1. Preterm Birth Present by: Dr.Worapa Asavaritikrai Health Promotion Center Region 4

2. Objective Definition Risk factors Diagnosis Treatment

3. Definition of Preterm Birth A birth that occurs before 37 completed weeks of gestation (<259 days) Late preterm births, defined as 34-36 +6 weeks of gestation (~ 75% of all preterm birth)

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6. SURVIVAL RATE OF INFANTS RAMATHIBODI HOSPITAL (2000-2008)

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8. Reasons for preterm delivery 4 main direct reasons: – Maternal or fetal indications – Spontaneous unexplained preterm labor with intact membranes – Idiopathic preterm premature rupture of membranes (PPROM) – Twins Cunningham et al, 23 rd Ed Williams Obstetrics

9. Definition of PPROM Defined as rupture of the membranes before labor and prior to 37 weeks of gestation

10. Antecedents & Contributing Factors Threatened Abortion Lifestyle Factors Racial & Ethnic Disparity Work During Pregnancy Genetic Factors Periodontal Disease

11. Antecedents & Contributing Factors Birth Defects Interval between Pregnancies & Preterm Birth Prior Preterm Birth Infection Bacterial Vaginosis

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14. ร่างแผนการดูแลการเจ็บครรภ์คลอดก่อน กำหนด Clinical Practice Guidelinen of Preterm labor Prevention of preterm birth

15. Primary Prevention Secondary Prevention Tertiary Prevention Preventions of Preterm Birth

16. Primary Prevention

17. Preconceptional Public educational interventions: – Increased awareness – Uterine curettage or endometrial biopsy – Reduce prevalence of smoking – Reduce risk of higher-order multiple gestation – Socioeconomic approach

18. During Pregnancy Smoking cessation in pregnancy Prenatal care Periodontal care ?? Screening of low-risk women Screening of low-risk women

19. Smoking cessation A Cochrane review reported that smoking cessation programmes in pregnancy successfully reduce the incidence of preterm birth (RR 0·84, CI 0·72–0·98) Lumley J.Cochrane Database Syst Rev 2004

20. Prenatal Care High rate of preterm birth in women who receive no prenatal care than from the content of care for those who receive it

21. Periodontal care Treatment during pregnency improved periodontal disease and it is safe, but it did not significantly alter rate of preterm birth Michalowicz BS. N Engl J Med 2006; 355: 1885–94

22. Screening of low-risk women -Screening and treatment of asymptomatic bacteriuria prevent pyelonephritis -Given antibiotic in low-risk does not reduce this risk of preterm birth Cunningham et al, 23 rd Ed Williams Obstetrics

23. Secondary Prevention

24. Fetal fibronectin testing Glycoprotein Marker of choriodecidual disruption Levels > 50 ng/mL ( >22 weeks) associated with an increased risk of spontaneous preterm birth The Cochrane Library 2009, Issue 2

26. Cervical length Cervical shortening is a risk factor for preterm delivery Especially useful in asymptomatic women : at 24 wks, a cervical length < 25 mm

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28. Tertiary Prevention

29. Early diagnosis of preterm labour Treatment of women with acute risk of preterm birth  to arrest preterm labour : tocolysis  antenatal corticosteroid use  antibiotic for group B streptococcal prophylaxis

30. Regular contractions accompanied by cervical change at less than 37 weeks ACOG 1997 criteria preterm labor: – Contractions of four in 20 min. or eight in 60 min. + progressive change in the cervix – Cervical dilatation > 1 cm – Effacement > 80%. Diagnosis of preterm labor

31. Regular contractions without cervical change Threatened preterm labor

32. Management of Preterm Labor PPROM Preterm labor with intact membranes

33. Table 36-8

34. Tocolytic agents ACOG 2007 has concluded that tocolytic agents do not markedly prolong gestation, but may delay delivery in some women for at least 48 hours

35. Tocolytic agents Β- Adrenergic receptor agonists – Ritodrine, Terbutaline Magnesium sulfate Prostaglandin inhibitors Calcium-channel blockers Atosiban Nitric oxide donors

36. Terbutaline DoseCIMaternal SEFetal SE 0.25 mg SC every 20 min to 3 h (hold for P>120 bpm) Cardiac arrhythmia, poorly control thyrotoxicosis or DM Cardiac arrhythmia, pulmonary edema, MI, hypotension, hyperinsulinemia, antidiuresis, hypokelemia, Tachycardia, hyperinsulinemia, hyperglycemia, neonatal hypoglycemia, hypocalcemia, hypotesion, myocardial and septal hypertrophy, MI Hearne AE, Nagey DA. Therapeutic agents in preterm labor: tocolytic agents. Clin Obstet Gynecol 2000;43:787-801

37. Magnesium sulfate DoseCIMaternal SEFetal SE 4-6 gm bolus then 2-3 gm/hr Myasthenia gravis Flushing, lethargy, headache, muscle weakness, diplopia, dry mouth, pulm edema, cardiac arrhythmia Lethargy, hypotonia, resp. depression, demineralization with prolong use Hearne AE, Nagey DA. Therapeutic agents in preterm labor: tocolytic agents. Clin Obstet Gynecol 2000;43:787-801

38. Nifedipine DoseCIMaternal SEFetal and neonatal SE 30 mg Loading Then 10-20 mg q 4-6 hr Cardiac dis, use caution with renal dis,BP<90/50m mHg, Avoid use with MgSo4 Flushing, headache, dizziness, Nausea, transient hypotension None note as yet Hearne AE, Nagey DA. Therapeutic agents in preterm labor: tocolytic agents. Clin Obstet Gynecol 2000;43:787-801

39. Corticosteroid Therapy Enhance fetal lung maturation Rescue therapy? Betamethasone is superior to Dexamethasone Regimens: – Two doses of Betamethasone12 mgIMq 24 hrs – Four doses of Dexamethasone 6 mgIMq 12 hrs

40. Goal is neonatal sepsis prevention Goal is neonatal sepsis prevention Not to prevent preterm birth Not to prevent preterm birth Group B streptococcus prophylaxis

41. Centers for Disease Control and Prevention, 2002d

42. Cunningham et al, 23 rd Ed Williams Obstetrics

43. Recommended Management of Preterm Labor Confirmation of preterm labor GA <34 weeks: corticosteroids are given for enhancement of fetal lung maturation GA <34 weeks: reasonable to attempt inhibition of contractions to delay delivery while given corticosteroid & group B streptococcal prophylaxis GA >34 weeks: monitor for labor progression & fetal well-being

44. Thank You