BY
M. ZEESHAN KHAN
RIZWAN ANWER
ZEESHAN LODHI
PRETERM AND POST-TERM
LABOUR
CONTENTS
 PRETERM LABOUR
 DEFINITION
 RISK FACTORS
 DIAGNOSIS
 INVESTIGATIONS
 PREDICITON AND PREVENTIONS
 TOCOLYTI...
DEFINITIONS
 PRE TERM PREGNANCY
 DELIVERY BEFORE 37 WEEKS OF GESTATION
 TERM PREGNANACY
 GP FROM 37 TO 41 + 6 days WEE...
PRETERM LABOUR
 Preterm labour is defined by WHO as Onset of
labour prior to the completion of 37 weeks of
gestation, in ...
CONT’
 This condition tends to be over diagnosed and over
treated.
 Nearly 50-60% of preterm births occur following
spon...
 Half of all neonatal morbidity occurs in preterm
infants.
 Inspite of all major advances in obstetric and
neonatal care...
Incidence
 Preterm birth occurs in 5-12% of all pregnancies and
accounts for majority of neonatal deaths and nearly
half ...
 One of the major reasons for increase in incidence of
premature births is the increase in numbers of
multiple pregnancie...
PRETERM LABOUR
5 -> 4 -> 4
 Mildly preterm 32 – 36 weeks
 Very preterm 28 – 31 days weeks
 Extremely preterm 24 – 27 we...
AETIOLOGY
 INFECTIONS
 OVER-DISTENSION
 VASCULAR
 SURGICAL PROCEDURES AND INTERCURRENT
ILLNESS
 ABNORMAL UTERINE CAVI...
NON MODIFIABLE(MAJOR AND
MINOR)
MODIFIABLE
RISK FACTORS
RISK FACTORS
 MAJOR NON MODIFIABLE
 Last birth preterm: 20% risk
 Last two birth preterm : 40%risk
 Twin pregnancy: 50...
 Non modifiable , Minor
 Parity 0 or >5
 Ethnicity(Black)
 Poor socioeconomic status
 Education
 Teenagers having se...
 Modifiable
 Smoking :2x risk of PPROM
 Drug abuse : especially cocaine
 BMI <20
 Inter Pregnancy interval: <1year
DIAGNOSIS
 SYMPTOMS WITH CERVICAL WEAKNESS
 Increased vaginal discharge
 Mild Lower abdominal pain
 Bulging membranes ...
DIGNOSTIC CRITERIA
1. GESTATIONAL AGE : 24-37 WEEKS
2. UTERINE CONTRACATION: ATLEAST 3
CONTRACTIONS IN 30 MINUTES
3. CERVI...
DIFFERNTIAL DIAGNOSIS
 UTI
 RED DEGERATION OF FIBROID
 PLACENTAL ABRUPTION
 CONSTIPATION
 GASTROENTERITIS
DIAGNOSTIC APPROACH
 HX
 EXAMINATIONS
 INVESTIGATIONS
 FBC
 CRP
 MID STREAM URINE SAMPLE
 U/S
 TVS
 FETAL FIBRONE...
PREVENTION
 Rx of BV
 Cervical Cerclage
 Selective Reduction of pregnancy numbers
 Progesterone ?
PREDICITON
 Cervical length
 TVS improves diagnostic accuracy
 Normal length 35 mm
 In asymptomatic women with singlet...
cont
 Fetal Fibronectin(fFn)- glue like protein at
choriodecidual interface
 fFN test offers rapid assessment of risk in...
TOCOLYTIC AGENTS AND STEROIDS
 Used to prevent labour and delivery
 May prolong pregnancy but not more than 72 hours
 U...
IMPORTANT TOCOLYTIC DRUNGS
TOCOLYTIC DRUGS SIDE EFFECTS
MAGNESIUM SULFATE
Competitive inhibitors of calcium
Overdose treat...
cont
Calcium channel Blocker
Dec. intracellular Calcium
e.g nifidipine ,
Hypotension
Myocardial depression
Tachycardia
Pro...
MATERNAL STEROIDS
 Reduces the rates of respiratory distress,
intraventricular hemorrhage and neonatal death
 Given as I...
MANAGEMENT OF PRETERM LABOUR
 Confirm labour using three criteria listed above.
 Rule out contraindications of tocolysis...
