Preterm labour

Preterm labour - Definition , risk factors , Diagnosis , Investigation, management

1. Preterm labour - DR. SUPRIYA MAHIND

2. CONTENTS DEFINITION RISK FACTORS DIAGNOSIS INVESTIGATIONS PREDICTIONS AND PREVENTIONS TOCOLYTIC AGENTS MANAGEMENT PPROM (INTRODUCTION , DIAGNOSIS MANAGEMENT)

3. DEFINITIONS PRE TERM PREGNANCY DELIVERY BEFORE 37 WEEKS OF GESTSTION TERM PREGNANCY GESTATIONAL PERIOD FROM 37 TO 41 + 6 days WEEKS POST TERM PREGNANCY GESTATIONAL PERIOD FROM 42 WEEKS ONWARDS

4. PRETERM LABOUR Preterm labour is defined by WHO as onset of labour prior to the completion of 37 weeks of gestation , in a pregnancy beyond 20 weeks of gestation . Preterm labour is considered to be established if regular uterine contractions can be documented atleast 4 in 20 minutes or 8 in 60 minutes with progressive change in the cervical score in the form of effacement of 80% or more and cervical dilatation > 1 cm

5. This condition tends to be over diagnosed and over treated Nearly 50 – 60 % of preterm births occur following spontaneous labour 30% due to preterm premature rupture of membranes Rest are iatrogenic terminations for maternal or fetal benefit

6. PRETERM LABOUR Mildly preterm 32 – 36 weeks Very preterm 28 – 31 weeks Extremely preterm 24 – 27 weeks

7. AETIOLOGY INFECTIONS OVER – DISTENTION VASCULAR SURGICAL PROCEDURES AND INTERCURRENT ILLNESS ABNORMAL UTERINE CAVITY CERVICAL WEAKNESS IDIOPATHIC

8. RISK FACTORS NON MODIFIABLE ( MAJOR AND MINOR) MODIFIABLE

9. RISK FACTORS MAJOR NON MODIFIABLE Last birth preterm : 20% risk Last two birth preterm : 40% Twin pregnancy : 50% risk Uterine abnormalities Cervical anamolies Factors in current pregnancy

10. Non modifiable , minor Parity 0 or > 5 Ethnicity (black) Poor socioeconomic status Education Teenagers having second or subsequent babies

11. Modifiable Smoking : risk of PPROM Drug abuse : especially cocaine BMI < 20 Inter Pregnancy interval : < 1 year

12. DIAGNOSIS SYMPTOMS WITH CERVICAL WEAKNESS Increased vaginal discharge Mild abdominal pain Bulging membranes on examination SYMPTOMS WITH INFECTION , ABRUPTION Lower abdominal pain Painful uterine contraction

13. DIAGNOSTIC CRITERIA GESTATIONAL AGE : 24 - 37 WEEKS UTERINE CONTRACTIONS : ATLEAST 3 CONTRACTIOS IN 30 MINUTES CERVICAL CHANGE : CHANGE IN CERVICAL DILATATION OR 2 CM DILATED CERVIX

14. differential diagnosis UTI RED DEGENERATION OF FIBROID CONSTIPATION GASTOENTERITIS

15. DIAGNOSTIC APPROACH HISTORY EXAMINATIONS INVESTIGATIONS FBS CRP MID STREAM URINE SAMPLE ULTRASOUND TVS FETAL FIBRONECTIN

16. PREVENTION Treatment of Bacterial Vaginosis Cervical encirclage Selective reduction of pregnancy numbers Progesterone

17. PREDICTION Cervical length TVS improves diagnostic accuracy Normal length 35 mm In asymptomatic women with singleton pregnancy Cervix < 15 mm long : risk of delivering before 32 weeks is 4% Cervix less than 5 mm long : risk of delivering before 32 weeks is 78% In symptomatic women with singleton pregnancy Cervix < 15 mm long : risk of delivering within 7 days is 50% Cervix > 15 mm long : risk of delivery within 7 days is < 1 %

18. Fetal Fibronectin(fFn) – glue like protien at choriodecidual interface fFn test offers rapid assessment of risk in symptomatic women with minimal cervical dilatation fFn is protien not usually present in cervicovaginal secretions at 22 – 36 weeks fFn positive test indicates that women is likely to deliver fFn predicts preterm birth within 7 – 10 days of testing

19. TOCOLYTIC AGENTS AND STEROIDS Used to prevent labour and delivery May prolong pregnancy but not more than 72 hrs Useful for fetal lung maturity by maternal IM steroids Transportation of mother to a facility with neonatal intensive care

20. IMPORTANT TOCOLYTIC DRUGS TOCOLYTIC DRUGS SIDE EFFECTS Isoxsuprine (relaxes smooth muscles of the uterus) Nausea , vomiting , nervousness , Weakness , difficulty in breathing MAGNESIUM SULFATE Competitive inhibitors of calcium Overdose treated by IV ca gluconate Respiratory depression Muscle weakness Pulmonary edema Beta – Adrenergic agonist Terbutaline HTN and tachycardia Hypocalemia Hyperglycemia Calcium channel Blocker e.g. nifidipine Hypotension Myocardial depression Tachycardia

21. MATERNAL STEROIDS Reduces the rates of respiratory distress, intraventricular hemorrhage and neonatal death Given as IM injection two doses 12-24 hrs apart Maximum benefit is seen after 48 hrs [ Two doses of Inj . Betamethasone (12mg) 12 or 24 hrly ]

22. MANAGEMENT OF PRETERM LABOUR Confirm labour using three criteria listed above Rule out contraindications of tocolysis Administer IV line Start MgSO4 tocolysis with 5 gm IV for 20 min , then 2g/hr Adminster maternal IM betamethasone to stimulate type II pnumocyte

23. Clear plan about Mode of delivery Monitoring in labour Presence of pediatrician IV antibiotics in labour

24. PRETERM PRERUPTURE OF MEMBRANES (PPROM ) Rupture of fetal membranes occurring before 37 wks of gestation. It complicates about 3% of pregnancies and contributes to one third of preterm births

25. RISK FACTORS Ascending infection of lower genital tract – most common Multiple pregnancy Polyhydramnios Antepartum hemorrhage Placental abruption Cervical weakness Idiopathic

26. Diagnosis of PPROM History of sudden escape of watery amniotic fluid Oligohydramnios on Ultrasound Pooling of amniotic fluid in posterior vagina A sterile speculum examination confirms that the fluid is coming through the os Nitrazine test : turns blue from yellow if amniotic fluid leak Fern test Ultrasound examination shows oligohydramnios

27. DIFFERENTIAL DIAGNOSIS It needs to be differentiated from stress urinery incontinence And profuse normal vaginal discharge UTI Vaginal infection

28. Management of PPROM Correct and prompt diagnosis is imperative for optimum management PPROM remote from term : conservative management is advisable , provided acute cord complications like prolapse and compression , placental abruption and fetal distress have been excluded . Oligohydramnios is non an indication Antibiotics : help to prolong latency and improve perinatal outcomes Corticosteroids : should be given to patients between 24 and 34 weeks of gestation

29. PPROM nearer to term ( 34 -36 wks) It is preferable to induce labour unless fetal lung maturity or gestational age is doubtful.

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