Preterm Labour and Premature Rupture of Membranes <ul><li>Date : 17.04.2009 </li></ul><ul><li>Dr. Pradeep Kumar Garg </l...
Preterm Labour (PTL) <ul><li>Definition </li></ul><ul><li>WHO : Regular contractions associated with cervical changes </li...
Definitions <ul><li>Preterm (or premature) infant </li></ul><ul><ul><li>Infant born before 37 completed weeks of gestation...
Magnitude of the Problem <ul><li>The infant mortality rate for very preterm infants (delivered < 32 weeks of gestation) is...
Pathways to Preterm labour proteases PT L Uterine Contractions Cervical Change • Infection: - Chorion-Decidual - Systemi...
History of previous preterm birth Primary risk for a preterm delivery in multiparas is a history of previous preterm birth...
<ul><li>Causes </li></ul><ul><li>Maternal </li></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Acute pyelonephritis </li...
<ul><li>Uterine anomalies </li></ul><ul><ul><li>Cervical incompetence </li></ul></ul><ul><ul><li>Malformation of uterus </...
INFECTION … <ul><li>ASCENDING INTRAUTERINE INFECTION IS CONSIDERED TO HAVE FOUR STAGES </li></ul><ul><li>The first stage ...
<ul><li>Risk Factors </li></ul><ul><li>Non white race </li></ul><ul><li>Previous preterm delivery </li></ul><ul><li>Low b...
How do we identify who is at Risk? Preterm Birth Risk Factors Cervical Length Fetal Fibronectin Symptoms of PTL
<ul><li>THE PAPIERNIK-BERKHAUER(1969)SCORING MATRIX </li></ul><ul><li>MODIFIED BY GONIK –CREASY (1980-1986) </li></ul>0-5:...
<ul><li>Signs / Symptoms </li></ul><ul><li>Persistent contractions (painful or painless) associated with cervical changes ...
<ul><li>Biological markers for predicting PTL </li></ul><ul><li>Fetal fibronectin </li></ul><ul><ul><li>Glycoprotein produ...
Fetal fibronectin (cont) <ul><li>False positive : bleeding, ruptured membranes and digital cervical exam </li></ul><ul><l...
<ul><li>Biological markers for predicting PTL (contd…) </li></ul><ul><li>Salivary estriol </li></ul><ul><ul><li>Maternal l...
<ul><li>CRH </li></ul><ul><ul><li>Source placenta and fetal membranes; highest in T3. </li></ul></ul><ul><ul><li>RR 3.3 at...
<ul><li>Cervical length (CL) </li></ul><ul><li>Risk of PTD increases if CL is 30mm or less at 24 weeks, </li></ul><ul><li...
<ul><li>TransaAdominal USG of Cx is inadequate </li></ul><ul><li>1.fetal can obscure the Cx especially after 20 weeks </li...
 
<ul><li>Infection </li></ul><ul><ul><li>Ureoplasma </li></ul></ul><ul><ul><li>Gonorrhoea </li></ul></ul><ul><ul><li>Chlamy...
<ul><li>Bacterial vaginosis </li></ul><ul><ul><li>Bacterial vaginosis is an alteration of the normal vaginal flora, reduct...
<ul><li>Bacterial vaginosis: </li></ul><ul><ul><li>two fold risk of PTB </li></ul></ul><ul><ul><li>Cochrane meta-analysis...
<ul><li>Multiple pregnancy </li></ul><ul><li>PTL occurs in 50% of twins </li></ul><ul><li>76% triplets </li></ul><ul><li>9...
<ul><li>Treatment of PTL </li></ul><ul><li>WHY? </li></ul><ul><ul><li>To prevent complication of prematurity </li></ul></u...
Prevention/Intervention Strategies Tocolytics Education Targeting High Risk Women Bedrest Home Uterine Monitoring Frequent...
<ul><li>Prevention of PTB </li></ul><ul><li>Primary Prevention </li></ul><ul><li>1.improve quality of life and nutritional...
<ul><li>Secondary prevention </li></ul><ul><li>1.cerclage </li></ul><ul><li>2.antibiotics </li></ul><ul><li>3.tocolysis </...
<ul><li>Prophylactic therapy like bed rest, hydration and sedation in asymptomatic women at increased risk for preterm del...
