3/2/2016 4:08:01 PMManagrement of Preterm Labour1 PRETERM LABOR Associate Professor Iolanda Elena Blidaru, MD, PhD

3/2/2016 4:08:01 PMManagrement of Preterm Labour2 PRETERM LABOR Delivery between 24(20) & 37 weeks gestation Different from Low birthweight ( LBW) –LBW < 2500gm –Very LBW < 1500gm –Extremely LBW < 1000gm Major cause of fetal, perinatal & Infant death High cost of survival

3/2/2016 4:08:01 PMManagrement of Preterm Labour3 PRETERM LABOR Incidence : 6- 10% Spontaneous : 40-50% PROM : 25-40% Obstetrically indicated : 20-25%

3/2/2016 4:08:01 PMManagrement of Preterm Labour4 PRETERM LABOR Most mortality and morbidity is experienced by babies born before 34 weeks.

3/2/2016 4:08:01 PMManagrement of Preterm Labour5 PRETERM LABOR Major Fetal Risks Of Preterm Delivery Death Respiratory distress syndrome Hypothermia Hypoglycemia Necrotising enterocolitis Jaundice Infection Retinopathy of prematurity

3/2/2016 4:08:01 PMManagrement of Preterm Labour6 PRETERM LABOR  Amnionic fluid infection  Cervical incompetence  Placenta praevia  Placental abruption  Uterine anomalies, fibroids  Polyhydramnios ETIOLOGY (I)

3/2/2016 4:08:01 PMManagrement of Preterm Labour7 PRETERM LABOR  Hypertension  Fetal anomalies  Immunological  Trauma or surgery ETIOLOGY (II)  IDIOPATHIC - Cause undetectable

3/2/2016 4:08:01 PMManagrement of Preterm Labour8 PRETERM LABOR 1.Complications of pregnancy that mandate delivery (fetal / maternal risk ) 2.Spontaneous preterm labor with intact membranes – true / false labour 3.Preterm / premature rupture of membranes (PROM) CLASSIFICATION

3/2/2016 4:08:01 PMManagrement of Preterm Labour9 Prediction 1.Assessment of risk factors 2.Vaginal examination to assess the cervical status 3.Ultrasound visualization of cervical length and dilatation 4.Detection of biological markers

3/2/2016 4:08:01 PMManagrement of Preterm Labour10 1.Assessment of risk factors

3/2/2016 4:08:01 PMManagrement of Preterm Labour11 RISK FACTORS OF PRETERM LABOR Risk assessment - Papiernik There is strong evidence that intrauterine infection plays a role in preterm labor. Bacterial vaginosis increases the risk of preterm delivery >2-fold.

3/2/2016 4:08:01 PMManagrement of Preterm Labour12  Poor socioeconomic/ education/ hygiene/ nutritional status  Young ( 35y.)  Nuliparity or grand multiparity  Short stature or low weight (BMI < 19.0)  Medical or surgical illness in pregnancy  Antiphospholipid syndrome RISK FACTORS OF PRETERM LABOR (I)

3/2/2016 4:08:01 PMManagrement of Preterm Labour13  Previous preterm delivery: risk %  Obstetric complications: hypertension in pregnancy, antepartum hemorrhage, infection, polyhydramnios, fetal abnormalities.  Cigarette smoking: risk 20-30%  Multiple pregnancy: risk >50%  Cervical incompetence  Uterine abnormalities RISK FACTORS OF PRETERM LABOR (II)

3/2/2016 4:08:01 PMManagrement of Preterm Labour14  Cervical effacement and/or dilatation > 20weeks  Pelvic pressure  Low back pain  Uterine contraction RISK FACTORS OF PRETERM LABOR (III)

3/2/2016 4:08:01 PMManagrement of Preterm Labour15 2. Vaginal examination to assess the cervical status

3/2/2016 4:08:01 PMManagrement of Preterm Labour16 Digital examination is the traditional method used to detect cervical maturation, but quantifying these changes is often difficult.

3/2/2016 4:08:01 PMManagrement of Preterm Labour17 3. Ultrasound assessment of cervical length and dilatation Vaginal ultrasonography → a more objective examination of the cervix (≈ 35mm).

Transvaginal sonogram in early pregnancy showing a normal cervix. Arrows point to the internal and external os

Funneled and short cervix.