 Clear plan about
 Mode of delivery
 Monitoring in labour
 Presence of pediatrician
 In antibiotics in labour
PRETERM PRELABOUR OF MEMBRANES
(PPROM)
 Rupture of fetal membranes occurring before 37 wks
of gestation.
 It complicates...
RISK FACTORS
 Ascending infection of lower genital tract-most
common
 Multiple pregnancy
 Polyhydramnios
 Antepartum h...
Diagnosis of PPROM
 History of sudden escape of watery amnoitic fluid.
 Oligohydramnios on US
 Pooling of amniotic flui...
Differential diagnosis
 It needs to be differentiated from stress urinary incontinence
 and profuse normal vaginal disch...
Management of PPROM
 Correct and prompt diagnosis is imperative for
optimum management.
PPROM remote from term: Conserva...
PPROM nearer to term(34-36 wks):
 It is preferable to induce labour unless fetal lung
maturity or gestational age is doub...
POST-TERM PREGNANCY
 Any pregnancy that exceeds 42 weeks from the first
day of last menstrual period in women with regula...
INCIDENCE
 The generally quoted incidence of PT pregnancy is
10%
 Incidence is decreasing b/c of better estimation of
du...
RISK FACTORS
 Past history of prolonged pregnancy
 Family history
 Race (White>black)
 Anencephaly
 Congenital adrena...
COMPLICATION
 FETAL COMPLICATION
 Macrosomia Syndrome
 Dysmaturity Syndrome
 MATERNAL COMPLICATION
 Anxiety
 Prolong...
Fetal Complications
 Macrosomia Syndrome
 Occurs when placental function is maintained(80% cases)
 Results in healthy b...
 Dysmaturity syndrome
 When placental function deteriorates (20% cases)
 Placental insufficiency results in reduction o...
MATERNAL COMPLICATIONS
 Anxiety
 Is commonly seen postdate pregnancy b/c of worry of inc. in
gestation period from the E...
MANAGEMENT
 It depends on the
 Confirmation of gestational age
 Favorability of cervix
CONFIRAMTION OF GESTATIONAL AGE
 In a booked case confirmation of gestational age is
easily determined
 In an unbooked c...
DETERMINATION OF GESTATIONAL AGE
 HISTORY
 LMP
 EARLY U/S
 FAMILY HISTORY
 HX OF NTDs
 EXAMINATION
 SFH
 BISHOP SC...
INVESTIGATIONS
 U/S
 NST
 AFI
After confirmation of gestational age management
plan is decided
CONSERVATIVE MANAGEMENT
 50% women going beyond 42 weeks of gestation
experience spontaneous labour in 4-5 days
 Poor bi...
INDUCTION OF LABOUR
1. Favorable cervix
2. Oligohydramnios
3. Fetal macrosomia
4. Non reactive NST
FOR YOUR PATIENCE 
Thanks
of 47

preterm and postterm labour

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


Transcripts - preterm and postterm labour

  • 1. BY M. ZEESHAN KHAN RIZWAN ANWER ZEESHAN LODHI PRETERM AND POST-TERM LABOUR
  • 2. CONTENTS  PRETERM LABOUR  DEFINITION  RISK FACTORS  DIAGNOSIS  INVESTIGATIONS  PREDICITON AND PREVENTIONS  TOCOLYTIC AGENTS  MANAGEMENT  PPROM(INTRODUCTION, DIAGNOSIS,MANAGEMENT)  POST-TERM LABOUR  INTRODUCTION  SIGNIFICANCE  CLINICAL APPROACH  MANAGEMENT
  • 3. DEFINITIONS  PRE TERM PREGNANCY  DELIVERY BEFORE 37 WEEKS OF GESTATION  TERM PREGNANACY  GP FROM 37 TO 41 + 6 days WEEKS  POSTERM PREGNANCY  GP 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 wks 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 dialatation >1cm.
  • 5. CONT’  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.  Half of all neonatal morbidity occurs in preterm infants.  Inspite of all major advances in obstetric and neonatal care, there has been no decrease in incidence of preterm labour over half a century.  On the contrary , it has been increasing in the developed countries as more and more high risk mothers dare to get pregnant.
  • 7. Incidence  Preterm birth occurs in 5-12% of all pregnancies and accounts for majority of neonatal deaths and nearly half of all cases of congenital neurological disability, including cerebral palsy.  A neonate weighing 1000- 1500 g today has ten times greater chance of surival then what it had in 1960s.  The focus is hence shifting to early preterm births(<32 weeks) which account for 1-2% of all births but contribute to 60% of perinatal mortality and nearly all neurological morbidity.