<ul><li>Progesterone therapy to prevent PTL </li></ul><ul><ul><li>decrease in myometrial progesterone receptor with PTL a...
<ul><li>Cervical Cerclage </li></ul><ul><li>RCOG study concluded that 96% of elective cerclages were unnecessary,with no p...
<ul><li>Cervical cerclage cont. </li></ul><ul><ul><li>high risk patients screened 1 to 4 weekly between 16 and 24 weeks </...
<ul><li>Cervical cerclage cont. </li></ul><ul><li>Adjuntive treatment </li></ul><ul><ul><li>Antibiotics: multiple urogen...
<ul><li>Cerclage in Multifetal pregnancy : no evidence to support use of elective, urgent, emergent cerclage </li></ul><ul...
<ul><li>Infection and preterm birth </li></ul><ul><ul><li>50% of PTB associated with ascending genital tract infection eg....
<ul><li>Treatment of infections </li></ul><ul><ul><li>antibiotics should not be given routinely in PTL with intact membra...
<ul><li>Tocolytics in PRL </li></ul><ul><li>1. beta agonist </li></ul><ul><li>2. magnesium sulphate </li></ul><ul><li>3. a...
<ul><li>Betamimetic </li></ul><ul><li>MOA : b2 activator </li></ul><ul><li>Terbutaline 0.25mg s/c every 20 min to 3 hrs </...
<ul><li>Magnesium sulphate </li></ul><ul><li>MOA : calcium antagonist; </li></ul><ul><ul><li>Inhibits calcium refluxat cel...
<ul><li>Calcium channel blockers </li></ul><ul><li>Blocking Voltage dependent L-type calcium channels in smooth muscles; ...
<ul><li>Antiprostaglandin drugs </li></ul><ul><ul><li>inhibit prostaglandin synthetase or cyclooxygenase (COX) </li></ul...
<ul><li>Prostaglandin synthetase inhibitors </li></ul><ul><li>Indomethacin 50mg rectally or 50-100 mg orally, 25-50mg eve...
<ul><li>Summary </li></ul><ul><li>Although tocolytics may prolong pregnancy they don’t improve perinatal outcomes, but do ...
<ul><li>Antenatal corticosteroids </li></ul><ul><li>All fetuses between 24 – 34 wks POG at risk of preterm delivery should...
<ul><li>Until data establish a favorable benefit-to-risk ratio,repeat courses of steroids including rescue therapy should ...
<ul><li>Conduct of Delivery </li></ul><ul><li>Tertiary care centre, specialized staff </li></ul><ul><li>Cesarean delivery ...
<ul><li>Preterm Premature Rupture of Membranes </li></ul><ul><li>Risk factors </li></ul><ul><ul><li>SES </li></ul></ul><ul...
<ul><li>Complications </li></ul><ul><li>Maternal infection </li></ul><ul><li>Abruptio </li></ul><ul><li>Prematurity </li><...
<ul><li>Management </li></ul><ul><li>Diagnosis </li></ul><ul><ul><li>Speculum examination </li></ul></ul><ul><ul><li>Nitra...
<ul><li>Maternal infection </li></ul><ul><li>Fever, uterine tenderness, fetal or maternal tachycardia, foul smelling, vagi...
<ul><li>For queries mail me at </li></ul><ul><li>[email_address] </li></ul>
<ul><li>To see laparoscopic surgeries in Gynae logon to </li></ul><ul><li>www.youtube.com </li></ul><ul><li>and </li></...
