Management of Preterm labour in O&G.pptx

PTL

1. Management of Preterm Labour (PTL) By Dr Georges Tshimbalanga 24 March 2021

2. TABLE OF CONTENTS Introduction Definition Aetiology Predictors of PTL Pathophysiology Diagnosis Management Conclusion

3. 1. INTRODUCTION PTL continues to be one of the most serious problems in obstetrics, both medically and socioeconomically. it has been estimated that the incidence of PTL varies from 5% to 10% in most developed countries. After foetal anomalies, PTL is the leading cause of perinatal mortality, resulting in 70% of perinatal losses. Preterm delivery can be associated with immediate and long‐term neonatal complications, long‐term morbidity including mental retardation, cerebral palsy, seizure disorders , blindness, deafness and non neurologic disorders such as chronic pulmonary disease and retinopathy of prematurity .

4. The neonatal outcome is dependent on the gestational age at delivery and associated features such as infection. The lower the gestational age, the higher the risk of mortality and morbidity. The underlying physiology and molecular biology of PTL is complex and not yet fully understood. The causes are also diverse and multifactorial. This presentation will concentrate on the prediction, prevention and treatment of preterm labour and discuss the ways in which antenatal interventions can optimise the outcome for the fetus

5. 2. DEFINITION . Preterm labour is the onset of regular uterine contractions associated with progressive cervical change between viability (24 - 28 weeks) and before 37 completed weeks of gestation. 3.ETIOLOGY It is multifactorial High risk factors H istory Complication in present pregnancy Iatrogenic idiopathic

6. 3.1. History Previous history of induced or spontaneous abortion or preterm delivery. Recurrent urogenital tract infections, STDs,... Smoking habits Low socio-economic Increased emotional stress Pregnancy followed by assisted reproductive techniques .

7. 3.2. Complication in present pregnancy Maternal Hypertensive Disorder in Pregnancy PPROM APH Cervical incompetence Polyhydramnios Malformation of uterus ( Uni - or bicornuateuterus ) Urogenital tract infections, chronic infections and systemic infections associated with pyrexia,... DM Low BMI

8. Fetal complications: Multiple Pregnancy Congenital malformations IUFD Placental complications: Infraction Thrombosis Placenta previa Abruption placenta Marginal implantation of the umbilical cord

9. 3.3. Iatrogenic Induced preterm delivery due to medical or obstetric complication. 3.4. Idiopathic Premature effacement of the cervix Early engagement of the fetal head

10. 4. PREDICTORS OF PTL 4.1. Clinical predictors: Overdistension of uterus History of preterm birth Presence of GTI, UTI, Pyrexia as result of an infection Symptoms and signs of PTL: Uterine hyperactivity, Sensation of vaginal, rectal or perineal pressure, V aginal discharge, Development of lower uterine segment. If any of the above symptoms or signs are present, a vaginal examination should be done to assess the length, position, consistency of the cervix, as well as the state of the external and internal cervical os .

11. 4.2 . Biophysical predictors Uterine contraction > 4/hr Bishop score > 4 Cervical length < 2.5 cm 4.3 . Biochemical predictors Fetal fibronectine ( fFN ) in cervicovaginal discharge Cytokines (IL-6, IL-8, TNF- ἀ ) Salivary oestriol

12. 5. Pathophysiology

13. 6. DIAGNOSIS 6.1. Symptoms In patient with threatening PTL there is no progressive cervical change, but in case of confirmed PTL, cervical effacement and dilatation develop over a period of 2 to 4 hours, with regular and painful uterine contraction. 6.2 . Cervical change Dilatation: ≥ 2 cm Effacement: 80% of cervix Length of cervix ≤ 2.5 cm Funnelling of internal os

14. 6.3. Investigations FBC, CRP UMCS Cervical vaginal swab for culture and fetal fibronectine USG to assess fetal wellbeing and normality, cervical length, EFW, placental location, EGA,… CTG Serum Electrolytes and Glucose level when tocolytic agents are to be used.

15. 7. MANAGEMENT To prevent preterm onset of labour if possible To arrest PTL if not contraindicated Appropriate management of labour Effective neonatal care The main pharmacological considerations are whether to administer tocolytics , steroids or antibiotics.

16. 7.1. Prevention of PTL Interventions to prevent PTL can be divided into those that aim to prevent cervical dilatation ( cervical cerclage ) and those that aim to prevent the initiation of myometrial contractility (mainly detection and appropriate therapy of GTI,UTI, PET, Placenta previa , Polyhydramnios …) Identification of risk factor from history and employing measures to reduce the prevalence of adverse lifestyle and health activities in certain populations (nutritional supplement, avoidance of smoking, adequate rest…)

17. 7.2. Treatment GA ≥ 34 weeks or EFW ≥ 2 kg: Exclude and treat specific causes of PTL ( chorioamnionitis or other infections and abruptio placenta ) Admit to labour ward and manage labour as for term pregnancy : Left Lateral Position IV Fluid to maintain adequate hydration Urinary catheter Analgesic Continuous Fetomaternal monitoring

18. B. GA 26 – 33 + weeks or EFW 800 g – 1999 g: Admit the patient in a HC area Give 2 doses of steroid Run a CTG With evidence of pre- eclampsia , abruptio placenta or chorioamnionitis, allow labour to proceed with continuous CTG, or consider caesarean section If the cervix is > 6 cm dilated , allow labour to proceed If the cervix is <6 cm dilated , tocolyse the patient Deliver the baby slowly and gently, with an episiotomy if the perineum is tight

19. C. GA 24+ weeks or EFW 600 + g: Admit to labour ward Allow labour to proceed Give Steroid for 2 doses If the baby is born alive, transfer to the nursery for resuscitation D. GA ≤ 24 weeks, or EFW ≤ 600 g: Manage as an inevitable miscarriage Counsel the woman appropriately

20. 7.2.1. Antibiotics To prevent neonatal infection, especially with GBS, 12 hours after ROM. Ampicilline or Benzyl Penicilline IV Metronidazol IV 7.2.2. Glucocorticoids To reduce neonatal RDS, IVH and NEC Help fetal lung maturity ( choline-phosphotransferase induction ) Betamethasone 12 mg 12 hourly IM (PVL) or Dexamethasone 12 mg 12hourly IM

21. 7. 3.3. Tocolytics Inhibit uterine contraction, commonly used: Calcium channel Blockers ( Nifedipine , verapamil ) Prostaglandine synthesis inhibitor ( Indomethacine ) Mg So4 (competitive inhibition of calcium ions, with neuroprotective effects) Oxytocine recreptor antagonists: blocks myometrial oxytocin receptors( Atosiban ) Betamimetics ( Salbutamol , Terbutalin ): activation of intracellular adenyl - cyclase reducing so intracellular free calcium Nitric oxide ( smouth muscles relexant )

22. CONCLUSION PTL is a multifactorial condition associated with a high risk of morbidity and mortality, particularly at early gestational ages . Prevention is directed towards identification of women at risk and comprises screening and treatment for bacterial vaginosis , insertion of cerclage in appropriate women. The treatment of established PTL should be directed towards identifying those women in whom a delay in delivery is likely to be beneficial and those in whom it may be deleterious in terms of neonatal or infant outcome. Our recommendations are to treat threatening, uncomplicated PTL with a tocolytic to delay delivery for steroid administration and antibiotic where it is indicated and deliver the baby accordingly.

23. END Thanks

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