea ,vomiting , and headache.

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    Nifedipine

    Nifedipine- compared with ritodrine -

    has:

    Higher delaying of delivery for >48 H.

    Lower risk of RDS &Neonatal jundice.

    Lower admission to NN ICU

    Fewer maternal adverse effects

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    NifedipineWhen tocolysis is indicated for women in

    preterm labor, calcium channel blockers

    are preferable to other tocolytic agents

    compared, mainly betamimetics.

    Further research should address the

    effects of different dosage regimens and

    formulations

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    Nifedipine

    20mg initial

    10-20 mg /4-6 h

    Epilate capsule :10mg

    Epilate retard Tablet: 20 mg

    Maintenance Tocolysis Is Not

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    Maintenance Tocolysis Is NotRecommended For Routine Practice.

    There is insufficient evidence for any

    firm conclusions about whether or not

    maintenance tocolytic therapyfollowing threatened preterm labor is

    worthwhile. Therefore maintenance

    therapy cannot be recommended for

    routine practice.

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    CorticosteroidsAntenatal corticosteroids are associated

    with a significant reduction in rates of

    RDS, neonatal death and

    intraventricular haemorrhage, although

    the numbers needed to treat increase

    significantly after 34 weeks' gestation.

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    Corticosteroids

    The optimal treatment-delivery

    interval for administration of

    antenatal corticosteroids is

    after 24 hours but < 7 days after

    the start of treatment.

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    CorticosteroidsTwo 12 mg doses of betamethasone

    given IM 24 hours apart, Or

    Four 6 mg doses of dexamethasone

    given IM 6 hours apart

    There is no proof of efficacy for anyother regimen.

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    AntibioticsThere is no evidence of clearoverall benefit from

    prophylactic antibiotics forpreterm labour with intact

    membranes on neonataloutcomes.

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    Screening for GB Strep.

    ACOG Advises

    Screening AllPregnant Women

    for Group B Strep.

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    Group B Streptococci (GBS) Prophylaxis

    All patients in preterm labor areconsidered at high risk for

    neonatal GBS sepsis andshould receive prophylactic

    antibiotics regardless ofculture status.

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    Group B Streptococci (GBS) Prophylaxis

    The goal of this strategy isto prevent neonatalsepsis, and not to

    prevent preterm birth.

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    Prophylactic Vitamin K Or Phenobarbital

    Have not been shown tosignificantly preventperiventricularhaemorrhages in preterminfants.

    C l i

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    ConclusionsVarious strategies that have beenused to prevent or treat preterm

    labor, haven't proven effective.

    Tocolysis should be considered only

    for 2 days- if needed - forcorticosteroids thereby , or in uterotransfer to a tertiary center .

    C l i

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    ConclusionsIf a tocolytic drug is

    used, ritodrine nolonger seems the

    best choice.

    C l i

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    ConclusionsOther drugs with fewer adverse effects and

    comparable effectiveness are now

    recommended

    Atosiban or nifedipine have been

    recommended by RCOG

    endomethacin may be used as a 2nd line

    tocolytic or if there is polyhydramnous

    C l i

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    ConclusionsMaintenance tocolytic

    therapy has no proven

    effect.

    It cannot be recommendedfor routine practice.

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    THANKS