Thank you
of 53

Preterm Labour and Premature Rupture of Membranes

Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Preterm Labour and Premature Rupture of Membranes

  • 1. Preterm Labour and Premature Rupture of Membranes <ul><li>Date : 17.04.2009 </li></ul><ul><li>Dr. Pradeep Kumar Garg </li></ul><ul><li>Assistant Professor </li></ul><ul><li>Department of Obstetrics and Gynaecology </li></ul><ul><li>All India Institute of Medical Sciences </li></ul><ul><li>New Delhi </li></ul><ul><li>Email:pkgarg_in2004@yahoo.com </li></ul>
  • 2. Preterm Labour (PTL) <ul><li>Definition </li></ul><ul><li>WHO : Regular contractions associated with cervical changes </li></ul><ul><ul><li><37->20 weeks of pregnancy </li></ul></ul><ul><li>Incidence - 8-10% </li></ul><ul><ul><li>60% of all neonatal mortality </li></ul></ul><ul><li>Threatened PTL - presence of uterine contractions in absence of cervical changes. </li></ul>
  • 3. Definitions <ul><li>Preterm (or premature) infant </li></ul><ul><ul><li>Infant born before 37 completed weeks of gestation </li></ul></ul><ul><li>Moderately preterm infant </li></ul><ul><ul><li>Infant born between 32 and 36 completed weeks of gestation </li></ul></ul><ul><li>Very preterm infant </li></ul><ul><ul><li>Infant born before 32 completed weeks of gestation </li></ul></ul>
  • 4. Magnitude of the Problem <ul><li>The infant mortality rate for very preterm infants (delivered < 32 weeks of gestation) is nearly 75 times the rate for infants born at term </li></ul><ul><li>20% all infants born <32 weeks do not survive the first year of life </li></ul><ul><li>Preterm birth is directly responsible for 75–90% of all neonatal deaths that are caused by lethal congenital malformations. </li></ul>
  • 5. Pathways to Preterm labour proteases PT L Uterine Contractions Cervical Change • Infection: - Chorion-Decidual - Systemic Decidual Hemorrhage CRH E1-E3 Thrombin Thrombin Rc Pathological Uterine Distention • Multifetal Pregnancy • Polyhydramnios • Uterine Abnormality Inflammation • Maternal-Fetal Stress • Premature Onset of Physiologic Initiators Activation of Maternal-Fetal HPA Axis CRH + Chorion Decidua uterotonins Mechanical Stretch Gap jct PG synthase Oxt recep PPROM Ils, Fas L TNF + Abruption Source: Lockwood CL. Unpublished data, 2002.
  • 6. History of previous preterm birth Primary risk for a preterm delivery in multiparas is a history of previous preterm birth (relative risk [RR] 2.62) Mercer BM,Am J Obstet Gynecol. 1999;181:1261–1221 Evaluation of the literature shows that history of a previous preterm delivery is consistently the most important risk factor for subsequent preterm birth.
  • 7. <ul><li>Causes </li></ul><ul><li>Maternal </li></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Acute pyelonephritis </li></ul></ul><ul><ul><li>Acute appendicitis </li></ul></ul><ul><ul><li>Abdominal operation </li></ul></ul><ul><li>Chronic disease </li></ul><ul><ul><li>Hypertension, nephritis, diabetes, severe anemia, decompensated heart disease </li></ul></ul><ul><li>Pregnancy complications </li></ul><ul><ul><li>Pregnancy induced hypertension </li></ul></ul><ul><ul><li>Antepartum hemorrhage </li></ul></ul>
  • 8. <ul><li>Uterine anomalies </li></ul><ul><ul><li>Cervical incompetence </li></ul></ul><ul><ul><li>Malformation of uterus </li></ul></ul><ul><li>Foetal </li></ul><ul><ul><li>Multiple pregnancy </li></ul></ul><ul><ul><li>PROM </li></ul></ul><ul><ul><li>Hydramnions </li></ul></ul><ul><ul><li>Congenital fetal malformation </li></ul></ul><ul><li>Idiopathic </li></ul>
  • 9. INFECTION … <ul><li>ASCENDING INTRAUTERINE INFECTION IS CONSIDERED TO HAVE FOUR STAGES </li></ul><ul><li>The first stage : change in the vaginal/cervical microbial flora or the presence of pathologic </li></ul><ul><li>organisms </li></ul><ul><li>Second stage : deciduitis . </li></ul><ul><li>Third stage ( choriovasculitis ) or ( amnionitis ) </li></ul><ul><li>Fourth stage : Once in the amniotic cavity, the bacteria may gain access to the fetus by different ports of entry </li></ul>R Goldenberg NEJM 2000