  • 8.  One of the major reasons for increase in incidence of premature births is the increase in numbers of multiple pregnancies , particularly higher order pregnancies, resulting from the use of fertility drugs and assisted reproduction.
  • 9. PRETERM LABOUR 5 -> 4 -> 4  Mildly preterm 32 – 36 weeks  Very preterm 28 – 31 days weeks  Extremely preterm 24 – 27 weeks
  • 10. AETIOLOGY  INFECTIONS  OVER-DISTENSION  VASCULAR  SURGICAL PROCEDURES AND INTERCURRENT ILLNESS  ABNORMAL UTERINE CAVITY  CERVICAL WEAKNESS  IDIOPATHIC
  • 11. NON MODIFIABLE(MAJOR AND MINOR) MODIFIABLE RISK FACTORS
  • 12. RISK FACTORS  MAJOR NON MODIFIABLE  Last birth preterm: 20% risk  Last two birth preterm : 40%risk  Twin pregnancy: 50% risk  Uterine abnormalities  Cervical Anomalies  Factors in current pregnancy
  • 13.  Non modifiable , Minor  Parity 0 or >5  Ethnicity(Black)  Poor socioeconomic status  Education  Teenagers having second or subsequent babies
  • 14.  Modifiable  Smoking :2x risk of PPROM  Drug abuse : especially cocaine  BMI <20  Inter Pregnancy interval: <1year
  • 15. DIAGNOSIS  SYMPTOMS WITH CERVICAL WEAKNESS  Increased vaginal discharge  Mild Lower abdominal pain  Bulging membranes on examination  SYMPTOMS WITH INFECTION, ABRUPTION  Lower abdominal pain  Painful uterine contraction
  • 16. DIGNOSTIC CRITERIA 1. GESTATIONAL AGE : 24-37 WEEKS 2. UTERINE CONTRACATION: ATLEAST 3 CONTRACTIONS IN 30 MINUTES 3. CERVICAL CHANGE: CHANGE IN CERVICAL DIALTATION OR 2CM DILATED CERVIX
  • 17. DIFFERNTIAL DIAGNOSIS  UTI  RED DEGERATION OF FIBROID  PLACENTAL ABRUPTION  CONSTIPATION  GASTROENTERITIS
  • 18. DIAGNOSTIC APPROACH  HX  EXAMINATIONS  INVESTIGATIONS  FBC  CRP  MID STREAM URINE SAMPLE  U/S  TVS  FETAL FIBRONECTIN
  • 19. PREVENTION  Rx of BV  Cervical Cerclage  Selective Reduction of pregnancy numbers  Progesterone ?
  • 20. PREDICITON  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 <5 mm long: risk of delivering before 32 weeks is 78%  In symptomatic woman with singleton pregnancy  Cervix <15mm long : risk of delivering within 7 days is 50%  Cervix >15 mm long: risk of delivery within 7 days is <1%
  • 21. cont  Fetal Fibronectin(fFn)- glue like protein at choriodecidual interface  fFN test offers rapid assessment of risk in symptomatic women with minimal cervical dilatation,  fFN is protein not usually present in cervicovaginal secretions at 22-36weeks  fFN positive test indicates that women is likely to deliver  fFN predicts preterm birth within 7 – 10 days of testing  Implying disruption of choriodecidual interface
  • 22. TOCOLYTIC AGENTS AND STEROIDS  Used to prevent labour and delivery  May prolong pregnancy but not more than 72 hours  Useful for fetal lung maturity by maternal IM steroids  Transportation of mother to a facility with neonatal intensive care
  • 23. IMPORTANT TOCOLYTIC DRUNGS TOCOLYTIC DRUGS SIDE EFFECTS MAGNESIUM SULFATE Competitive inhibitors of calcium Overdose treated by IV ca gluconate Resp depression Muscle weakness Pulmonary edema Beta- Adrenergic agonist Terbutaline HTN and tachycardia Hypokalemia Hyperglycemia
  • 24. cont Calcium channel Blocker Dec. intracellular Calcium e.g nifidipine , Hypotension Myocardial depression Tachycardia Prostaglandin synthetase inhibitor Dec. smooth muscle contractility e.g. Indomethacin Fetal complications like oligohydramnios, premature closure of ductus and necritising enterocolitis have restricted their use.
