Andrew Booker

Global problem

15 million babies every year

Leading cause of death children <5 1 million children a year

Estimated 75% could be saved

Stark inequality btw high and low income countries 50% mortality under 32/40 due to lack of basic care

In high income countries most survive

60% Preterm delivery occurs in Africa and Asia

In Australia – 8.6% <37 weeks (of approx 300,000 births)

Most Stillbirths are preterm 84%

Perinatal death rate 20-27 weeks – 708 per 1000 births

37-41 weeks – 2/1000

Indigenous Australians do WORSE 1.7x more likely (approx 14% of births)

Less ANC, high rate of smoking, more chronic illness

Extreme preterm 20-27 weeks Account for 0.8% births

Very Preterm 28-31 weeks Account for 0.8% births

Moderate to Late Preterm 32-36 week Accounting for 7% births

Past history of preterm delivery

Maternal age - <20 and >40

Cervical incompetence

HT/PET/HELLP

Multiples/TTTS

Placenta previa and abruption

Placental insufficiency/IUGR

PROM

Medical – diabetes, HT, renal, rhesus, UTI, Uterus

Substance abuse

Cerebral Palsy

Neurodevelopmental delay

Learning difficulties

Blindness

Deafness

Chronic Respiratory Problems

Social impacts

Economic impacts

Palpable painful contractions without cx change

Hard to establish incidence

60% deliver at term

How do we triage? History

Examination

Cervical assessment with TV ultrasound

Fetal fibronectin

Extracellular glycoprotein

Produced by the chorion “biological glue” Binds the blastocyst to the endometrium

Present up to 22 weeks when the chorion fuses

Simple ward test collected from the posterior fornix

Helpful to determine need for costly transfer

Contraindications include RM, Cx>3cm, Cerclage, bleeding, SI, BV, recent PV

PPV NPV

24-26 weeks 27.8% 84%

27-30 weeks 25.8% 90.5%

31-34 weeks 18.8% 83.3%

Role in prediction and prevention Checked at routine morph scan

Useful in TPL

Role in those with past history Preterm delivery

Cervical incompetence

Leave to Dr Ramsay to discuss

2003 NEJM, 17 –OH Prog reduced recurrent preterm birth

2011 Ultrasound Obstet gynaecol showed vaginal progesterone reduced risk of preterm birth in those with foreshortened cx

2007 NEJM no benefit of progesterone with twins

Some controversy IM vs PV progesterone

Role of Cerclage clear if PHx preterm birth AND a short cx

2014 Int, J of Gynae and Obstets.Slight prolongation if TPL halted 33 vs 23 days

Preventative Screening normal population 20/40 with swab for BV,

trichomonas, candida

Reduction Birth <37weeks RR 0.55

Reduction in Preterm del & <2500 RR 0.48

Reduction in Preterm del & <1500 RR 0.34

Vienna

Cochrane reviewed - moderate reliability

Threatened Preterm Labour with intact membranes Cochrane review: 14 studies: 7837 women

Dominated by ORACLE 2 with followup to 7 yrs

No sig difference in perinatal or infant mortality

No reduction in preterm birth

Increase in NND RR 1.57

Slight increase risk of functional impairment

Increase in risk of CP with macrolides and beta lactams

Maternal infection reduced RR 0.74

PPROM

Cochrane 22 trials; 6872 women Reduction in Chorio RR 0.66

Decreased babies born at <48hrs and upto 7 days

Decrease Neonatal infeciton RR 0.67

Decrease use of surfactant, O2 therapy and abnormal head scan

Increased risk of NEC with Augmentin

Oracle Childrens Study Little effect on childrens health at 7 years

Cochrane: 12 trials: 3617 women

Expectant Vs Active management

No difference in Neonatal sepsis

Increased risk of ; RDS and ventilation and NICU admission

Neonatal mortality

IOL and LSCS

Endometritis

Decreased risk of chorioamnionitis

Aim - Prevent contractions and allow prolongation of pregnancy

Various agents used Ca channel blockers – Nidepine

Nitric Oxide donors – GTN

MgSO4

B – adrenergic agonists – salbutamol, terbutaline

Cyclooxygenase inhibitors – indomethacin

Oxytocin Receptor antagonist - Atosiban

Mostly used to allow for corticosteroids and transfer

Primary mechanism ?increase surfactant production

Dexamethasone or Betamethasone (24mg/24hrs)

>24hrs through to 7 days

Fetal Benefits Reduction NND 33%

Reduction RDS 44%

Reduction IVH 46%

Fetal Concerns 1 Cochrane review possible increase in CP with multiple

doses

Offered between 24 and 34+6 weeks (??23+)

Benefit after 1st dose

Strongest Data between 26 and 34+6

Safe for mothers No evidence of Puerperal sepsis

No evidence of chorioamnionitis

No maternal deaths

Andrew Booker