  • 10. <ul><li>Risk Factors </li></ul><ul><li>Non white race </li></ul><ul><li>Previous preterm delivery </li></ul><ul><li>Low body mass index </li></ul><ul><li>Extremes of ages (<17 and >35) </li></ul><ul><li>Strenous work stress </li></ul><ul><li>Tobacco use </li></ul><ul><li>Hemoglobin < 10 g </li></ul><ul><li>Bactereuria </li></ul><ul><li>Low socioeconomic status </li></ul>
  • 11. How do we identify who is at Risk? Preterm Birth Risk Factors Cervical Length Fetal Fibronectin Symptoms of PTL
  • 12. <ul><li>THE PAPIERNIK-BERKHAUER(1969)SCORING MATRIX </li></ul><ul><li>MODIFIED BY GONIK –CREASY (1980-1986) </li></ul>0-5:low risk 5-9 :medium risk ≥ 10 :high risk points Socio economic factors Previous medical history Daily habits Current pregnancy 1 2 children at home; low s.e status 1 abortion <1 yr since last birth Works outside Unusual fatigue 2 Age<20/>40 yr Single parent 2 abortions Smoke>10 cig/day >3 flights of stairs without elevator Gain<5 kg by 32 wk Albuminuria,bacteriuria,hypertension 3 V low s.e status Ht<150 Wt<45 kg 3 abortions Heavy/stressful work Long daily commuting Extensive travelling breech@32 wks Head engaged @32 wks Febrile illness 4 Age<18 yrs pyelonephritis Bleeding after 12wk Short cervix Open int os Uterine irritabily 5 Uterine anomaly T2 abortion Des Exp Cone bx Placenta praevia hydramnios 10 Ptb,repeated t2 abortion Twins Abdominal surgery
  • 13. <ul><li>Signs / Symptoms </li></ul><ul><li>Persistent contractions (painful or painless) associated with cervical changes </li></ul><ul><li>Intermittent abdominal cramping, pelvic pressure or backache </li></ul><ul><li>Increase in vaginal discharge </li></ul><ul><li>Vaginal spotting or bleeding </li></ul>
  • 14. <ul><li>Biological markers for predicting PTL </li></ul><ul><li>Fetal fibronectin </li></ul><ul><ul><li>Glycoprotein produced by the chorion </li></ul></ul><ul><ul><li>Normally present in cervical secretion in early gestation and just before term labor </li></ul></ul><ul><ul><li>Presence after >24 weeks is a marker for the disruption of the chorioamnion and underlying decidua due to inflammation with or without infection </li></ul></ul><ul><ul><li>If test is negative < 1% will deliver in next week or two and test is positive then risk of PTD on next week or two is 20%. </li></ul></ul>
  • 15. Fetal fibronectin (cont) <ul><li>False positive : bleeding, ruptured membranes and digital cervical exam </li></ul><ul><li>False negative : lubricant soap </li></ul><ul><li>Screenigof asymptomatc women at low risk is not recommended </li></ul><ul><li>Useful in women when; </li></ul><ul><ul><li>Symptom occurs between 24-34 weeks </li></ul></ul><ul><ul><li>Membranes are intact and cervical dilatation is <3 cm </li></ul></ul><ul><ul><li>For short term prediction ( 7-14 days ) </li></ul></ul>
  • 16. <ul><li>Biological markers for predicting PTL (contd…) </li></ul><ul><li>Salivary estriol </li></ul><ul><ul><li>Maternal levels of serum estradiol and salivary estriol increases before onset of term and PTL </li></ul></ul><ul><ul><li>A cut off > 2. 1ng/dl yielded a sensitivity of 40%, specificity of 93% </li></ul></ul><ul><ul><li>Levels infuenced </li></ul></ul><ul><ul><ul><li>Diurnal pattern (lowest during day , highest in night </li></ul></ul></ul><ul><ul><ul><li>Corticosteroids suppresses estriol value </li></ul></ul></ul>
  • 17. <ul><li>CRH </li></ul><ul><ul><li>Source placenta and fetal membranes; highest in T3. </li></ul></ul><ul><ul><li>RR 3.3 at 33 weeks </li></ul></ul><ul><li> hcg and  FP </li></ul><ul><li>Increased levels associated with PTL, abnormal placentation, disruption of choriodecidual integrity </li></ul><ul><li>Relaxin </li></ul>
