m. Preterm and Postterm.new Ppt

8/19/2019 m. Preterm and Postterm.new Ppt

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Department of Obstetrics and Gynecology


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I. AS TO SIZE

Small-for-gestational age / fetal grot!restriction / intra"terine grot! restriction#SGA/I$G%&

newborns with birthweight below the 10th

percentile for gestational age'arge-for-gestational age #'GA& birthweight above the 90th percentile

Appropriate-for-gestational age #AGA& newborns with weight between the 10th and 90th

percentiles


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II. AS TO AOG

(reterm or premat"re birt! neonates born too early

delivery before 37 completed weeksTerm )* + , ees

(ost term

, ees


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III AS TO 0EIG1T 'o birt!eig!t

refers to births 500 to 2500 g

2ery lo birt!eig!trefers to births 500 to 1500 g

E3tremely lo birt!eig!t

refers to births 500 to 1000 g.


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A.elivery for maternal or fetal indications inwhich labor is ind!ced or the infant isdelivered by prelabor cesarean delivery

".#pontaneo!s !ne$plained preterm laborwith intact membranes

%.&diopathic preterm premat!re r!pt!re of

membranes '(()*+,.-wins and higherorder m!ltifetal births


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4edical and Obstetrica' Indications


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e/ned as r!pt!re of the membranesbefore labor and prior to )* ees

(reterm premat!re r!pt!re of membranescan res!lt from a wide array of pathological

mechanisms incl"ding intra-amnionicinfection

%is factors low socioeconomic stat!s

low body mass inde$less than 19. n!tritional de/ciencies cigarette smoking


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(athogenesis of preterm labor'1, progesterone withdrawa

'2, o$ytocin initiation

'3, decid!al activation


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&. -hreatened Abortion

&&. ifestyle 4actors&&&. )acial and thnic isparity

&6. ork !ring pregnancy

6. 8enetics

6&. (eriodontal diseases

6&&. "irth efects

6&&&. &nterval "etween pregnancies and pretermbirth

&. (rior preterm birth

. &nfection


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I. T1%EATE5ED A6O%TIO5 6aginal bleeding or spotting is associated

with increased incidence of s!bse:!entpregnancy loss prior to 2; weeks pretermlabor and placental abr!ption


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III. 'I7EST8'E 7A9TO%SA%igarette smoking

". &nade:!ate maternal weight gain d!ring

pregnancy%. &llicit dr!g


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. *ther maternal factors yo!ng or advanced maternal age poverty short stat!re 6itamin % de/ciency occ!pational factors< prolonged walking or

standing stren!o!s working conditions andlong weekly work ho!rs

.depression an$iety and chronic stress4.omen in=!red by physical ab!se


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2. 0O%: D$%I5G (%EG5A598 oring long !o"rs and !ard p!ysical

labor are probably associated withincreased risk of preterm birth

2I GE5ETI9S )ec!rrent familial and racial nat!re of

preterm birth has led to the s!ggestion thatgenetics may play a ca!sal role

&mm!noreg!latory genes in potentiating

c!orioamnionitis in cases of pretermdelivery d!e to infection


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2I (E%IODO5TA' DISEASE associated with preterm birth

2II 6I%T1 DE7E9TSassociated with preterm birth


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INFECTION ETIOLOGY DIAGNOSTIC

FEATURES

MANAGEMENT

Periodontitis Fusobacteriumnucleatum and

Capnocytophaga species

Teeth cleaningand polishing;

deep rootscaling andplanning plusmetronidazole


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2III. Inter;al beteen(regnancies and (reterm 6irt!

intervals s!orter t!an ? mont!s were associatedwith increased risks for both preterm


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2II 6I%T1 DE7E9TS associated with preterm birth and low

birthweight

2III. Inter;al beteen(regnancies and (reterm 6irt!

intervals s!orter t!an ? mont!s were associatedwith increased risks for both preterm birth


