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Subject:PTL Dr shakeri

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Preterm labor Important cause of perinatal mortality & morbidity 50 % of all major neurologic handicaps

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Increased in survival Use of C.S Regionalization prenatal care Improved method of mechanical ventilation Use of surfactant Improved nutritional therapy

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Mechanism of labor onset Hormonal (progestron withdrawal) Oxytocin Prostaglandins Cytokines IL.1-IL.6-TNF ( stimulate the amnion and decidua to produce PG) B-TGF ( inhibit PG production) Other factors endothelin nitric oxide (NOS)

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Infection as a cause of preterm labor Linked with symtomatic nongenital infection Subclinical Infection an important cause of PTL a- Histologic chorioamnionitis increased b- recognized infections in mother and neonates c- sepsis and meningitis are increased 3 to 10 fold d- positive culture of amniotic fluid/membrane/decidua 3-24% (

Fetal fibronectin presence 20-34 w strongly associated with PTL Sensitivity is low Specificity is high Used to women with intact membrane, cervical dilation less than 3 cm,GA 24-34 w results should be available within 24h False positive (recent intercourse-vaginal examination presence of B.V -vaginal bleeding) >50 ng positive test

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All of these tests fail to meet the goals of an ideal screening test

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Preterm labor defined uterin contractions >4 contractions per 20 minutes Cervical dilation 2cm or more in N..P 3cm or more in M.P Cervical effacement > 80% Uterin contraction and cervical change

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treatment Hormonal treatment Alcohol treatment Bmimetics Mgso4 Antiprostaglandin agents Oxytocin analogs Ca channel blockers

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Absolute CI of tocolytic theraphy Severe preeclampsia Severe abruptio Severe bleeding Frank chorioamnionitis Fetal death Fetal anomaly incompatible with live Severe FGR Mature lung Maternal cardiac arrythmia

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Relative CI to tocolytic therapy Mild chronic hypertension Mild abruptio Stable previa Maternal cardiac disease Hyper thyroidism Uncontrolled diabetes Fetal distress Fetal anomaly Mild IUGR Cervix dilatation greater than 4 cm

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B - adrenergic agonists The most wildly prescribed Ritodrined and terbutaline (SC-IV) Disadvantage - side effect(none of them are completely B2 selective ( Negative B2 effect Maternal hypotension Decreased u.o.p increased glucose secretion Hypokalemia Pulmonary edema

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Negative B1 effect Tachycardia Palpitation Constipation Decreased gastric emptying Hypokalemia Agitation jilleriness

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Severe maternal adverse effect Cardiac arrhythmia Myocardial infraction Pulmonary edema Postpartum cardiomyopathy death

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Fetal effect Tachycardia Increased C.O.P Redistribution of blood flow Increased thickness of inter ventricular septum Neonatal supra ventricular tachycardia Myocardial ischemia and necrosis hydrops Hypoglycemia Intra ventricular hemorrhage

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Are B-mimetics efficacious?

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Magnesium sulfate In recent years, tocolytic of choice in many delivery units Protocol of administration The blood levels of 6-8mg/dl are optimal for tocolysis

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Maternal side effect Common (flushing-sense of warmth-headache nystagmus-nausea-dizziness-lethargy) Serious (pulmonary edema-neuromuscular blockage- osteopenia-respiratory depression-cardiac arrest)

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Neonatal side effect Respiratory depession Decreased beat to beat variability Decreased muscle tone Drowsiness Depression Poor respiratory effort Low apgar score

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Is mgso4 ?efficacious

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Ca channel blocker Mechanism Protocol of Ad Maternal side effect Decrease in mean arterial pressure Symptomatic hypotension Nausea-headache-facial flushing

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Neonatal side effect Well tolerated by the fetus Neonatal heart block Growth restriction, acidosis, stillbirth No protocol established the safety of using these medication together

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Prostaglandin synthesis inhibitors Mechanism Protocol of Ad Fetal CI Growth restriction Renal anomaly Oligohydramnios Chorioamnionitis Ductal dependant cardiac lesion Twin to twin transfusion syndrom

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Maternal CI Renal and hepatic D Active peptic ulcer Poorly control H.T Asthma in aspirin-sensitive patients Coagulation disorder Maternal side effect GI upset and hemorrhage Alteration in coagulation Thrombocytopenia Asthma in aspirin-sensitive patients Renal injury(prolonged treatment)

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Neonatal side effect Constriction of ductus arteriosus Neonatal PHT 5-10% Oligohydraminous increased ADH direct effect on renal blood flow Necrotizing enterocolitis Intraventricular hemorrhage

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Effective agent that is well tolerated by mother and fetus Indomethacin to be comparable to ritodrine and MgSo4 Exposure should be limited to 48 hrs and G.A less than 32 weeks

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Other tocolytic agents Atosiban (analog oxytocin) Nitroglycerin Cyclo-oxygenase inhibitor Progestin Nitroxide inhibitor

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Maintenance tocolysis following arrest of PTL Oral tocolysis with B-mimetic Continous subcutaneous administration of terbutalin Oral MgSO4 Oral nifedipine Long-term tocolysis with prostaglandin synthetases inhibitors is contraindicated

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Maintenance tocolytic agent .

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Ancillary therapy for women in PTL Antibiotic therapy Antibiotic therapy in PTL with intact membrane is not indicated GBS prophylaxis should be administered Hydration therapy Bed rest C.S (all women at risk for PTL prior to 34 weeks receive C.S

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Key points 1. The rate of PTL is increasing in the united states. 2. fFN and vaginal ultrasound of cervix and promising technologies to identify women at risk for preterm delivery. 3. Screening for B.V and T.Vaginal is not indicated. 4. Management of women with asymptomatic shortening of the cervix controversial 5. Tocolytic therapy has not been associated with improvements in neonatal outcome. 6. Weekly courses of antenatal C.S should not be routinely prescribed. 7. Antenatal progesteron therapy may reduce the risk of preterm birth (PTB) and low birth weight (LBW) in women with previous PTB

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