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DR G MUNISWARAN,
MFM SPECIALIST , OBSTETRICIAN & GYNAECOLOGIST,
MBBS(UM), MOBGYN(UM), MRCOG(UK), MFM (MAL/UK)
MATERNITY HOSPITAL KUALA LUMPUR
Care Bundles:
Preterm labour
Declaration
No conflict of interest
Impact
An estimated 15 million babies are born prematurely yearly
Increase in incidence - 5% to 18% between countries.
Racial and ethnic inequalities
Deaths from preterm birth complications - leading cause of under-5
mortality The unfinished agenda of preterm
births
The Lancet 12 November 2016
Significance
Most common cause of hospital admissions
Significant neonatal morbidity
Burden of disease enormous - USD 51,000 per premature
infant
Level III
Goldenberg RL, Culhane JF, Iams JD, Romero R.
Epidemiology and causes of preterm birth. Lancet 2008
Prevention
Teenage pregnancy
Nutrition & well-being
Spacing
Improvedantenatal
care
Modificationsof risk factors
Tobacco & substance
misuse
Prevention
Cervical screening
ProgesteroneAsymptomatic
bacteuria
Rescue
Cerclage
Cervical pessary
Universal screening
Transvaginal cervical length screening 19–23 6/7 weeks
Length of significance 25mm
FIGO Best practice in maternal–fetal medicine☆ International
Journal of Gynecology and Obstetrics 128 (2015) 80–82
SMFM Consult
Practicality? Cost effectiveness in resource limited countries?
Universal screening in
Malaysia?
Urine C&S at booking ??
Inconclusive evidence from Cochrane…
Smaill FM. Cochrane database. 2015
Progesterones
Progesterones for women with preterm or shortened cervix
Phase III trials and meta-analysis
Dodd JM, Cochrane database 2013FIGO Best practice in maternal–fetal medicine☆ International
Journal of Gynecology and Obstetrics 128 (2015) 80–82
RCT – benefits yet to be proven
Progesterones
Cervix<25mm
Significant risk Cerclage
No significantrisk
Vaginalprogesterone
Preterm labour and birth NICE guideline Published: 20
November 2015 nice.org.uk/guidance/ng25
Rescue cerclage
Consider between 16+0 and 27+6 weeks of pregnancy with a dilated cervix
and unruptured fetal membranes
Preterm labour and birth NICE guideline Published: 20
November 2015 nice.org.uk/guidance/ng25
Cervical pessary
Care bundles
Diagnosis Tocolysis Corticosteroids
Fetal neuroprotection
PPROMMode of delivery
Diagnosis
Challenges
Less than 10% of women with clinical diagnosis deliver within 7days of
presentation
30% resolve spontaneously
50% of hospitalized patients delivery at term
Fuchs IB et al. Sonographic cervical length in singleton pregnancies with intact membranes
presenting with threatened preterm labor. Ultrasound Obstet Gynecol 2004;24:554–7.
Level II-3
Contractions but no cervical
change..
Only 18% delivered before 37weeks and within 2weeks
Iams JD, Romero R. Preterm birth. In: Gabbe SG, Niebyl JR, Simpson JL,
editors. Obstetrics: normal and problem pregnancies. 5th ed.
Philadelphia (PA): Churchill Livingstone Elsevier; 2007. p. 668–712.
Level III
Threatened preterm labour – care
bundle
History
Secondary test
Examination
Cervical length
15mm
Quantitative fetal fibronectin
<10 or > 200ng/ml
Care bundle
If pregnancy is beyond 30weeks, consider performing cervical
length.
No interventions if cervix > 15mm
Preterm labour and birth NICE guideline Published: 20
November 2015 nice.org.uk/guidance/ng25
Additional test?
Fetal fibronection - Quantitative & qualitative
Ness A et l. Does knowledge of cervical length and fetal
fibronectin affect management of women with threatened
preterm labor? A randomized trial. Am J Obstet Gynecol
2007;197:426.e1–7.