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I@.(rior (reterm 6irt! -he risk of rec!rrent pretermdelivery for women whose /rst

delivery was preterm was increasedt!reefold compared with that ofwomen whose /rst neonate was born

at term


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@. I57E9TIO5 -wo microorganisms Ureaplasmaurealyticum and Mycoplasma

hominis have emerged as importantperinatal pathogens


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POTENTIAL ROUTES OF INTRAUTERINE INFECTION


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6A9TE%IA' 2AGI5OSIS normal hydrogen pero$ideprod!cing

lactobacill!spredominant vaginal >ora isreplaced with anaerobes that incl!de

Gardnerella vaginalis, Mobiluncus species andMycoplasma hominis iagnosis by gram stain and 5"gent score associated with spontaneo!s abortion preterm

labor preterm r!pt!re of membraneschorioamnionitis and amnionic >!id infection

s!sceptible T57-alp!a genotype had aninefold increased incidence of preterm birth


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INFECTION ETIOLOGY DIAGNOSTIC

FEATURES

MANAGEMENT

Bacterialvaginosis

Gardnerellavaginalis,Mobiluncus species, andMycoplasma

hominis

-Vaginal pH > 4.5-Homogenousvaginal discharge- mine odor !henvaginal secretions

are mi"ed !ith #$H- Vaginal epithelialcells heavil% coated!ith &acilli 'cluecells(- )ram staining o*vaginal secretions

sho! *e! !hite cellsalong !ith mi"ed*lora as compared!ith the normalpredominance o*lacto&acilli

+etronidazole 5mg B *or / da%s


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Trichomoniasis and0andida Vaginitis

Trichomonasvaginalis

- demonstration o*Trichomonads &% !et

mount o* vaginalsecretions;Trichomondas areidenti*ied mostaccuratel% &% cultureusing iamond medium,irect

immuno*lorescent,+onoclonal & stainingis sensitive and speci*icalternative

- 1outine screeningand treatmetn *or this

condition cannot &erecommended- +etronidazole 25mg T *or / da%s- +iconazole,0lotrimazole andn%statin are e**ective

*or vaginal candidiasis

3o!er genital tractin*ection

Chlamydiatrachomatis

- )enitourinar%0hlam%dial in*ection at24 !ees &ut not at 2!ees detected vialigase chain reactionassa% !as associated!ith a 2-*old increase insu&se6uentspontaneous preterm&irth

7r%throm%cin 5 mgP$ 8 *or / da%s


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painf!l or painless !terine contractions pelvic press!re menstr!allike cramps watery vaginal discharge pain in the low back

Braxton Hicks contractions

- contractions described as irreg!larnonrhythmical and either painf!l or painless canca!se considerable conf!sion in the diagnosis oftr!e preterm labor


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%ontractions fo!r in 20 min!tes

or eight in ?0 min!tes pl!sprogressive change in the cervi$%ervical dilatation greater than1 cm

%ervical e@acement of 0percent or greater


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A. 9E%2I9A' DI'ATATIO5


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#hort cervi$ by itself was

the poorest predictor ofpreterm birth whereasf!nneling pl!s a history ofprior preterm birth was highlypredictive.


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rec!rrent painless cervical dilatation andspontaneo!s midtrimester birth in the absence ofspontaneo!s membrane r!pt!re bleeding or

infection


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an e$ternal tocodynamometer is belted aro!ndthe abdomen and connected to an electronicwaist recorder

terine activity is transmitted via telephone

daily omen are ed!cated concerning signs and

symptoms of preterm labor and clinicians arekept apprised of their progress

A%*8 concl!ded that the !se of this e$pensiveb!lky and timecons!ming system does notred"ce t!e rate of preterm birt!


