PRETERM LABOUR\ PPROM Dr. A.M.ABDULMALEK - PowerPoint Presentation

Slide1

PRETERM LABOUR\ PPROM

Dr. A.M.ABDULMALEK

MB.BCH,DGO,JBOG,FICS,FRCOG.

Senior consultant OB&GYN /Head of Dept. Specialty hospital , Amman

Slide2

Preterm birth is defined as birth prior to the 37th week of pregnancy.

Each year in the United States, 12.5 percent of births (representing more than 475,000 infants) occur preterm.

The estimated additional cost for neonatal care is $17,300 per preterm infant. In Jordan: Infant and under-5 mortality rates in the past five years are 17 and 21 deaths per 1,000 live births, respectivelyUnder-5 mortality declined by 46 percent over the last 23 years from 39 deaths per 1,000 live births in 1990 to 21 deaths per 1,000 live births in 2012. The neonatal mortality rate is 14 deaths per 1,000 live births, The perinatal mortality rate is 17 per 1,000 pregnancies.

2

Slide3

Pathogenesis of spontaneous preterm birth

1-Activation of the maternal or fetal hypothalamic-pituitary-adrenal axis :

associated with either maternal anxiety and depression or fetal stress

2-Infection : Some organisms \ eg, Pseudomonas, Staphylococcus, Streptococcus,

Bacteroides

, and

Enterobacter) produce proteases, collagenases, and elastases that can degrade the fetal membranes. Bacteria also produce phospholipase A2 (which leads to prostaglandin synthesis) and endotoxin, substances that stimulate uterine contractions and can cause PTL3-Decidual hemorrhage: damaged decidual blood vessels which presents clinically as vaginal bleeding /or retroplacental hematoma formation 4-Pathological uterine distention Multiple gestation, polyhydramnios, 5-Pathologic cervical changes Cervical insufficiency

3

Slide4

4

Slide5

Significance — Preterm birth

*It is

the leading direct cause of neonatal death (death in the first 28 days of life). *It is responsible for

27 %of neonatal deaths

worldwide.

*The risk of neonatal mortality decreases as gestational age at birth increases. *The burden of preterm birth includes neonatal morbidity and long-term sequelae, including neurodevelopmental deficits and an increased risk of a spectrum of diseases in adulthood*In addition, preterm birth is the second most common cause of-death (after pneumonia) in children younger than 5 years.5

Slide6

Women known to be at risk for preterm birth include those with:

Prior preterm birth

Symptoms of preterm labor

Multiple gestationsShort cervix Other:

Abdominal surgery

Previous or threatened spontaneous abortion

Uterine anomaliesIncompetent cervixRisk Factors for Preterm BirthLikis FE, Andrews JC, Woodworth AL, et al. AHRQ Comparative Effectiveness Review No. 74. Available at www.effectivehealthcare.ahrq.gov/pretermbirth.cfm.

6

Slide7

7

Slide8

Approaches to Prevention of Preterm Birth

The ultimate goals of preventing preterm birth are:

To eliminate the risks of neonatal death or complications

To prevent long-term health consequencesTo promote normal childhood development

To reduce maternal complications

Interventions used once a woman has symptoms of preterm labor have not been reliable for preventing preterm birth.

Earlier interventions based on risk rather than symptoms are hoped to be more effective 8Likis FE et al. AHRQ Comparative Effectiveness Review No. 74. Available at www.effectivehealthcare.ahrq.gov/pretermbirth.cfm.

