1. Preterm labor

2. Preterm termination of pregnancy
Abortion: …22 week of gestation
Premature labor [PTL]:
23 – 36 week of gestation

3. Preterm labor [PTL] Spontaneous Iatrogenic
(result of therapeutic intervention)

4. Preterm labor : definition
Regular uterine contractions
Cervical effacement
Cervical dilation

5. The earlier treatment
the better results!

6. The earlier the gestational age the worse neonatal outcomes!

7. Consequences of PTL Preterm birth Perinatal death
Neonatal complications:
- Respiratory Distress Syndrome [RDS]
Intraventricular hemorrhage
Necrotizing enterocolitis
Sepsis
Seizures

8. Consequences of PTL Long-term morbidity: Bronchopulmonary dysplasia
Cerebral palsy
Developmental abnormalities

9. Etiology of PTL Idiopathic! Infections: local / generalized
Excessive uterine enlargement (hydramnios, multiple gestation)
Fetal congenital anomalies
Incompetent cervix
Premature rupture of membranes [PROM]
Dehydration
Uterine anatomical malformations
Maternal smoking!

10. Symptoms and signs of PTL
Uterine contractions
Abdominal / pelvic pressure
Low backache
Menstrual-like cramps
Changes in vaginal discharge:
volume, consistence, blood content

11. Prevention of PTL?
Patient education to recognize signs and symptoms of PTL
Risk scoring programs
Unfortunately:
the frequency of PTL is stable

12. Evaluation of a patient in PTL
Status of the cervix (dilation and effacement):
Speculum
Digital examination
2. Cervical culture
3. Contractions:
Electronic fetal monitoring (frequency and duration)
Abdominal palpation (intensity)

13. Evaluation of a patient in PTL
Ultrasound examination: gestational age of the fetus, fetal presentation, AFI, placental location
Vaginal bleeding: volume, fresh / dark blood (placenta previa? abruptio placentae?)
Urine: analysis, culture (infections)

14. Management of PTL To delay delivery (until fetal maturity)
Therapy of PTL itself
Detection and treatment of disorders leading to PTL

15. Tocolysis
Def.: the suppression of uterine contractions by pharmacologic treatment
One patient = one form of tocolysis
Additions: if previous treatment is not effective
Start: 20 – 34 weeks of gestation
Remember to stop therapy! (36 weeks)
Still controversial: do tocolytics prolong pregnancy?

16. Intravenous hydration
1. Compound electrolyte solution:
1000 ml / 12 hours
2. After 12 hours: reevaluation
Calcium-channel blockers (nifedidpine)
Quit therapy

17. Calcium-channel blockers: nifedipine
Loading dose: 3 x 10 mg in: 0` - 30 ` - 60`
Then:
4 x 20 mg p.o. (every 6 hours)
Potentiates effects of MgSO4
(hypotension! respiratory depression!)

18. Β-adrenergic agents: fenoterol
1 mg in 500 ml 0.9% NaCl
Keep the inflow: 2.5 – 3.0 ug/min
for 6 hours
Changes of inflow - dependent on result
Max. 48 hours
Control: HR, blood pressure, glucose levels, ions
In effective inhibition of uterine contractions: convert to nifedipine

19. Magnesium sulfate (MgSO4)
Loading dose: 4 g in 20 ml 0.9% NaCl i.v.
1st day: 8 g in 500 ml of compound electrolyte solution i.v. every 12 hours (twice a day)
2nd day: 6 g in 500 ml of compound electrolyte solution i.v. every 12 hours
Total dose: 30 – 32 g of MgSO4
Control: magnesium levels!

20. Prostaglandin synthetase inhibitors: indomethacin
Only in non- effectiveness of previously described tocolytics
Between 28 and 32 weeks of gestation
60 mg i.m. every 12 hours
Max. dose: 300 mg
Ultrasound control: AFI, ductus arteriosus blood flow (doppler)

21. Steroids To enhance fetal pulmonary maturity
24 – 34 weeks of gestation
Betamethasone 2 x 12 mg i.m. with 12 hours interval
Caution: steroids promote infections!
Control: CRP, glucose levels

22. General contraindications to tocolysis
Advanced labor (cervical dilation > 4 cm)
Mature fetus (>34 weeks of gestation)
Severely anomalous fetus
Intrauterine fetal death
Significant vaginal bleeding
Possibility of the adverse effects of tocolysis
Any complications contraindicating delay in delivery