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WELCOMENAMASKAR

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MANAGEMENT OF PRETERM

LABOUR

M.K.C.G.Medical College

Berhampur

Prof.Surendra Nath Panda, M.S .Dept.of OBGYN

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Motherhood

A dream of every woman We are obliged to fulfil

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PRETERM LABOUR Delivery between 20 & 37

weeks gestation

Different from LBW LBW

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PRETERM LABOUR

Cause-UncertainDiagnosis-ElusiveMethods-DebatableResults-UnpredictableCost- Enormous

THE PROBLEM

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MANAGEMENT OF PRETERM LABOUR

INFECTIONCERVICAL INCOMPETENCE

PLACENTA PREVIA / ABRUPTION

UTERINE ANOMALIES

DETECT & ELIMINATE / TREAT THE CAUSE: -

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PIHFOETAL ANOMALIES

IMMUNOLOGICAL?

DETECT & ELIMINATE / TREAT THE CAUSE: -

IDIOPATHIC - Cause undetectable

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PATIENTS AT RISK

THREATENED PRETERM

DELIVERY (Active preterm labour)

PRETERM PROM

THREE TYPES OF PATIENS: -

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Poor socioeconomic/ education/hygiene/ nutritional status

Young or advanced ageNulliparity or grandmultiparityShort stature or low weightSmokingMedical or surgical illnesscomplicating pregnancy

IDENTIFYING PATIENTS AT RISK OFPRETERM LABOUR

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History of preterm birth -After 1st preterm birth - 15%

After 2 preterm births - 32-70%If 1st term and 2nd preterm -23%

Cervical dilatation >20weeks

Pelvic pressureLow back pain

Uterine contraction

IDENTIFYING PATIENTS AT RISK OFPRETERM LABOUR

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MANAGEMENT OF PATIENTSAT RISK

GOAL

Prevention Of Preterm Labour METHODOLOGY

Multi-component preventive programs

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MANAGEMENT OF PATIENTS AT RISK

1.Education:-StaffPatientsPublic

1.Risk assessment:-


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Home visiting nurses/ midwives

Home helpFamily helpSocial worker assignmentStress management classes

Support systems: -


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Self-monitoring of uterineactivity at home: -

-External tocodynamometer


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1.Advice: -Reduce work

Reduce housework & child careReduce smokingReduce stressReduce travel,

commuting, moving house


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1.Advice: -

Reduce / Stop sexualactivityBed rest at home

Avoid hot & humid climateImprove nutrition (SeaFish+)


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1.Antenatal care: -

Increased frequency ofcontactContinuity of careFacilitated access totertiary hospital


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1.Antenatal care: -

Over Hydration (1.4Gallons/day)High dose calcium

AntioxidantsRegular cervicalexaminations (No

digital Exam.please)


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1.Antenatal care: -

Testing for imminent preterm labour with biological markers-

Foetal Fibronectin(FFN)E V Ultrasound of Cx.Salivary estriol(E3)(SalEst Test ).


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1.Specific obstetricinterventions:-

Bed rest in hospitalCervical sutureProgestogens

Dydrogesterone17-H P C

Progesterone V/O


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B-mimetics-Ritodrine 1x4-6Isoxsuprine 40mgx2Terbutaline 1x3 Salbutamol 1x3

Nifedipine 20mgx4

Tocolytics (Oral)?-


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Urinary Infection(Asymptomatic Bacteriuria)

Local InfectionBact.Vaginosis

Occult infection

Antibiotics -


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MANAGEMENT OF THREATENEDPRETERM DELIVERY

(Active preterm labour)Definitions of preterm labor vary, butthe research criteria commonly hold it

to be contractions occurring between20 and 36 weeks' gestation at a rate of four in 20 minutes or eight in 1 hour

with at least one of the following- :cervical change over time or dilatationgreater than or equal to 2.0 cm.

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LIASION WITH NEONATOLOGISTLIASION WITH NEONATOLOGIST

HOSPITALISATION

COUNSELLING

HYDRATION- Oral / IV

SEDATIVESSEDATIVES

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ANTIBIOTICS:- The array of agents,

routes of administration, anddurations of therapy preclude makingany recommendation but

Erythromycin appears to be a goodchoice

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STEROIDS(after 28 weeks) :- Beyond ashadow of doubt

Two Inj. of Betamethasone 12 mg IMat 12 24 hours interval

OR

Six inj. of Dexamethasone 4 mg IM 8hourly

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Potentially hazardous side

effectsClose monitoring essentialEffectiveness ?Use is debatableCombinations may be better

ACUTE TOCOLYSIS:-

MANAGEMENT OF THREATENED

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ACUTE TOCOLYSIS:-

Must be given parentrally for 18-48 hours

Risk/benefit ratio for both themother and fetus must be re-

evaluated on an ongoing basisShould be used selectively

Never after 33 weeks

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DiabetesHyperthyroidismCardiac disease