Slide9

UNPROVEN INTERVENTIONS

1-Diagnosis and treatment of genital tract infection 

2-Treatment of periodontal disease 

3-Weight management 4-Assessment of uterine activity 5-Bed rest and hospitalization 6-Abstinence

7-Prophylactic

tocolytic

drugs 8-Enhanced prenatal care 9-Social support and relaxation therapy 10-Thyroid hormone 9

Slide10

9

POTENTIALLY EFFECTIVE INTERVENTIONS

1-

Supplemental progesterone 

2-Inhibition of acute preterm labor 

3-Diagnosis and treatment of asymptomatic

bacteriuria 4-Smoking cessation 5-Avoidance of cocaine 6-Decrease the rate of multiple gestation from ART 7- Cervical cerclage 

8-

Pessary

9- Reduce occupational fatigue 

10-Nutritional intervention 

11-Avoiding a short

interpregnancy

interval 

12-Avoidance or treatment of malaria 

Slide11

Identification of and prevention in women at risk

The identification of women at high risk of preterm delivery remains a major challenge

.

Investigations such as fetal fibronectin or cervical ultrasound can be used to identify women at high risk.There is also good evidence that measurement of cervical length can be used as a predictor. determination of risk, therefore, tends to be based on obstetric history11

Slide12

Screening and treatment of bacterial vaginosis

screen women for bacterial

vaginosis

if they are at high but not at low risk of preterm delivery. administration of metronidazole in women with a positive fetal fibronectin may be associated with a worsening of pregnancy outcome topical clindamycin as the first‐choice treatment.12

Slide13

Progesterone

Progesterone

is considered a key hormone for pregnancy maintenance, A decline of progesterone action is implicated in the onset of parturition.

Progesterone

has been

recommended for pregnant women with prior preterm birth.This use is based on reviews of clinical research that indicated that progesterone can prolong pregnancy for women at risk of preterm birth, based on having a prior spontaneous preterm birth.13Likis FE, Andrews JC, Woodworth AL, et al. AHRQ Comparative Effectiveness Review No. 74. sept.2012.

Slide14

The clinical studies are supported by two recent meta‐analyses that suggest that both 17OHP and natural vaginal progesterone reduce the risk of preterm delivery in high‐risk women.

14

Slide15

Cervical cerclage

Elective

cerclage

may be indicated when there is a congenital or acquired weakness in the cervix that increases the risk of late miscarriage or preterm delivery. Unfortunately, there is little consensus on which women will benefit from cerclage and definitive evidence is often lacking.Recently, after the publication of a number of supporting trials, there has been a trend for cerclage in women identified to have a short cervix on midtrimester ultrasound15

Slide16

Transvaginal

techniques

(McDonald or

Shirodkar) McDonald procedure places a purse‐string stitch in the stroma of the ectocervix at the level of reflection of the vaginal fornices.The Shirodkar suture requires an incision in the vaginal mucosa, reflection of the pubo‐cervical fascia at the level of the internal os which the suture to be placed at the level of the cardinal ligaments.Trans‐abdominal

procedure

for the small proportion of women in whom the vaginal procedure is inappropriate.

16

Slide17

Treatment women admitted in threatened preterm

labour

should be appropriately assessed to determine the optimal time for delivery

.presence of fetal compromise or intrauterine infection can hinder prolonging the pregnancy, early gestational age and uncomplicated preterm labour with intact membranes can mitigate a delay in delivery.17

Slide18

Antibiotics

antibiotics cannot be justified for the treatment of preterm

labour

in the absence of prelabour rupture of the membranes.if rupture of the membranes occurs preterm before the onset of labour, administration of erythromycin is associated with prolongation of pregnancy and improved neonatal outcome.adverse effect of augmentin on neonatal necrotising enterocolitis was noted, erythromycin seems a logical first‐choice antibiotic.18

Slide19

Steroids

antenatal steroids should be given to mothers who have threatened preterm

labour

to reduce the incidence of neonatal respiratory distress syndrome, intraventricular haemorrhage and perinatal death.a single course of betamethasone should be given to almost all mothers in threatened preterm labour unless contraindicated or delivery is imminent.19

Slide20

Tocolysis

Meta‐analysis of

tocolysis

compared with placebo or no treatment has shown a delay in delivery and maternal side effects associated with tocolysis but without improved perinatal outcome.Assuming that tocolysis is administered, the question then becomes which drug should be used. the calcium channel blocker nifedipine or the oxytocin antagonist atosiban.20

Slide21

Nifedipine

fewer maternal side effects and improved neonatal outcome have been reported in women given

nifedipine rather than ritodrine a delay in delivery, reduction in deliveries at <34 weeksAtosiban Atosiban is an analogue of oxytocin that inhibits activity at oxytocin and vasopressin (V1a) receptors. atosiban is as effective as β sympathomimetics, without the maternal side effects.