Level II-2
Quantitative fetal
fibronection
American Journal of Obstetrics & Gynecology FEB 2013
ACOG 2015 May;125(5):1168-76.
Tocolysis
Optimal patients for
intervention
Delay in delivery by 48 hours will be beneficial
Common drugs for
tocolysis
Tocolysis
Nidefipine – 1st line ( off license use)
Atosiban – less maternal side effects
Not more superior than nifedipine or betamimetics
Vicki Flenady. Cochrane Database. 2014
Progesterones for acute
tocolysis
No evidence of benefits
Lin-Lin Su. Cochrane Database. 2014
Corticosteroids
Corticosteroids
Single course - 24-34 weeks
Most efficacious 2-7days of delivery
Reduction in neonatal death, RDS, IVH, NEC & need for
mechanical ventilation
Number needed to treat increases after 34weeks
Devender Roberts. Cochrane Database March 2017
Corticosteroids dosage
Bethamethasone
IM 12mg OD x 2days
Dexamethasone
IM 6mg QID x 2 days
No benefits of “accelerated dosing” or repeat doses
ACOG. 2016
Cochrane database. 2013.
BMJ 2016;355:i5044 | doi: 10.1136/bmj.i5044
Lee et al.NICHD. Pediatrics 2008;121:289–96
Rescue dose
Repeat IM 12mg if given 14days later from initial dose
Reduction in RDS, need for surfactant and composite morbidity
No difference in long term outcomes
Garite TJ, Obstetrix Collaborative Research Network
Am J Obstet Gynecol 2009;200:248.e1–9
2015 Crowther Cochrane meta-analysis
Fetal
neuroprotection
Magnesium sulphate for fetal
neuroprotection
Up till 31 weeks plus 6 days
Continue tocolysis despite on magnesium sulphate
Dose 4g IV over 30minutes & 1g/hour
Minimum duration – 4 hours
Discontinue after 24 hours
Insufficient evidence for repeat doses
Nguyen T-MN. Cochrane database 2013.
SOGC 2011
PPROM
PPROM
Most sensitive diagnosis – per speculum examination
if pooling of amniotic fluid is not observed, consider performing an
insulin-like growth factor binding protein-1 test or placental alpha-
microglobulin-1 test of vaginal fluid.
Antibiotics
Do not rely on single test of CRP or raised WBC to make a decision
Mode of
delivery
Mode of delivery for preterm singletons
Caesarean section conferred no benefits in singleton
pregnancies
Breech – individualized management
Avoid ventouse < 34weeks
Zarko Alfirevic. Cochrane Database. 2013
Not recommended
Prophylactic &Repeat steroids
Antibiotics for intact
membranes
Prolonged tocolysis
Non pharmacological
measures
Future
PAMG – 1 – placental alpha microglubilin 1 (Partosure)
Vyacheslav Bolotskikh J. Obstet. Gynaecol. Res. 2017
ACOG 2014. DOI: http://dx.doi.org/10.1016/j.ajog.2014.10.174J Perinatal Med. 2014 Jul;42(4):473-7. doi: 10.1515/jpm-2013-0234.
Care bundle for preterm
labour
IM 6mg Dexa 6 hourly x 2 days if delivery within 7
days
MgSo4
before 32 weeks
( 4 hours)
Delay delivery for 48 hours (nifedipine)
Use cervical length or
quantitative fibronectin
Progesterones & cerclage has a
role in preventionEES for PPROM
17th November
References
ACOG practice bulletin. Number 171, October 2016
Cochrane database 2013
FIGO Best practice in maternal–fetal medicine☆ International Journal of Gynecology and Obstetrics 128 (2015) 80–82
Preterm labour and birth NICE guideline Published: 20 November 2015 nice.org.uk/guidance/ng25
THANK
YOU
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