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CH11 Preterm Labor
CH11 Preterm Labor
CH11 Preterm Labor
International
Preterm Labor
Preterm Labor
International
Objectives
Definition and Incidence
Etiology
Diagnosis
Management
- Delaying delivery
- Promoting fetal maturity
- When to transfer
- Delivery
Preterm Labor
International
Definition
regular uterine contractions accompanied by
progressive cervical dilatation and/or
effacement at less than 37 weeks gestation
20 to 50% of PTL diagnosis is incorrect
Preterm Labor
International
Dilemma
interventions to stop preterm labor are not
particularly effective - especially when not
instituted early
'Solution'
diagnosis based on some degree of uterine activity
combined with a single cervical exam suggesting
early dilatation or effacement
Preterm Labor
International
Diagnosis
establish dates
history of contractions, risk factors
abdominal exam for uterine activity
cervical exam - serial if reasonable
sterile speculum exam alone should be done in PPROM
defer digital exam if there is undiagnosed vaginal
bleeding until _______ of placenta is known
Preterm Labor
International
Preterm Labor
International
Preterm Labor
International
Preterm Labor
International
Incidence
preterm delivery occurs in about 7% of pregnancies
there has been little change in this rate despite new
technologies
Preterm Labor
International
Significance
preterm birth accounts for 75% of perinatal mortality
significant longterm neonatal/pediatric sequelae
- CNS and neurodevelopmental
- respiratory
- blindness and deafness
Preterm Labor
International
Etiology
Idiopathic
Antepartum haemorrhage
Preterm prelabor rupture of membranes
Chorioamnionitis
Multiple pregnancy / Polyhydramnios
Incompetent cervix / Uterine Anomaly
Maternal disease
Fetal anomaly
Preterm Labor
International
Preterm Labor
International
Management - Prolongation of
Pregnancy
Preterm Labor
International
Preterm Labor
International
Preterm Labor
International
Preterm Labor
International
Preterm Labor
International
Preterm Labor
International
Contraindications to -mimetics
Maternal cardiac disease - structural, ischemic, rhythm
Significant antepartum haemorrhage
Poorly controlled medical condition
- type I diabetes mellitus
- hyperthyroidism
Contraindication to prolongation of pregnancy
- preeclampsia or other medical indication
- chorioamnionitis, suspected fetal compromise
- mature fetus / imminent delivery / IUFD or anomaly
Preterm Labor
International
Preterm Labor
International
Preterm Labor
International
1
10
Odds Ratio (95% Confidence Interval)
Preterm Labor
International
Recommendations
Which steroid ?
betamethasone 12 mg IM q 24h x 2 doses (or q 12h)
dexamethasone 6 mg IV q 12h x 4 doses (or q 6h)
Beware
steroids in the presence of infection
steroids in combination with tocolytics in multiple
gestation or diabetes
Preterm Labor
International
Recommendations
When should steroid therapy be instituted?
lower gestation limit
22 - 24 weeks
34 - 36 weeks
prophylactic administration
depends on
diagnosis and risk
repeated administration
unknown
Preterm Labor
International
Recommendations
Who is a candidate for antenatal steroid therapy?
preterm labour
preterm PROM
hypertensives
diabetics
IUGR
multiple gestation
YES
YES
YES
YES
YES
YES
Considerations
cause
infection
urgency
type, sugars
urgency
pulmonary edema
Preterm Labor
International
Decision to Transport
Available level of neonatal or obstetrical care
Available transport and skilled personnel
Travel time
Risk of journey - maternal and fetal/neonatal well-being
Risk of delivery en route
- Parity, length of previous labour
- State of cervix
- Contractions
- Response to tocolytics
Preterm Labor
International
Transport Plan
Copies of antenatal forms, lab results, ultrasounds
Communication
- with patient and family
- with receiving physician re: indication, stabilization,
optimization, mode of transport, E.T.A.
Appropriate attendant
IV access, indicated medications, appropriate equipment
Assess patient immediately prior to transport
Preterm Labor
International
Preterm Delivery
caesarean not indicated on basis of prematurity
recommendation for C/S of breech < 31 weeks not
based on good evidence
prophylactic outlet forceps not indicated
routine episiotomy not indicated
personnel skilled in neonatal resuscitation present
Preterm Labor
International
Conclusion
Prompt and accurate diagnosis
Identify and treat underlying cause if possible
Attempt to prolong pregnancy if appropriate
Intervene to minimize neonatal mortality and morbidity
- antenatal steroid therapy
- maternal transport
- optimize local resources if unable to transport
Preterm Labor
International
Preterm Labor
International
Objectives
Definition
Diagnosis
Management - Preterm and Term
Preterm Labor
International
Definition
rupture of the membranes before the onset of labor
preterm - < 37 weeks gestation (PPROM)
term
- 37 weeks gestation (TPROM)
Preterm Labor
International
Latent Period
time from rupture until onset of labor
earlier the gestation the longer the latent period
At term - 90% go into labor within 24 hours
At 28 - 34 weeks
50% go into labor within 24 hours
80 - 90% go into labor within 1 week
Preterm Labor
International
Etiology of PROM
idiopathic
infection (e.g. bacterial vaginosis)
polyhydramnios
cervical incompetence
uterine abnormality
following cervical cerclage or amniocentesis
trauma
Preterm Labor
International
Diagnosis of PROM
history
sterile speculum exam ( avoid digital exam)
glistening, washed out vagina
fluid pooling in posterior fornix
free flow from cervix
pH testing of fluid (nitrazine paper) - non specific
ferning
ultrasound - PROM less likely if normal fluid volume
Preterm Labor
International
Preterm Labor
International
Preterm Labor
International
Management - General
assess maternal and fetal well-being
confirm diagnosis
assess cervical status by speculum exam (sterile)
avoid digital cervical exam
assess for conditions requiring concurrent management
e.g.
fetal tachycardia
assess for indications for immediate delivery
Preterm Labor
International
Preterm Labor
International
Preterm Labor
International
Preterm Labor
International