persentasi preterm labor - show

Preterm Labour

Preterm Birth

Medical Paper Presentation

Aditiawan, Fitriyani

OBSTETRICS AND GYNECOLOGY CLERKSHIP

TARUMANAGARA UNIVERSITY

RSUD CIAWI, BOGOR

Period February 2nd 2015 - April 11st 2015

Definition

Preterm labor is defined as the presence of contractions of sufficient strength and frequency to effect progressive effacement and dilatation of the cervix between 20 and 37 weeks gestation

(Williams Obstetric, 24ed)

Incidence

Overall incidence of PTL : 6 % - 10 %

Spontaneous : 40 50 %

PROM : 25 40 %

Obstetrically indicated : 20 25 %

(Slattery and Morrison 2002 )

Survival in Premature Infants

26 wks 80%

27 wks 90%

28-31 wks 90 to 95%

32-33 wks 95%

34-36 wks approaches term survival rates

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Complications of Prematurity

RDS

Intraventricular Hemorrhage of the new born

Necrotizing enterocolitis

Apnea

PDA

Infection

Jaundice

Hypothermia

Neurobehavioral

Anemia

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Risk Factors

I-Maternal factors :

Previous preterm delivery .

Low socioeconomic status .

Maternal age 40 years .

Preterm premature rupture of the membranes .

Multiple gestation .

second-trimester abortions .

Maternal complications (medical or obstetric) .

Lack of prenatal care .

Smoking. (Murphy.2007)

Risk Factors

II-Uterine causes :

Uterine septum .

Bicornuate uterus .

Cervical incompetence .

III-Fetal causes :

Intrauterine fetal death .

Intrauterine growth retardation .

Congenital anomalies .

IV-Placental causes :

Abnormal placentation (Murphy.2007)

Risk Factors

V- Infectious factors :

Genital :

* Bacterial vaginosis (BV) * Chlamydia

* Group B streptococcus * Mycoplasmas

Intra-uterine :

* Ascending (from genital tract)

* Transplacental (blood-borne)

* Transfallopian (intraperitoneal)

* Iatrogenic (invasive procedures)

Extra-uterine :

* Malaria

* Typhoid fever * Pneumonia

* Listeria * Asymptomatic bacteriuria

(Jane Norman.2005)

The Challenge: Identification

Labor = regular, painful uterine contractions that produce cervical dilation and/or effacement

Uterine contractions are seen in normal pregnancies at early gestational ages

Up to 50% of women hospitalized for PTL go on to deliver at term

9

Prediction of preterm labor

1. Risk factors .

2. Cervical ultrasonography (Cx. Length assessment) .

3. Salivary estriol .

4. Screening for bacterial vaginosis (BV) .

5. Screening for fetal fibronectin (fFN) .

( Edwin and Sabaratnam. 2005)

Fetal Fibronectin

99% negative predictive value for delivery within 2 wks

Positive predictive value worse, about 30%

22 to 35 weeks

Sample collection issues

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Fetal fibronectin testing

Sample :

from the posterior fornix of the vagina

Indications:

1- Symptomatic preterm labour 24 - 36 weeks

2- Intact membranes and

3- Cervical dilatation less than 3 cm

Contraindications:

1- Ruptured membranes 2- Vaginal bleeding

3- Cervical cerclage insitu

Relative Contraindications:

1- After the use of lubricants or disinfectants

2- Within 24 hours of coitus or vaginal examination

(The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2008)

Prevention of premature labor

Primary prevention :

Aim :

lower the prevalence of premature labor by improving maternal health in general and by avoiding risk factors before or during pregnancy

Measures :

1- Smoking cessation .

2- Nutritional counseling .

3- lower workload for women with stressful jobs

( Flood and Malone ,2012 )

Prevention of premature labor

Secondary prevention :

Aim :

Early identification of pregnant women at a risk of preterm labor and helped them to carry their pregnancies to term.

Measures :

1- Self-measurement of the vaginal pH for B.V. (Bitzer.,et al.2011)

2- Cervix length measurement by TVS . ( Crane and hutchens ,2008)

(The accepted cutoff value for cervix length is 25 before GW 24 )

3- Cerclage and complete closure of the birth canal (Berghella.,et al.2011 )

4- Progesterone supplementation . ( Romero.,etal.2012)

Assessment and management of PTL

Secondary prevention :

Aim :

Early identification of pregnant women at a risk of preterm labor and helped them to carry their pregnancies to term.

