done by : –mazen basheikh done by : –mazen basheikh

•Done by :–Mazen Basheikh

•Done by :–Mazen Basheikh

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Definitions & StatisticsDefinitions & Statistics

• Preterm labor Vs. Preterm birth.

• Incidence of preterm labor: 5-15 % of all pregnancies.

• Mortality rate.

• 30% of preterm births are due to preterm labor.

• Preterm labor Vs. Preterm birth.

• Incidence of preterm labor: 5-15 % of all pregnancies.

• Mortality rate.

• 30% of preterm births are due to preterm labor.

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• Previous history of preterm birth:

the relative risk increase to 3.9, and it increase to 6.5 with 2 previous preterm deliveries.

• 2nd trimester abortions.

• Previous history of preterm birth:

the relative risk increase to 3.9, and it increase to 6.5 with 2 previous preterm deliveries.

• 2nd trimester abortions.

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• Uterine / vaginal infections: e.g. bacterial vaginosis, Chlamydia and gonorrhea.

• Uterine / vaginal infections: e.g. bacterial vaginosis, Chlamydia and gonorrhea.

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• Short cervix: the relative risk increase from

2.4 for 3.5 cm ( 50th percentile ) to 6.2 for 2.5 cm ( 10th percentile )

• Placental causes.

• Short cervix: the relative risk increase from

2.4 for 3.5 cm ( 50th percentile ) to 6.2 for 2.5 cm ( 10th percentile )

• Placental causes.

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• Psychological factors: Why ??

• Socioeconomic status: Why ??

• Psychological factors: Why ??

• Socioeconomic status: Why ??

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• Other risk factors:UTI, multiple gestation, uterine

anomalies, polyhydramnios, and incompetent cervix.

• Other risk factors:UTI, multiple gestation, uterine

anomalies, polyhydramnios, and incompetent cervix.

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• 1) Documented uterine contractions.

• 2) Documented cervical changes.

• 1) Documented uterine contractions.

• 2) Documented cervical changes.

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• CBC.• Random blood glucose.• U&E.• Urine analysis.• Urine culture & sensitivity.

• CBC.• Random blood glucose.• U&E.• Urine analysis.• Urine culture & sensitivity.

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• Vaginal swab for :• Culture.• PH.• 10% KOH test.

• Vaginal swab for :• Culture.• PH.• 10% KOH test.

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• Cervical & vaginal fetal fibronectin:Detected when Fetal membrane

disruption occurs in :– Repetitive uterine activity or cervical

shortening.– Presence of infection.

• A positive fetal fibronectin test at 22 to 24 weeks predict more than half of the spontaneous preterm births that oocur before 28 weeks.

• Cervical & vaginal fetal fibronectin:Detected when Fetal membrane

disruption occurs in :– Repetitive uterine activity or cervical

shortening.– Presence of infection.

• A positive fetal fibronectin test at 22 to 24 weeks predict more than half of the spontaneous preterm births that oocur before 28 weeks.

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UltrasoundUltrasound

• To assess fetal weight.• To document presentation.• To assess cervical length.• To rule out the presence of

any congenetal malformations.

• To assess fetal weight.• To document presentation.• To assess cervical length.• To rule out the presence of

any congenetal malformations.

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Initial assessment :Initial assessment :• Hx &General examination .• Pelvic examination : 1-cervix evaluation ( length ,

effacement and dilatation) 2-presenting part and station .

• Utrine activity .• investigations for correctable

causes ( e.g. UTI , vaginal infection , chorioamnionitis ……. )

Initial assessment :Initial assessment :• Hx &General examination .• Pelvic examination : 1-cervix evaluation ( length ,

effacement and dilatation) 2-presenting part and station .

• Utrine activity .• investigations for correctable

causes ( e.g. UTI , vaginal infection , chorioamnionitis ……. )

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- During this assessment oral or IV fluid + bed rest should be started , as in 20 %20 % of the patients the uterine contractility cease .

• If the patient doesn'tdoesn't respond to bed rest and hydration , then tocolytictocolytic therapy should be initiated if there is no no contraindicationcontraindication to it .

- During this assessment oral or IV fluid + bed rest should be started , as in 20 %20 % of the patients the uterine contractility cease .

• If the patient doesn'tdoesn't respond to bed rest and hydration , then tocolytictocolytic therapy should be initiated if there is no no contraindicationcontraindication to it .

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Tocolytics :Tocolytics :1- Magnisum Sulfate .2- Nifidipine .3- prostaglandin synthetase

inhibitors

Tocolytics :Tocolytics :1- Magnisum Sulfate .2- Nifidipine .3- prostaglandin synthetase

inhibitors

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First :First : Magnisum Sulfate :

• Drug of choice for initiating tocolytic therapy .

• Mechanism of action :Mechanism of action : Act by competing with

calcium for entry into the cell during depolarization .

So , low calcium intracellular lead to muscle relaxation .

First :First : Magnisum Sulfate :

• Drug of choice for initiating tocolytic therapy .

• Mechanism of action :Mechanism of action : Act by competing with

calcium for entry into the cell during depolarization .

So , low calcium intracellular lead to muscle relaxation .

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• Side effect :Side effect :

Short term :Short term : For the mother :• Warmth & flush .• Respiratory distress at serum level of 12- 15

mg / dl • Cardic arrest at higher level

For the baby :• Decrease muscle tone • Drowsy • ( ….. and this can lead to low abgor score …..)