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glycoprotein prod!ced in 20 di@erent molec!lar formsby hepatocytes /broblasts and endothelial cells andby fetal amnion

(resent in high concentrations in maternal blood andin amnionic >!id which play a role in intercell"lar

ad!esion d"ring implantation and in t!emaintenance of placental ad!esion to t!edecid"a

detected in cervicovaginal secretions in women whohave normal pregnancies with intact membranes at

term and it appears to re>ect stromal remodelingof t!e cer;i3 prior to labor


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/bronectin detection in cervicovaginal secretionsprior to membrane r!pt!re was a possiblemarer for impending preterm labor

meas!red !sing an enyme-linedimm"nosorbent assay

;al"es e3ceeding >B ng/m are consideredpositive

positive val!e for cervical or vaginal fetal/bronectin assay as early as = to ees powerf!l predictor of s!bse:!ent preterm birth


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A. (%OGESTE%O5E +aternal plasma progesterone levels

increase thro!gho!t pregnancy +aintain !terine :!iescence and BblockB

labor initiation


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(rogesterone t!erapy s!o"ldbe limited to omen it! a

doc"mented !istory of apre;io"s spontaneo"s birt!at less t!an )* ees

merican 0ollege o* $&stetricians

and )%necologists 92:


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6.9E%2I9A' 9E%9'AGE&C&%A-&*C# 4*) %)%A8 history of rec!rrent midtrimester losses and

who are diagnosed with an incompetentcervi$

women identi/ed d!ring sonographice$amination to have a short cervi$.

Bresc!eB cerclage done emergently whencervical incompetence is recogniDed in thewomen with threatened preterm labor


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I.DIAG5OSIS (%ETE%4 %$(T$%ED4E46%A5ES

A history of vaginal leakage of >!id sho!ldprompt a sterile spec"l"m e3amination

to vis!aliDe gross vaginal pooling ofamnionic >!id clear >!id from the cervicalcanal or both

%on/rmation by "ltrasonograp!ic e$amination to assess amnionic >!idvol!meE to identify the presenting partE andif not previo!sly determined to estimategestational age


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7e;er is the only reliable indicator for thisdiagnosis and temperat!re of 3F%'100.;F4, or higher accompanying r!pt!redmembranes implies infection

4aternal le"ocytosis alone has not beenfo!nd to be reliable

!ring e$pectant management monitoring for s!stained maternal or fetal tachycardia

for !terine tenderness and for a malodoro!svaginal discharge is warranted.


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+ACA8+C- &f chorioamnionitis is diagnosed prompt

e@orts to e@ect delivery preferably;aginallyC are initiated.


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A99E'E%ATE 7ETA' S$%7A9TA5T(%OD$9TIO5

chronic renal or cardiovasc!lar disease hypertensive disorders heroin addiction fetalgrowth restriction placental infarction

chorioamnionitis preterm r!pt!red membranes


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+etaanalysis indicated that only three of 10 o!tcomeswere possibly bene/ted<

'1, fewer women developed chorioamnionitis'2, fewer newborns developed sepsis '3, pregnancy was more often prolonged 7 days in womengiven antimicrobials.

Ceonatal s!rvival however was !na@ected as was theincidence of necrotiDing enterocolitis respiratory distress

or intracranial hemorrhage.

+ercer and rheart 9


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-here is no consens!s regardingtreatment between ) and ),ees. -hey are notrecommended prior to , ees.


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-he cornerstone of treatment is to avoiddelivery prior to ), ees if possible.

1. Amniocentesis to detect infection

2. #teroid therapy to enhance fetal l!ng

mat!ration

3.Antimicrobials

;.mergency or resc!e cerclage


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1. "ed rest

2. Gydration and sedation

3. "eta adrenergic receptor agonist'e$)itodrine &so$s!prine,

5. +agnesi!m s!lfate?. (rostaglandin inhibitors 'e$.