  • 18. <ul><li>Cervical length (CL) </li></ul><ul><li>Risk of PTD increases if CL is 30mm or less at 24 weeks, </li></ul><ul><li>Manual examination </li></ul><ul><ul><li>subjective, interobserver variability 52% </li></ul></ul><ul><ul><li>internal os not measurable </li></ul></ul><ul><li>Transvaginal USG vs digital examination </li></ul><ul><ul><li>TVS can detect shortening of Cx canal earlier </li></ul></ul><ul><ul><li>no significant inoculation with bacteria </li></ul></ul><ul><ul><li>minimal discomfort </li></ul></ul><ul><ul><li>99% agreed for similar procedure </li></ul></ul>
  • 19. <ul><li>TransaAdominal USG of Cx is inadequate </li></ul><ul><li>1.fetal can obscure the Cx especially after 20 weeks </li></ul><ul><li>2.requires UB filling which can elongate Cx and mask funneling </li></ul><ul><li>3.visualization not clear due to long distance </li></ul><ul><li>TransLabial/Transperineal USG is more useful </li></ul><ul><li>1.fetal parts don’t obscure vision </li></ul><ul><li>2.bladder filling not required </li></ul><ul><li>3.no pressure exerted on cervix </li></ul><ul><li>4.additional transducer not required </li></ul><ul><li>5.well accepted </li></ul><ul><li>Drawback:gas in rectum can hamper vision specially ext os. </li></ul><ul><li>Difficult to master. </li></ul>
  • 21. <ul><li>Infection </li></ul><ul><ul><li>Ureoplasma </li></ul></ul><ul><ul><li>Gonorrhoea </li></ul></ul><ul><ul><li>Chlamydia </li></ul></ul><ul><ul><li>Syphilis </li></ul></ul><ul><ul><li>Untreated UTI </li></ul></ul>
  • 22. <ul><li>Bacterial vaginosis </li></ul><ul><ul><li>Bacterial vaginosis is an alteration of the normal vaginal flora, reduction in lactobacilli with increase in gram negative and anaerobic bacteria (G. vaginalies, bacteroides, mobiluncus, peptostreptococcus, mycoplasma </li></ul></ul><ul><ul><li>3 of 4 criteria should be present </li></ul></ul><ul><li>Diagnosis </li></ul><ul><ul><li>Vaginal pH > 4.5,Amine odour with 10% KOH, Clue cells on wet mount, Homogenous vaginal discharge </li></ul></ul>
  • 23. <ul><li>Bacterial vaginosis: </li></ul><ul><ul><li>two fold risk of PTB </li></ul></ul><ul><ul><li>Cochrane meta-analysis : no reduction by routine screening and treatment.But those with history of PTB benefited. </li></ul></ul><ul><ul><li>screen pts with history of PTB. treat with oral metronidazole for 7 days (vaginal treatment had no effect) . </li></ul></ul><ul><ul><li>vaginal clindamycin for 3 days or oral 5 day course also effective </li></ul></ul>
  • 24. <ul><li>Multiple pregnancy </li></ul><ul><li>PTL occurs in 50% of twins </li></ul><ul><li>76% triplets </li></ul><ul><li>90% quadruplets </li></ul><ul><li>Those with preterm contractions but without cervical changes do not require tocolytics. </li></ul><ul><li>Those in preterm labor : tocolysis + steroids </li></ul><ul><li>Greater risk of pulmonary edema with tocolytics </li></ul>
  • 25. <ul><li>Treatment of PTL </li></ul><ul><li>WHY? </li></ul><ul><ul><li>To prevent complication of prematurity </li></ul></ul><ul><ul><li>e.g. </li></ul></ul><ul><ul><ul><li>Respiratory distress syndrome (RDS) </li></ul></ul></ul><ul><ul><ul><li>Intraventricular haemorrhage (IVH) </li></ul></ul></ul><ul><ul><ul><li>Bronchopulmonary dysplasia (BPD) </li></ul></ul></ul><ul><ul><ul><li>Patent ductus arteriosus (PDA) </li></ul></ul></ul><ul><ul><ul><li>Necrotizing enterocolitis (NEC) </li></ul></ul></ul><ul><ul><ul><li>Retinopathy of prematurity (ROP) </li></ul></ul></ul><ul><ul><ul><li>Sepsis </li></ul></ul></ul>
  • 26. Prevention/Intervention Strategies Tocolytics Education Targeting High Risk Women Bedrest Home Uterine Monitoring Frequent Digital Exam Hydration Population Based strategies