Long term :Long term :• Osteoporosis • Vertebral fracture ( As a prophylactic to these side effects we add

calcium supplement )

• Side effect :Side effect :

Short term :Short term : For the mother :• Warmth & flush .• Respiratory distress at serum level of 12- 15

mg / dl • Cardic arrest at higher level

For the baby :• Decrease muscle tone • Drowsy • ( ….. and this can lead to low abgor score …..)

Long term :Long term :• Osteoporosis • Vertebral fracture ( As a prophylactic to these side effects we add

calcium supplement )

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Second :Second : Nifidipine :• Very effective with less side

effects and gradually replace IV magnisum sulfate .

• Mechanism of action :Mechanism of action : Inhibit slow calcium infusion

during the action potential which lead to muscle relaxant .

Second :Second : Nifidipine :• Very effective with less side

effects and gradually replace IV magnisum sulfate .

• Mechanism of action :Mechanism of action : Inhibit slow calcium infusion

during the action potential which lead to muscle relaxant .

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Side effects :Side effects :• Flushing • Headache• Hypotension• Tachycardia( …. And the last 2 can be corrected by good hydration & TED hose stocking )

Side effects :Side effects :• Flushing • Headache• Hypotension• Tachycardia( …. And the last 2 can be corrected by good hydration & TED hose stocking )

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Third :Third : prostaglandin synthetase inhibitors :

Most commonly drug used is IndomethacinIndomethacin but it used for short term only due to:

• it's side effects• And short 1/2 life of

prostaglandin . ( for example it's used in

preterm lapor associated with fibroid )

Third :Third : prostaglandin synthetase inhibitors :

Most commonly drug used is IndomethacinIndomethacin but it used for short term only due to:

• it's side effects• And short 1/2 life of

prostaglandin . ( for example it's used in

preterm lapor associated with fibroid )

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Side effects :Side effects :• Oligohydraminos • Premature closure of PDA• Decrease renal function• Increase the risk of

necrotizing enterocolitis • Increase the risk of IVH .

Side effects :Side effects :• Oligohydraminos • Premature closure of PDA• Decrease renal function• Increase the risk of

necrotizing enterocolitis • Increase the risk of IVH .

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What is the efficacy of tocolytic What is the efficacy of tocolytic therapy in the management ??therapy in the management ??

Although the tocolytic agent has failed to decrease preterm birth in large population studies but it has an effect in :

• prolongation of the gestational age

• neonatal survival ( by decreasing the incidence of RDS and increasing the birth weight of the infant )

What is the efficacy of tocolytic What is the efficacy of tocolytic therapy in the management ??therapy in the management ??

Although the tocolytic agent has failed to decrease preterm birth in large population studies but it has an effect in :

• prolongation of the gestational age

• neonatal survival ( by decreasing the incidence of RDS and increasing the birth weight of the infant )

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what are the contraindications for what are the contraindications for tocolytics therapy ??tocolytics therapy ??

• severe preeclampsia .• severe bleeding from placenta

previa or abrubio .• chorioamnionitis .• IUGR.• fetal anomaly incompatible with life

• fetal demise .

what are the contraindications for what are the contraindications for tocolytics therapy ??tocolytics therapy ??

• severe preeclampsia .• severe bleeding from placenta

previa or abrubio .• chorioamnionitis .• IUGR.• fetal anomaly incompatible with life

• fetal demise .

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what are the role of : Antibiotics and Glucocorticoid ??

First :First : Antibiotics : It's found that 15 % of those who

have Idiopathic P.T.L , have colonizing of pathogens in the amniotic fluid .

So , it's reasonable to use prophylactic antibiotics to prevent further complications .

what are the role of : Antibiotics and Glucocorticoid ??

First :First : Antibiotics : It's found that 15 % of those who

have Idiopathic P.T.L , have colonizing of pathogens in the amniotic fluid .

So , it's reasonable to use prophylactic antibiotics to prevent further complications .

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Second :Second : Glucocorticoid :• It should be used in the

gestational age of 24 to 34 weeks to those at risk of P.T.L

To reduce :• mortality rate .• incidence of RDS• IVH Drugs :Drugs :• Betmethasone : 2 doses of 12 mg

given IM 24 h apart or • Dexamethazone : 4 doses of 6

mg givin IM 12 hours apart … the benefits begins 24 h after

initiation of therapy and last 7 days .

Second :Second : Glucocorticoid :• It should be used in the

gestational age of 24 to 34 weeks to those at risk of P.T.L

To reduce :• mortality rate .• incidence of RDS• IVH Drugs :Drugs :• Betmethasone : 2 doses of 12 mg

given IM 24 h apart or • Dexamethazone : 4 doses of 6

mg givin IM 12 hours apart … the benefits begins 24 h after

initiation of therapy and last 7 days .

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what if the patient does not respond to what if the patient does not respond to tocolytic therapy ??tocolytic therapy ??

some patients will not respond to tocolytics therapy so the goal in these patients to deliver the baby ( but not less than 24 weeks of gestation or 500 g due the viability )

• with vertex presentationwith vertex presentation , vginal delivary is preferred

• with breech presentationwith breech presentation , , neonatal outcome improved by cesarean section

what if the patient does not respond to what if the patient does not respond to tocolytic therapy ??tocolytic therapy ??

some patients will not respond to tocolytics therapy so the goal in these patients to deliver the baby ( but not less than 24 weeks of gestation or 500 g due the viability )

• with vertex presentationwith vertex presentation , vginal delivary is preferred

• with breech presentationwith breech presentation , , neonatal outcome improved by cesarean section

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