preterm labor. preterm termination of pregnancy abortion: …22 week of gestation abortion: …22...

Preterm laborPreterm labor

Preterm terminationPreterm termination of of pregnancypregnancy

• Abortion: …22 week of gestationAbortion: …22 week of gestation

• Premature labor [PTPremature labor [PTLL]:]:

23 – 36 week of gestation23 – 36 week of gestation

PretermPreterm laborlabor [PTL] [PTL]

• SpontaneousSpontaneous

• Iatrogenic Iatrogenic

(result of therapeutic (result of therapeutic intervention)intervention)

Preterm labor : definitionPreterm labor : definition

• Regular uterine contractionsRegular uterine contractions

• Cervical effacementCervical effacement

• Cervical dilation Cervical dilation

The earlier treatment The earlier treatment

the better results!the better results!

The earlier the gestational The earlier the gestational age age

the worse neonatal the worse neonatal outcomesoutcomes!!

Consequences of PTConsequences of PTLL

• Preterm birthPreterm birth

• Perinatal deathPerinatal death

• Neonatal complications:Neonatal complications:

- - Respiratory Distress Syndrome [RDS]Respiratory Distress Syndrome [RDS]

- Intraventricular hemorrhageIntraventricular hemorrhage

- Necrotizing enterocolitisNecrotizing enterocolitis

- SepsisSepsis

- SeizuresSeizures

Consequences of PTLConsequences of PTL

• Long-term morbidity: Long-term morbidity:

- BBronchopulmonary dysplasiaronchopulmonary dysplasia

- Cerebral palsyCerebral palsy

- Developmental abnormalitiesDevelopmental abnormalities

Etiology of PTLEtiology of PTL

• Idiopathic!Idiopathic!• Infections: local / generalizedInfections: local / generalized• Excessive uterine enlargement Excessive uterine enlargement

(hydramnios, multiple gestation)(hydramnios, multiple gestation)• Fetal congenital anomaliesFetal congenital anomalies• Incompetent cervixIncompetent cervix• Premature rupture of membranes Premature rupture of membranes

[PROM][PROM]• DehydrationDehydration• Uterine anatomical malformations Uterine anatomical malformations • Maternal smoking!Maternal smoking!

Symptoms and signs of PTLSymptoms and signs of PTL

• Uterine contractionsUterine contractions

• Abdominal / pelvic pressureAbdominal / pelvic pressure

• Low backacheLow backache

• Menstrual-like crampsMenstrual-like cramps

• Changes in vaginal discharge: Changes in vaginal discharge:

volume, consistence, blood contentvolume, consistence, blood content

Prevention of PTL?Prevention of PTL?

• Patient education to recognize signs Patient education to recognize signs and symptoms of PTLand symptoms of PTL

• Risk scoring programsRisk scoring programs

• Unfortunately:Unfortunately:

the frequency of PTL is stablethe frequency of PTL is stable

Evaluation of a patient in Evaluation of a patient in PTPTLL

1.1. Status of the cervix (dilation and Status of the cervix (dilation and effacement):effacement):

• SpeculumSpeculum

• Digital examinationDigital examination

2. Cervical culture2. Cervical culture

3. Contractions: 3. Contractions:

• Electronic fetal monitoring Electronic fetal monitoring (frequency and duration)(frequency and duration)

• Abdominal palpation (intensity)Abdominal palpation (intensity)

Evaluation of a patient in Evaluation of a patient in PTLPTL

• Ultrasound examination: gestational Ultrasound examination: gestational age of the fetus, fetal presentation, age of the fetus, fetal presentation, AFI, placental locationAFI, placental location

• Vaginal bleeding: volume, fresh / Vaginal bleeding: volume, fresh / dark blooddark blood (placenta (placenta previa? abruptio previa? abruptio placentae?)placentae?)

• Urine: analysis, cultureUrine: analysis, culture (infections) (infections)

Management of PTLManagement of PTL

• To delay delivery (until fetal To delay delivery (until fetal maturity)maturity)

1.1. Therapy of PTL itselfTherapy of PTL itself

2.2. Detection and treatment of Detection and treatment of disorders leading to PTL disorders leading to PTL

TocolysisTocolysis

• Def.: tDef.: the suppression of uterine he suppression of uterine contractions by pharmacologic contractions by pharmacologic treatmenttreatment

• One patient = one form of One patient = one form of ttocolysisocolysis

• Additions: if previous treatment is not Additions: if previous treatment is not effectiveeffective

• Start: 20 – 34 Start: 20 – 34 weeks of gestationweeks of gestation

• Remember to stop therapy! (36 weeks)Remember to stop therapy! (36 weeks)

• Still controversial: do tocolytics prolong Still controversial: do tocolytics prolong pregnancy?pregnancy?

