Preterm labour د.علية شعيب
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Transcript of 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