Severe PIHEclampsia

Exclusion criteria : -

Maternal factors -

Abruptio PlacentaHydramniosChorioamnionitis

Cervical dilationmore than 3 cm

ACUTE TOCOLYSIS

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Severe IUGRFoetal Anomaly incompatible with life

Foetal distress

Exclusion criteria : -

Foetal factors -

ACUTE TOCOLYSIS

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Start 100 mcg /min, go up to350 mcg, in increments of 50

mcg, until 12 hours ofcessation of contractions,then switch to 10mg tab 2hourly & maintain at 10-20 mg2-6 hourly

High Cost, Side effects

Beta Mimetic:-

Ritodrine - (150mg in 500 ml DS)

ACUTE TOCOLYSIS METHODS

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60mg in 500ml 0.2-1mg / minute

IV drip for 12 hours ofcessation of contractions 10mg IM/6hourly for 48 hours then switch to oral 20mg X 3-4/ 40mg x 2 timesLow cost, Moderate sideeffects,widely used in India

since long

Beta Mimetic:-

Isoxsuprine-


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250 mcg IV / SC for 12hours of cessation ofcontractions followed byOral 5 mg 2/4/6 hoursLow cost, widely used ,

Moderate side effects

Beta Mimetic:-

Terbutaline-


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IV for 12 hours of cessationof contractions followed by2/4mg 2/4/6/8 hours Oral

Low cost, Moderate sideeffects, mostly used in

Australia

Beta Mimetic:-

Salbutamol-

ACUTE TOCOLYSISACUTE TOCOLYSIS METHODS

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4-6 Gm IV/IM loading dose over20 minutes, followed by 2-4 Gm IV/IM every hour for 12 hoursafter contractions stop to befollowed by beta agonistsorally

For IV 40 Gms in one Lit of5%DS or 0.45% Normal saline Watch for hypermagnesemia

Monitor Mg level

Magnesium sulfate:-


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5mg S/L every 15 minutes for

2 hours-10mg Tab, 8hourlyLow cost, Moderate sideeffects, sporadic use

Move to ban sublingualgetting wider acceptance ,

Nifedipine:-


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Initial loading dose of 50 mgthen 25-50 mg oral every 4 hoursuntil contractions cease

Maintenance therapy at 25 mgsoral every 4 - 6 hours up to 35weeks

Not widely accepted because ofside effectsCan be given for short periods

of

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It is a nitric oxidedonorGood for very short

periodsHypotension

Nitroglycerine :-


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A Nona peptide oxytocin analog Acts as a oxytocin/ADH

antagonistStart IV bolus 675 mg, then300mg/minute IV for 3 hours and 100mg/minute IV thereafter.Efficacy same as beta agonistswith lesser side effects

Not available in India at

present

Atosiban(Tractocile) :-


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TOCOLYSIS IN PRETERMLABOUR

Most tocolytics are effective in stoppinglabor for 48-72 hours. None have beenshown to decrease the rate of pretermdelivery. Once the uterus is quiescent andintravenous tocolytics are stopped,

prolonged use of tocolytics has not beenshown to be effective in preventingpreterm birth.

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TOCOLYSIS IN PRETERMLABOUR

Long-term use of tocolytics isdifficult to justify at this time

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TOCOLYSIS IN PRETERM LABOUR

What is the HOPE FOR THE FUTURE?

A Designer Drug

A selective 2 Adrenergicreceptor modulator

PRETERM PROM

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PRETERM PROM

Vaginal /Cervical infectionMembrane PhysiologyNutritional factors

Incompetent CervixPreterm Labour

Risk Factors

PRETERM PROM

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PRETERM PROM

Patient History

Fluid ObservationUlrasound

Nitrazine TestFerning TestDye Injection

Diagnosis

MANAGEMENT OF PRETERM PROM

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MANAGEMENT OF PRETERM PROM

Hospitalisation Monitor for-

Infection Antibiotics

Labour

Tocolysis(

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Intra Partum Managements of Preterm Labour

Routine use of prophylactic forceps &episiotomy not recommendedIf Foetal distress- CS?

Below 28 weeks - NO CSBelow 32 weeks - ?Above 32 weeks - CSVertical skin & uterine incision

Minimise Maternal Hypotension andFoetal hypoxia and acidosis < RDS

S r i al Rate According to Gestational Age &

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Survival Rate According to Gestational Age &Birth Weight

(Oklahoma Medical Center, 1981-1994)

Gest. Age Survivors24 weeks 2025 25

26 5027 7528 8329 94

30 9531 9532 9733+ 99

Birth Weight Survivors2500 99

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MANAGEMENT OF PRETERMLABOUR

SLIGHT OVER-REACTION+

COMMON SENSE+

JUDGEMENT

= CORRECT MANAGEMENTFOR THE INDIVIDUAL.

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ANY QUESTIONSPLEASE

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