Intravenous hydrationIntravenous hydration

1. 1. Compound electrolyte solution: Compound electrolyte solution:

1000 ml / 12 hours1000 ml / 12 hours

2. After 12 hours: reevaluation 2. After 12 hours: reevaluation

• Calcium-channel blockersCalcium-channel blockers (nifedidpine)(nifedidpine)

• QuitQuit therapy therapy

Calcium-channel blockers: Calcium-channel blockers: nifedipinenifedipine

• Loading dose: 3 x 10 mg in: 0` - 30 ` - Loading dose: 3 x 10 mg in: 0` - 30 ` - 60`60`

• Then:Then:

4 x 20 mg p.o. (every 6 hours)4 x 20 mg p.o. (every 6 hours)

• Potentiates effects of MgSOPotentiates effects of MgSO44

(hypotension! respiratory depression!)(hypotension! respiratory depression!)

Β-adrenergic agents: Β-adrenergic agents: fenoterolfenoterol

• 1 mg in 500 ml 0.9% NaCl1 mg in 500 ml 0.9% NaCl• Keep the inflow: 2.5 – 3.0 ug/min Keep the inflow: 2.5 – 3.0 ug/min

for 6 hoursfor 6 hours• Changes of inflow - dependent oChanges of inflow - dependent onn result result• Max. 48 hoursMax. 48 hours• Control: HR, blood pressure, glucose Control: HR, blood pressure, glucose

levels, ionslevels, ions • In effective inhibition of uterine In effective inhibition of uterine

contractions: convert to nifedipinecontractions: convert to nifedipine

Magnesium sulfate (MgSOMagnesium sulfate (MgSO44))

• Loading dose: 4 g in 20 ml 0.9% NaCl Loading dose: 4 g in 20 ml 0.9% NaCl i.v.i.v.

• 1st day: 8 g in 500 ml of compound 1st day: 8 g in 500 ml of compound electrolyte solution i.v. every 12 hours electrolyte solution i.v. every 12 hours (twice a day)(twice a day)

• 2nd day: 6 g in 500 ml of compound 2nd day: 6 g in 500 ml of compound electrolyte solution i.v. every 12 hourselectrolyte solution i.v. every 12 hours

• Total dose: 30 – 32 g of MgSOTotal dose: 30 – 32 g of MgSO44 • Control: magnesium levels!Control: magnesium levels!

Prostaglandin synthetase Prostaglandin synthetase inhibitors: inhibitors:

indomethacinindomethacin • Only in non- effectiveness of Only in non- effectiveness of

previously described tocolytics previously described tocolytics

• Between 28 and 32 weeks of gestationBetween 28 and 32 weeks of gestation

• 60 mg i.m. every 12 hours60 mg i.m. every 12 hours

• Max. dose: 300 mgMax. dose: 300 mg

• Ultrasound control: AFI, ductus Ultrasound control: AFI, ductus arteriosus blood flow (doppler)arteriosus blood flow (doppler)

SteroidsSteroids

• To enhance fetal pulmonary maturityTo enhance fetal pulmonary maturity

• 24 – 34 weeks of gestation24 – 34 weeks of gestation

• Betamethasone 2 x 12 mg i.m. with Betamethasone 2 x 12 mg i.m. with 12 hours interval12 hours interval

• Caution: steroids promote infections!Caution: steroids promote infections!

• Control: CRPControl: CRP, , glucose levelsglucose levels

General contraindications to General contraindications to tocolysistocolysis

• Advanced labor (cervical dilation > 4 Advanced labor (cervical dilation > 4 cm)cm)

• Mature fetus (>34 weeks of gestation)Mature fetus (>34 weeks of gestation)• Severely anomalous fetusSeverely anomalous fetus• Intrauterine fetal deathIntrauterine fetal death• Significant vaginal bleedingSignificant vaginal bleeding• Possibility of the adverse effects of Possibility of the adverse effects of

ttocolysisocolysis• Any complications contraindicating Any complications contraindicating

delay in deliverydelay in delivery