  • 27. <ul><li>Prevention of PTB </li></ul><ul><li>Primary Prevention </li></ul><ul><li>1.improve quality of life and nutritional status </li></ul><ul><li>2.reduction in physical and emotional stress. bed rest. </li></ul><ul><li>3.education programs for signs and symptoms, contractions, pelvic pressure, vaginal discharge </li></ul><ul><li>4.hydration </li></ul><ul><li>5.progesterone </li></ul><ul><li>6.antioxidants and omega-3 fatty acids : uncertain </li></ul><ul><li>7.cerclage </li></ul><ul><li>8.diagnosis & treatment of infections </li></ul><ul><li>9.role of ART </li></ul><ul><li>10.twins and high order multiples </li></ul>
  • 28. <ul><li>Secondary prevention </li></ul><ul><li>1.cerclage </li></ul><ul><li>2.antibiotics </li></ul><ul><li>3.tocolysis </li></ul>
  • 29. <ul><li>Prophylactic therapy like bed rest, hydration and sedation in asymptomatic women at increased risk for preterm delivery has not been demonstrated to be effective. </li></ul><ul><li>ACOG practice bulletin 2003, Cochrane review 2003 </li></ul><ul><li>Stop smoking and substance abuse and reduce heavy work load </li></ul><ul><li>Role of ART : reduce rate of multiple pregnancies, single embryo transfer </li></ul>
  • 30. <ul><li>Progesterone therapy to prevent PTL </li></ul><ul><ul><li>decrease in myometrial progesterone receptor with PTL and term labor. </li></ul></ul><ul><ul><li>antinflammatory response, </li></ul></ul><ul><ul><li>immunosuppression : suppresses cytokine pathways thus preventing rejection of fetus in utero. </li></ul></ul><ul><ul><li>17 alpha hydroxyprogesterone caproate weekly I.m.to women at high risk for PTL results in lower rates of PTB </li></ul></ul>
  • 31. <ul><li>Cervical Cerclage </li></ul><ul><li>RCOG study concluded that 96% of elective cerclages were unnecessary,with no perinatal improvement . </li></ul><ul><li>In a post-hoc analysis those with three or more pregnancy losses seemed to have improved outcome </li></ul><ul><li>Recommendations </li></ul><ul><ul><li>high risk patients can be followed by serial Cervical USG </li></ul></ul><ul><ul><li>TVS during 2 nd trimester. </li></ul></ul><ul><ul><li>Except:anatomic defect at or near internal os, </li></ul></ul><ul><ul><li>3 or more losses, </li></ul></ul><ul><ul><li>inability to follow with TVS </li></ul></ul>
  • 32. <ul><li>Cervical cerclage cont. </li></ul><ul><ul><li>high risk patients screened 1 to 4 weekly between 16 and 24 weeks </li></ul></ul><ul><li>Elective transabdominal cerclage </li></ul><ul><ul><li>lacerations upto LUS, </li></ul></ul><ul><ul><li>cervical surgical amputation </li></ul></ul><ul><ul><li>Cx Length < or =2.5 at 24 weeks (10 th percentile) is the critical threshold for increased risk for PTB) </li></ul></ul>
  • 33. <ul><li>Cervical cerclage cont. </li></ul><ul><li>Adjuntive treatment </li></ul><ul><ul><li>Antibiotics: multiple urogenital cultures should be obtained . Short course of antibiotics before cerclage placement or as empiric medical therapy can be considered, but no evidence to support it. Long-term antibiotics avoided (increases resistance) </li></ul></ul><ul><ul><li>Tocolytics: short-term indomethacin anti-inflammatory properties and tocolytic, but no data to support empiric use. Absence of anti-inflammatory properties of beta blocker, nifedipine, Mg sulphate precludes there use </li></ul></ul><ul><ul><li>Corticosteroids: not used before 24 weeks </li></ul></ul>
  • 34. <ul><li>Cerclage in Multifetal pregnancy : no evidence to support use of elective, urgent, emergent cerclage </li></ul><ul><li>After delivery: </li></ul><ul><ul><li>if during pregnancy urogenital infection documented then evaluation for subclinical gynecologic infection indicated. </li></ul></ul><ul><ul><li>Anatomical evaluation using HSG,hysteroscopy, MRI, TVS </li></ul></ul>
