Preterm labor
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Transcript of Preterm labor
PRETERM LABOR
DR V L DESHMUKH
ASSO PROF
DEPT OBGY
INTRODUCTION
• Gestation age –40 wk
• 37 wk
• Less than 37 wk
• Baby is affected
• Before 37 wk and after 28 wk
• Early preterm –28 to 34 wk
• Late preterm-34 to 37 wk
Intro---
• Commonest perinatal problems
• 45% of pt with threatened preterm –deliver within 48 hrs
• 55% of pt with threatened preterm stop contracting and do not deliver
• Cause largely not known
• Controversy in inv and t/t part
defination
• Labour before 37 wk
• Between 28 to 37 wk
• Before 28 wk –abortion
• With PROM-prognosis is guarded
• Sufficient urine contractions to cause cx dilation and effacement
• Show may or maynot be present
incidence
• 10%
• Early preterm-critical with resoect to survival rate, handicap risk and overall morbidity and mortality
• Late preterm-prognosis is better
• Costs of t/t is tremendous
• Cost and ges age go hand in hand togather
epidemiology
• Teen age
• low SES
• Illiteracy
• ht <140cm
• Wt <45 kg
• Anaemia
• Malnourished
Epi---
• Smoking
• Bacterial vaginosis
• UTI
• Twins
• Ut abnormality
• Previous h/o preterm labour
• Previous h/o PROM
Epi---
• Genetic predisposition
• Polyhydramnions
• Mother is herselves born as preterm
• Diseases requiring preterm induction eg PIH
• Cx incompetence
• Idiopathic
aieteology
• 75%-no cause is found• 10-20%-infection eg-UTI, Bacterial vaginosis• 10% associated with PROM• ABRUPTIO PLACENTA, FIBROID UTERUS• Twins,triplets quadriplets-(34-36 wk)• Quadriplets even earlier• Cx incompetence• Abd trauma,abd operations
• 5
pathophysiology
• Many theories on why preterm occurs
• None is proved
• But all may explain why preterm occurs
• This includes infection,role of nitric oxide,prostaglandin, and cx changes
Patho---
• Infection-chorioamnitis, UTI,bacterial vaginosis
• Myometrial NO/PG balance-CONTROL MYOMETRIAL CONTRACTILITYdisturbance may lead to preterm contractions.NO IS A SMOOTH MUSCLE RELAXANT.PG has both relaxant and contracting property.
Patho---
• Cx is a complex fibromuscular organ which carries the pregnancy upto term
• If the cx softens, dilates and gets hydrated,it gets altered in form rapidly.
• This change in cx alters the quiescence of uterine muscles
• Predispose to preterm labor
Clinical features
• Painful uterine contractions
• Asso with PROM
• Cont are regular, frequent
• Cx effacement and dilatation occurs
• Only backache may be the complaint
• Sense of heaviness in pelvis
• Difficulty in walking
symptoms
• Abdominal pain
• Backache
• Decreased fetal movements
• Nausea,vomiting
• Diarrhoea
• Increased vaginal discharge
• Vg bldg
Symp---
• Important to exclue gastroenteritis or UTI
• H/O NAUSEA,VOMITING, LOOSE MOTIONS, DYSURIA
• H/o amniocentesis,ut anamokies
• Or bldg in early pregis relevant
Symp--
• Check dates.is it relly preterm?
• Ash h/o fetal movements (IUFD)
• RULE OUT PL ABRUPTION
• RULE OUT PROM
signs
• Tachycardia
• Mild pyrexia
• Palpable contractions
• Cx ffacement and dilatation
• Membranes+/_
• Show+/-
General exam
• Rule out systemic disorders
• Temp, pulse, BP,
• Skin turgur
• Hydration status
Per abdominal exam
• Look for rebound tenderness, guarding, rigidity.may suggest pyelonephritis or appendicitis as a cause of preterm labor
• Rule out pl abruption .tenderness,stony hard• Fibroid(lump in abd)• Keep in mind horioamnitis• Obs exam-ut ht, presentation, FHS,
contractions
P/v
• Aseptic precautions
• Cx dilatation
• Cx effacement
• Membranes+/-
• Station
• Bldg p/v
treatment
• Pt comfrtable
• Reduce anxiety
• Antibiotics
• Correct dehydration
• Decide which tocolytic is appropriate
• Give steroids for lung maturity
investigations
• Urine-micro• High vg swab• CBC• ESR• TVS EXAM-for the maturity of baby,
liquor, presentation, pl previa, pl abruption,baby wt, ut anamoly cx length, FHS+/-
ANTIBIOTICS
• INFECTION may lead to uterine irritabilitydue to the liberation of cytokines
• UTI-antibiotic of choice is with gr –ve spectrum 3RD generation cephalosporinis recommended
• BV• PPROM-ANTIBIOTIC for mother and
baby both
steroids
• For lung maturity
• Dexamethasone or betamethasone
• Given Imly
• 12 hrs apart
• Reduce RDS
• NO HARM TO FETUS
• Act after 48 hrs
tocolytics
• Drugs used to decrease uterine contractility• Act as smooth muscle relaxant• Give time-may be 48 hrs after steroid
administration or till transfer to tertiary centre
• Contraindications-PROM,chorioanitis,fetal anamoly,APH
• Prolong pregnancy significant time
Toco---beta agonists
• Act on beta 2 recepters• Ritrodrine,salbutamol,terbutaline• Given IV, IM, orally• Quite effective in t/t of preterm labor• In theraupeutic doses it can cause
tachycardia, sweating,headache and rarely life threatening CVS comprimise with pulmonary edema
Calcium chanel blockers
• Nefidepine
• Given orally
• Acts as a smooth muscle relaxant
• Side effects are maternal
• Cause headache and flushing
• Rarely used
NSAID
• ANTIPROSTAGLANDINS• PG play a major role in causation of labor• Acts to prevent uterine contraction• Given orally or rectally• Sideeffects are fetal and cause
oligohydramnions,IVH,PDA which requires surgical ligation
• Hence not used
Glyceryl trinitrite
• GTN-nitric oxide donor
• Causes smooth muscle relaxation
• Relatively safe
• Well tolerated
• Effective
• Transdermal patches/IV
• costly
Toco---
• Choice is difficult
• All prolong the pregnancy effectively
• Sideeffects are significant
• Combination drug therapy leads to multiple sideeffects and offer no therapeutic benefit
• Safe ones are GTN and calcium blockers
• Hupotension is really troublesome
Mgt of labor
• If labor is established then certain aspects differ from normal labor
• Good analgesia
• Hydration
• Neonatologist available
• Antibiotic cover
• Monitoring for FD
LABOR
• Membranes preserved as far as possible
• Breech presentation demands LSCS to avoid head entrapment and fetal demise
• IVH is also a possibility
• Forceps are used in 11 stage of labor. They protect the fetal head from excessive compression
Fetal fibronectin
• Protein present at the choriodecidual junction
• Excreated in excess in preterm labor• Values >50 ng/ml are significant• Results are promising if raised FFN present
along with reduced cx length• Negative predictive value is more
significant
summary
• Preterm occurs in 7% • PPROM is asso with highmorbidity and mortality• Aieteology is unknown in 50% of cases• Tocolytics are only moderately effective• H/o preterm labor is important factor for having
preterm labor again• Measurement of cx length at 22-24 wk is
predictive of preterm labor