21

Slide22

ConclusionPreterm

labour

is a multifactorial condition associated with a high risk of morbidity and mortality

,treat threatened, uncomplicated preterm labour with an oxytocin antagonist to delay delivery for steroid administration or transfer to an appropriate unit for delivery. Given that a single course of steroids should be given, we believe there is no indication for subsequent retreatment.22

Slide23

Preterm Premature Rupture of Membranes (PPROM)

Patient

presents with suspected

PPROM

.

CONFIRM PPROM Evident intrauterine infection, bleeding sufficient to threaten maternal well-being, or fetal death? yes DELIVER expeditiously23TRANSFER TO L&Das needed, give tocolytic ONLY to allow transport of PPROMpatients having labor contractions.ASSESS for PPROMMedical history and physical exam, other tests as needed.

Slide24

NO MANAGE

per

gestational age as outlined below 1- Less than 24 weeks PROVIDE COUNSELING to patient and family Per patient choice, either: • INDUCE labor

•

MANAGE

expectantly/ MAKE decision to resuscitate (INPATIENT) • MANAGE expectantly/ MAKE decision not to resuscitate (OUTPATIENT)24

Slide25

2- 24

weeks–33 weeks 6

days MANAGE expectantly (inpatient)25

GIVE magnesium for

neuroprotection

if delivery at <32 weeks is expectedwithin 24 hrsGIVE corticosteroidGIVE antibiotic to prolong latencyPROVIDE surveillance: • Daily nonstress test to monitorfetal health.• Periodic (not daily) ultrasound toassess amniotic fluid; if patient no longerreports leakage of fluid, do u/s to check forreaccumulation of fluid suggesting resealingof the rupture. (If resealed, the patient maybe discharged home.)

Slide26

3-

34

weeks or greater

26DELIVER(usually by induction of labor)

GIVE corticosteroid

GIVE antibiotic for GBS prophylaxis

as needed, following Prevention of Perinatal GBS guidelines

Slide27

ASSESSMENT AND MANAGEMENTCONSIDERATIONS

PPROM

AssessmentPPROM is a clinical diagnosis usually based on patient history and visualization of amniotic fluid during physical exam. In some cases, lab tests are needed to exclude other possible causes of vaginal or perineal wetness.Medical history:

Timing and quantity of leaking or wetness, weeks gestation / EDD, pregnancy history of PPROM,

etc

Physical exam: Avoid digital exam unless active labor or imminent delivery is expected.Use sterile speculum examination to:27

Slide28

Visually

inspect for cervicitis, umbilical cord

prolapse

, or fetal prolapseAssess cervical dilation and effacementObtain cultures as needed Visually confirm PPROM diagnosis Test: if diagnosis of PPROM can’t be visually confirmed:Test pH of fluid from posterior vaginal fornix Look

for

arborization

of fluid from posterior vaginal fornix 28

Slide29

Consider

ultrasound

:to check amniotic fluid volume; to assess fetal weight, gestationalage, and presentation; to check for fetal anatomic abnormality; or to confirm diagnosis ofPPROM by guiding transabdominal instillation of indigo carmine dye.Consider amniotic fluid-specific biomarker test (e.g., AmniSure or ROM Plus) If diagnosis of PPROM remains uncertain after physical examination, nitrazine, and fern tests.

29

Slide30

MEDICATION MANAGEMENT

Magnesium for

neuroprotection

in PPROM <32 weeks when delivery is expected within 24 hoursCorticosteroid to lower risk of RDS Antibiotics to prolong latency30