  • 35. <ul><li>Infection and preterm birth </li></ul><ul><ul><li>50% of PTB associated with ascending genital tract infection eg. intrauterine, lower genital tract infection, distant infection like periodontitis </li></ul></ul><ul><ul><li>polymicrobial ureaplasma urealyticum, Mycoplasma hominis, anaerobes, group B streptococci, Gardenella vaginalis, E. coli, peptostreptococci, Bacteroides </li></ul></ul>
  • 36. <ul><li>Treatment of infections </li></ul><ul><ul><li>antibiotics should not be given routinely in PTL with intact membranes for prolonging pregnancy </li></ul></ul><ul><ul><li>definitely diagnosed intra-amniotic infection either by clinical criteria (fever, uterine tenderness, maternal or fetal tachycardia) or by amniocentesis, give i.v. antibiotics and deliver regardless of gestation </li></ul></ul><ul><li>Consider amniocentesis if </li></ul><ul><ul><li>any signs and symptoms of chorioamnionitis </li></ul></ul><ul><ul><li>early gestation <28 wks </li></ul></ul><ul><ul><li>failure of tocolysis (eg. before a second tocolytic) </li></ul></ul>
  • 37. <ul><li>Tocolytics in PRL </li></ul><ul><li>1. beta agonist </li></ul><ul><li>2. magnesium sulphate </li></ul><ul><li>3. antiprostaglandins </li></ul><ul><li>4. calcium channel antagonists </li></ul><ul><li>5. oxytocin antagonists </li></ul><ul><li>6. nitric oxide donors </li></ul>Goals 1. allow administration of corticosteroids 2. allow time for transfer to tertiary care 3. during maternal antenatal surgeries 4. uterine relaxation during ECV
  • 38. <ul><li>Betamimetic </li></ul><ul><li>MOA : b2 activator </li></ul><ul><li>Terbutaline 0.25mg s/c every 20 min to 3 hrs </li></ul><ul><li>Ritodrine : start at 50-100 mg/min, increase 50µg/ every 10min, max 350µg </li></ul><ul><li>CI : cardiac disease, poorly controlled diabetes and thyroid disease </li></ul><ul><li>Mat S/E : arrhythmias, pulmonary edema, hypotension, tachycardia, hyperglycemia, hypokalemia </li></ul><ul><li>Fetal S/E : Tachycardia, hyperglycemia, myocardial and septal hypertrophy </li></ul><ul><li>Neonatal : tachycardia, hypoglycemia, hypocal, hyperbil, IVH </li></ul>
  • 39. <ul><li>Magnesium sulphate </li></ul><ul><li>MOA : calcium antagonist; </li></ul><ul><ul><li>Inhibits calcium refluxat cell membrane, competes for binding sites </li></ul></ul><ul><ul><li>Increased intracellular c AMP which further decreases calcium. </li></ul></ul><ul><li>Dose : 4-6gm bolus IV for 20 min then 2-3g/hr </li></ul><ul><li>CI : myasthenia gravis, impaired renal function </li></ul><ul><li>Mat S/E : flushing, lethargy, headache </li></ul><ul><li>Muscle weakness, pulmonary edema, cardiac arrest </li></ul><ul><li>Fetal S/E : lethargy, hypotonia, respi depression </li></ul>
  • 40. <ul><li>Calcium channel blockers </li></ul><ul><li>Blocking Voltage dependent L-type calcium channels in smooth muscles; nifedipine and ritodrin. </li></ul><ul><li>Dose : 30mg loading dose, then 10-20mg 4-6 hr </li></ul><ul><li>CI : cardiac, renal disease, maternal hypotension, concomitant use with magnesium sulphate </li></ul><ul><li>Mat S/E : flushing, headache, dizziness </li></ul><ul><li>Transient hypotension </li></ul><ul><li>Fetal S/E none </li></ul>
  • 41. <ul><li>Antiprostaglandin drugs </li></ul><ul><ul><li>inhibit prostaglandin synthetase or cyclooxygenase (COX) </li></ul></ul><ul><ul><li>PG facilitate entry of calcium into cell, enhance development of gap junctions </li></ul></ul>
  • 42. <ul><li>Prostaglandin synthetase inhibitors </li></ul><ul><li>Indomethacin 50mg rectally or 50-100 mg orally, 25-50mg every 6 hr for 48 hrs </li></ul><ul><li>CI : sig hepatic or renal disease, peptic ulcer disease, coagulation disorder, thrombocytopenia, sensitivity </li></ul><ul><li>Mat S/E : nausea, heartburn </li></ul><ul><li>Fetal S/E : constriction of DA, pulmonary hypertension, reversible decrease in renal function, hyperbil, NEC, IVH </li></ul>