Measures :

1- Self-measurement of the vaginal pH for B.V.

2- Cervix length measurement by TVS .

(The accepted cutoff value for cervix length is 25 before GW 24 )

3- Cerclage and complete closure of the birth canal

4- Progesterone supplementation

Queensland Maternity and Neonatal Clinical Guideline (2009)

Treatment of premature labor

Inhibition of uterine contractions with tocolysis

Corticosteroids to induce fetal lung maturation

Treatment of infection with antibiotics

Bed rest and hospitalization.

(Schleuner.2013)

Goals of Treatment of PTL

Tocolysis often halts contractions only temporarily

Allow 48 hr+ for steroids to be given

Allow for transport to delivery location with NICU capability

Allow for correction of reversible causes

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Tocolysis

Aim of tocolysis :

Suppress uterine contractions and delay preterm delivery to :

1-allow in-utero transfer to an appropriate level facility .

2-allow for the administration of corticosteroids.

(King .,et al.2003)

Tocolysis

Contraindications :

Gestation > 34 weeks

Labour is too advanced

In utero fetal death

Lethal fetal anomalies

Suspected fetal compromise

Placental abruption

Suspected intra-uterine infection

Maternal hypotension: BP < 90 mmHg systolic

Relative contraindications :

pre-eclampsia . Multiple pregnancy

placenta praevia . Rupture of membrane

(Di Renzo et al., 2007)

c

Tocolysis

Tocolytic drugs that are used in clinical practice

Calcium antagonists . ( Nifedipine )

Oxytocin-receptor antagonists . ( Atosiban )

Inhibitors of prostaglandin synthesis . ( Indomethacin )

NO donors . ( Nitroglycerin)

Betamimetics . ( Terbutaline & Ritodrine )

Magnesium sulfate . ( MgSO4 )

Tocolysis

(Schleuner 2013)

Mechanisms of action of tocolytic drugs

Calcium channel blockers (Nifedipine)

Dosage and administration :

30 mg loading dose,|then 1020 mg every 46 h.

Contraindications :

. Cardiac disease . . Renal disease .

. Maternal hypotension (< 90/50 mm Hg) .

. Avoid concomitant use with magnesium sulphate .

Maternal side effects :

. Flushing, headache . . Nausea .

. Transient hypotension . . Transient tachycardia .

Fetal and neonatal side effects :

. Sudden fetal death . . Fetal distress .

(Conde et al.,2011)

Atosiban (Tractocile)


Initial bolus dose 6.75 mg over one minute, followed by an

Infusion of 18 mg/h for 3 h and then 6 mg/h for up to 45 h.

Contraindications :

. None .


. Nausea .

. Allergic reaction .

. Headache .


. None

( De Heus et al.,2009 )

Prostaglandin synthetase inhibitors( Indomethacin )


loading dose of 50 mg rectally or 50-100 mg orally, then

25-50 mg orally every 6 hr 48 hr.

Contraindications :

. Renal or Hepatic impairment


. Nausea, heartburn gastritis . Renal impairment function

. Increased PPHge . Headache, dizziness


. Constriction of ductus arterious . Pulmonaryhypertension

. Oligohydramnios, . Intraventricularhemorrhage

. Hyperbilirubinemia, . Necrotizing enterocolitis

( Haas et al.,2009 )

Nitric oxide donors


10 mg patch for every 12 hr continuing until contraction

cease up to 48 hours

Contraindications :

. Headache


. Headache .

. Hypotension .


. Neonatal hypotension

( Smith et al.,2007 )

Betamimetics


1-Terbutaline 0.25 mg subcutaneously every 20 min. to 3 hr .

2-Ritodrine initial dose of 50-100 g/min i.v., increase 50 g/min

every 10 min until contractions cease or side effects develop,

maximum dose = 350 g/min

Contraindications :

. Uncontrolled thyroid desease, & diabetes mellitus

. Cardiac arrythmias (Anotayanonth et al.,2010 )


. Hypokalemia . Hyperglycemia . Hypotension

. Pulmonary edema . Arrhythmias . Myocardial ischemia


. Tachycardia. . Hyperinsulinemia . Hyperglycemia

Magnesium sulfate


Loading dose: 4g MgSO4 as a SLOW BOLUS over 15-30 minutes

Maintenance dose: 1g/hr. for 24/hr.

( Stop infusion if: RR

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