&ndomethacin,

7. %alci!m channel blockers

Cifedipine. Atosiban 'o$ytocin antagonist,

9. Citric o$ide donors 'nitroglycerin, H note@ective


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◦ )itodrine◦ -erb!taline &so$!prine


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inhibiting prostaglandin synthesis or byblocking their action on target organs

associated with early clos!re of patentclos!re of d!ct!s arterios!s


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-he combination of nifedipine withmagnesi!m for tocolysis is potentiallydangero"s

"enAmi and coworkers reported that

5ifedipine en!ances ne"rom"sc"larblocing eects of magnesi"m that caninterfere with p!lmonary and cardiacf!nction


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-he following considerations sho!ld be given towomen in preterm labor<

1. %on/rmation of preterm labor2. 4or pregnancies less than 3; weeks in women

with no maternal or fetal indications fordelivery close observation with monitoring of!terine contractions and fetal heart rate isappropriate and serial e$aminations are doneto assess cervical changes.

3. 4or pregnancies less than 3; weeksgl!cocorticoids are given for enhancement offetal l!ng mat!ration.


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;.%onsideration is given for maternalmagnesi!m s!lfate inf!sion for 12 to 2;ho!rs to a@ord fetal ne!roprotection

5. 4or pregnancies less than 3; weeks in

women who are not in advanced laborsome practitioners believe it is reasonableto attempt inhibition of contractions todelay delivery while the women are given

corticosteroid therapy and gro!p "streptococcal prophyla$is.


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?.4or pregnancies at 3; weeks or beyondwomen with preterm labor are monitoredfor labor progression and fetal wellbeing

7.4or active labor an antimicrobial is given

for prevention of neonatal gro!p "streptococcal infection.


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). Deli;ery #ta@ pro/cient in res!scitative techni:!es

commens!rate with the gestational age of the newbornand f!lly oriented to any speci/c problems sho!ld bepresent

,. (re;ention of neonatal intracranial !emorr!age

(reterm newborns have germinal matri$ bleeding thatcan e$tend to more serio!s intraventric!lar hemorrhage

&t was hypothesiDed that cesarean delivery to obviatetra!ma from labor and vaginal delivery might preventthese complications

Avoidance of activephase labor is impossible in most

preterm births beca!se the ro!te of delivery cannot bedecided !ntil the active phase labor is /rmly established


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4ar astern niversityDr. 5icanor %eyes 4edical 7o"ndation

Department of Obstetrics and Gynecology


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Postmature relatively !ncommon speci/cclinical fetal syndrome in which the infanthas recogniDable clinical feat!res indicatinga pathologically prolonged pregnancy.

Postterm or prolonged preferred e$pressionfor an e$tended pregnancy

According to A%*8'1997, < ;2 completedweeks '29; days, or more from the /rst day

of the last menstr!al period.


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-wo categories of pregnancies that reach ;2completed weeks

'1, those tr!ly ;0 weeks past conception

'2, those of less advanced gestation b!t with

inacc!rately estimated gestational age -here is no acc"rate met!od to identify

the tr!ly prolonged pregnancy all those =!dged to be ;2 completed weeks sho!ld bemanaged as if abnormally

prolonged


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&ncidence of postterm pregnancy rangesfrom ; to 19 percent

-here are contradictory ndingsconcerning the signi/cance of maternal

demographic factors s!ch as parity priorpostterm birth socioeconomic class and age

-hey reported that only prepregnancybody mass inde3 #64I& > and

n"lliparity were signi/cantly associatedwith prolonged pregnancy


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&nfants either live or stillborndemonstrating these clinical characteristicsare now diagnosed to be pathologically

postmature, or to have the postmaturity

syndrome +any were serio!sly ill d!e to birt!

asp!y3ia and meconi"m aspiration.


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4A-)# *4 (*#- +A-)&-I #IC)*+ wrinkled patchy peeling skin long thin body s!ggesting wasting openeyed !n!s!ally alert appears old and worried skin wrinkling can be partic!larly

prominent on the palms and soles

nails are typically long


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Postmature in*ant delivered at 4= !ees gestation. Thic, viscous

meconium coated the des6uamating sin. ?ote the long, thin

appearance and !rinling o* the hands.