  • 43. <ul><li>Summary </li></ul><ul><li>Although tocolytics may prolong pregnancy they don’t improve perinatal outcomes, but do have adverse maternal effect </li></ul><ul><li>As a rule they should be given with corticosteroids </li></ul><ul><li>Most do not recommend use of tocolytics >= 34 weeks POG </li></ul><ul><li>No role of maintenance tocolysis </li></ul>
  • 44. <ul><li>Antenatal corticosteroids </li></ul><ul><li>All fetuses between 24 – 34 wks POG at risk of preterm delivery should be considered </li></ul><ul><li>Decision should not be altered by race, gender, availability of surfactant replacement therapy </li></ul><ul><li>Those eligible for tocolysis are eligible for corticosteroids </li></ul><ul><li>Optimal benefit begins 24 hrs after initiation </li></ul><ul><li>Significant decrease in incidence and severity of RDS, IVH, NEC </li></ul>
  • 45. <ul><li>Until data establish a favorable benefit-to-risk ratio,repeat courses of steroids including rescue therapy should be reserved for patients enrolled in clinical trials. Multiple courses lead to worse outcome or no benefit </li></ul><ul><li>Long-term FU of infants given single course show no adverse effects </li></ul><ul><li>Betamethasone and dexamethasone </li></ul><ul><li>Readily cross placenta </li></ul><ul><li>Have long half lives </li></ul><ul><li>Limited mineralocoticoid activity </li></ul><ul><li>Similar efficacy in decreasing RDS ( 51% vs 44%) </li></ul><ul><li>Betamethasone is more effective in reducing IVH, PVL than dexamethasone so betamethasone is a better choice </li></ul>
  • 46. <ul><li>Conduct of Delivery </li></ul><ul><li>Tertiary care centre, specialized staff </li></ul><ul><li>Cesarean delivery to obviate trauma from labor and vaginal delivery has not been validated </li></ul><ul><li>CS did not lower risk of mortality or ICH in <1500 gm </li></ul><ul><li>Episiotomy may be necessary in absence of relaxed vagina outlet </li></ul><ul><li>No use of routine forceps </li></ul><ul><li>Cesarean section for preterm breech </li></ul>
  • 47. <ul><li>Preterm Premature Rupture of Membranes </li></ul><ul><li>Risk factors </li></ul><ul><ul><li>SES </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Vaginal bleeding x 2-7 </li></ul></ul><ul><ul><li>Short cervix </li></ul></ul><ul><ul><li>Prior cervical surgery </li></ul></ul><ul><ul><li>Vitamin C, copper and zinc deficiency </li></ul></ul><ul><ul><li>Multifetal pregnancy </li></ul></ul><ul><ul><li>Previous history of PTB or PPROM </li></ul></ul><ul><ul><li>Pre-existing medical illness </li></ul></ul><ul><ul><li>Genital tract infection, BV, chlamydia, mycoplasma </li></ul></ul>
  • 48. <ul><li>Complications </li></ul><ul><li>Maternal infection </li></ul><ul><li>Abruptio </li></ul><ul><li>Prematurity </li></ul><ul><li>Fetal distress, cord compression </li></ul><ul><li>Deformation and contractures </li></ul><ul><li>Pulmonary hypoplasia </li></ul><ul><li>Fetal infection </li></ul>
  • 49. <ul><li>Management </li></ul><ul><li>Diagnosis </li></ul><ul><ul><li>Speculum examination </li></ul></ul><ul><ul><li>Nitrazine test </li></ul></ul><ul><ul><li>Ferning, </li></ul></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><li> -fetoprotein, FFN </li></ul></ul><ul><li>Gestational age </li></ul><ul><li>Presence of labour </li></ul><ul><li>Infection </li></ul>
  • 50. <ul><li>Maternal infection </li></ul><ul><li>Fever, uterine tenderness, fetal or maternal tachycardia, foul smelling, vaginal discharge, leukocytosis, uterine contractions </li></ul>
  • 51. <ul><li>For queries mail me at </li></ul><ul><li>[email_address] </li></ul>
  • 52. <ul><li>To see laparoscopic surgeries in Gynae logon to </li></ul><ul><li>www.youtube.com </li></ul><ul><li>and </li></ul><ul><li>type </li></ul><ul><li> pradeep aiims </li></ul>
  • 53. Thank you

Related Documents