  • 25. 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 hours.
  • 26. MANAGEMENT OF PRETERM LABOUR  Confirm labour using three criteria listed above.  Rule out contraindications of tocolysis  Administer IV line  Start MgSO4 tocolysis with 5g IV for 20 min, then 2g/h  Adminster maternal IM betamethasone to stimulate type II pneumocyte
  • 27.  Clear plan about  Mode of delivery  Monitoring in labour  Presence of pediatrician  In antibiotics in labour
  • 28. PRETERM PRELABOUR 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
  • 29. RISK FACTORS  Ascending infection of lower genital tract-most common  Multiple pregnancy  Polyhydramnios  Antepartum hemorrhage  Placental abruption  Cervical weakness  Idiopathic
  • 30. Diagnosis of PPROM  History of sudden escape of watery amnoitic fluid.  Oligohydramnios on US  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  Amnisure test(immunochromatographic method) detects trace amounts of placental microglobulin (PAMG-1)
  • 31. Differential diagnosis  It needs to be differentiated from stress urinary incontinence  and profuse normal vaginal discharge.  UTI  Vaginal Infection
  • 32. 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 not an indication.  Antibiotics: help to prolong latency and improve perinatal outcomes.  Corticosteroids: should be given to patients between 24 and 34 weeks of gestation.
  • 33. PPROM nearer to term(34-36 wks):  It is preferable to induce labour unless fetal lung maturity or gestational age is doubtful  Serial transabdominal amnioinfusions in<26 wks pregnancies with PPROM and severe oligohydramnios in selected women reduce the risk of pulmonary hypoplasia and improve neonatal survival.
  • 34. POST-TERM PREGNANCY  Any pregnancy that exceeds 42 weeks from the first day of last menstrual period in women with regular 28 day cycles  Aka Postdate pregnancy and prolonged pregnancy
  • 35. INCIDENCE  The generally quoted incidence of PT pregnancy is 10%  Incidence is decreasing b/c of better estimation of duration of gestation and timely induction of labour.
  • 36. RISK FACTORS  Past history of prolonged pregnancy  Family history  Race (White>black)  Anencephaly  Congenital adrenal hyperplasia  Extra uterine pregnancy
  • 37. COMPLICATION  FETAL COMPLICATION  Macrosomia Syndrome  Dysmaturity Syndrome  MATERNAL COMPLICATION  Anxiety  Prolonged labour  C-section
  • 38. Fetal Complications  Macrosomia Syndrome  Occurs when placental function is maintained(80% cases)  Results in healthy but large fetus  Amniotic fluid is normal  Inc risk of C-section b/c of prolonged and arrested labour  Shoulder dystocia
  • 39.  Dysmaturity syndrome  When placental function deteriorates (20% cases)  Placental insufficiency results in reduction of metabolic and respiratory support to fetus  Amniotic fluid is decreased  Inc risk of C-section b/c of non reassuring fetal heart rate patterns  Oligohydramnios results in umbilical cord compression
  • 40. MATERNAL COMPLICATIONS  Anxiety  Is commonly seen postdate pregnancy b/c of worry of inc. in gestation period from the EDD  Prolonged labour  Chances increases significantly and also the risk of instrumental delivery  C-section  Risk of C-section is also greatly increased
  • 41. MANAGEMENT  It depends on the  Confirmation of gestational age  Favorability of cervix
  • 42. CONFIRAMTION OF GESTATIONAL AGE  In a booked case confirmation of gestational age is easily determined  In an unbooked case , diagnosis of post term pregnancy poses a major challenge.
  • 43. DETERMINATION OF GESTATIONAL AGE  HISTORY  LMP  EARLY U/S  FAMILY HISTORY  HX OF NTDs  EXAMINATION  SFH  BISHOP SCORING
  • 44. INVESTIGATIONS  U/S  NST  AFI After confirmation of gestational age management plan is decided
  • 45. CONSERVATIVE MANAGEMENT  50% women going beyond 42 weeks of gestation experience spontaneous labour in 4-5 days  Poor bishop score  Good fetal health + adequate placental function
  • 46. INDUCTION OF LABOUR 1. Favorable cervix 2. Oligohydramnios 3. Fetal macrosomia 4. Non reactive NST
  • 47. FOR YOUR PATIENCE  Thanks

Related Documents