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%li@ord '195;, proposed

skin changes of postmat!ritywere d!e to loss of the protective

e@ects of verni$ caseosa.Ge also attrib!ted thepostmat!rity syndrome toplacental senescence altho!gh he

did not /nd placentaldegeneration histologically


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As conse:!ence of cord compressionassociated with oligohydramnios

&t is not associated with late decelerationscharacteristic of !teroplacental ins!Jciency.

&nstead one or more prolongeddecelerations preceded three fo!rths ofemergency cesarean deliveries fornonreass!ring fetal heart rate tracings. &n allb!t two cases there were also ;ariable

decelerations tracings Altho!gh not omino!s by itself was the

saltatory baseline


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AMNIOINFUSION

d!ring labor as away of dil!tingmeconi!m


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one t!ird of the postterm stillbirths weregrowth restricted

morbidity and mortality were signi/cantlyincreased in the growthrestricted infants


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A.O'IGO18D%A45IOS -he smaller the amnionic >!id pocket the

greater the likelihood that there wasclinically signicant oligo!ydramnios

A4& o;erestimated the n!mber ofabnormal o!tcomes in posttermpregnancies.


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6. 4A9%OSO4IA -he velocity of fetal weight gain peaks at appro$imately 37 weeks

0$) 2


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&t is generally !nwise to allow a pregnancy tocontin!e past ;2 weeks if with

gestational hypertensive disordersprior cesarean deliverydiabetes.


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(erformed twice weekly fetal testing !ntil ;2weeks.

;1 weeks with favorable cervi$ ind!celabor

;1 weeks with !nfavorable cervi$antepart!m fetal testing

;2 weeks whether the cervi$ is favorable ornot labor is generally ind!ced


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e/ne as cervi$ that is closedC "neaced

it! a bis!op score of less t!an * women in whom there was no cervical

dilatation at ;2 weeks had a twofoldincreased cesarean delivery rate for

Bdystocia.B cervical length of ) cm or less determined

by transvaginal !ltrasonography waspredictive of s!ccessf!l ind!ction

cervical length of > mm or less waspredictive of spontaneo!s labor or s!ccessf!lind!ction.


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9E%2I9A' %I(E5I5G(rostaglandin 2 '(82,(rostaglandin gel S0EE(I5G O% ST%I((I5G O7 T1E

4E46%A5ES +embrane stripping at 3 to ;0 weeks

decreased the fre:!ency of posttermpregnancy

rawbacks of membrane strippingincl!ded pain vaginal bleeding andirreg!lar contractions witho!t labor.


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STATIO5 O7 2E%TE@ cesarean delivery rate was directly related

to station9ESA%EA5 DE'I2E%8 %ATE STATIO5

? percent #-A-&*C 1

20 percent #-A-&*C 2

;3 percent #-A-&*C 3

77 percent #-A-&*C;


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merican 0ollege o* $&stetricians and

)%necologists 92/:

EVALUATION AND MANAGEMENT OF POSTTERM PREGNANCY


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. Postterm pregnanc% is de*ined as a pregnanc% that has e"tended to or &e%ond 42 completed

!ees.

2. @omen !ith a postterm gestation !ho have an un*avora&le cervi" can either undergo la&or

induction or &e managed e"pectantl%.

=. Prostaglandin can &e used *or cervical ripening and la&or induction.

4. eliver% should &e e**ected i* there is evidence o* *etal compromise or oligoh%dramnios.

5. t is reasona&le to initiate antenatal surveillance &et!een 4 and 42 !ees despite lac o*

evidence that monitoring improves outcomes.

A. nonstress test and amnionic *luid volume assessment should &e ade6uate, although no

single method has &een sho!n to &e superior.

/. +an% recommend prompt deliver% in a !oman !ith a postterm pregnanc%, a *avora&le cervi",

and no other complications.

rom the merican 0ollege o* $&stetricians and )%necologists 924:


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m. Preterm and Postterm.new Ppt