3/2/2016 4:08:01 PMManagrement of Preterm Labour20 4. Detection of biological markers Testing with biological markers (24-36 weeks): –Fetal Fibronectin (FFN) - in cervico-vaginal secretions (> 50ng/mL) –Salivary estriol (E3).

3/2/2016 4:08:01 PMManagrement of Preterm Labour21 DIAGNOSIS OF IMPENDING PRETERM DELIVERY (Active preterm labor)

3/2/2016 4:08:01 PMManagrement of Preterm Labour22 IMPENDING PRETERM DELIVERY (Active preterm labor) 3 criteria for active preterm labour (20-36w): uterine contractions - 4 in 20 min. or 8 in 1 h. + cervical changes over time (effacement 80%) or dilatation ≥ to 2 cm (at least 1)

3/2/2016 4:08:01 PMManagrement of Preterm Labour23 Prevention

3/2/2016 4:08:01 PMManagrement of Preterm Labour24 Antenatal care Self-monitoring of uterine activity at home: external tocodynamometer Reduce work, smoking, stress, travel, sexual activity, bed rest, improve nutrition Prevention of Preterm Labor

3/2/2016 4:08:01 PMManagrement of Preterm Labour25 PREVENTION OF PRETERM LABOR Specific obstetric treatment  Bed rest (in hospital)  Cerclage of the cervix  Antibiotics: urinary infection (asymptomatic bacteriuria), local infection (bacterial vaginosis), occult infection  Progesterone

3/2/2016 4:08:01 PMManagrement of Preterm Labour26 Treatment of active preterm labor 1. Inhibition of uterine contractions 2. Corticosteroids 3. Antibiotics

3/2/2016 4:08:01 PMManagrement of Preterm Labour27 Treatment of active preterm labor 1.Inhibition of uterine contractions Bed rest - hospitalisation Hydration and sedation ? Tocolytics Corticotherapy, Antibiotics

3/2/2016 4:08:01 PMManagrement of Preterm Labour28 Choice Of Tocolytic Drug 1.Beta –Sympathomimetic agents (Ritodrine, Isoxsuprine, Terbutaline, Salbutamol) 2.Magnesium sulphate 3. Nonsteroidal anti-inflammatory drugs (Indomethacin) 4.Calcium channel blockers (Nifedipine) 5.Nitric Oxide Donors (Nitroglyerin) 6.Oxytocin receptor antagonist (Atosiban = Tractocile)

3/2/2016 4:08:01 PMManagrement of Preterm Labour29 Choice Of Tocolytic Drug Atosiban: Tractocil a synthetic peptide, acts as a competitive antagonist of oxytocin at uterine oxytocin receptors.

3/2/2016 4:08:01 PMManagrement of Preterm Labour30 Choice Of Tocolytic Drug  Most authorities do not recommend use of tocolytics at or after 34 weeks'.  Tocolysis should be considered for completing a course of corticosteroids, or in utero transfer.

3/2/2016 4:08:01 PMManagrement of Preterm Labour31 Corticosteroids Antenatal corticosteroids are associated with a significant reduction in rates of RDS, neonatal death and intraventricular hemorrhage. The optimal interval between treatment and delivery is 24 hours.

3/2/2016 4:08:01 PMManagrement of Preterm Labour32 Treatment of active preterm labor CORTICOSTEROIDS (GA = weeks) 2 doses of Betamethasone 12 mg i.m. at 24 hours interval or 4 doses of Dexamethasone 6 mg i.m./i.v. at 12 hours interval

3/2/2016 4:08:01 PMManagrement of Preterm Labour33 Treatment of active preterm labor ANTIBIOTICS Ampicillin / Clindamycin / Erythromycin Screen All Pregnant Women for GBS - All patients in preterm labor are considered at high risk.

3/2/2016 4:08:01 PMManagrement of Preterm Labour34 Intra Partum Managements of Preterm Labour  Routine use of prophylactic forceps & episiotomy ?  Postpartum uterine control  If Fetal distress - CS?  Below 28 weeks - NO CS  Below 32 weeks - ?   Above 32 weeks - CS   Vertical uterine incision Minimise Maternal Hypotension and Fetal hypoxia and acidosis  < Respiratory Distress Syndrome