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BYM. ZEESHAN KHAN
RIZWAN ANWERZEESHAN LODHI
PRETERM AND POST-TERM LABOUR
CONTENTS
PRETERM LABOUR DEFINITION RISK FACTORS DIAGNOSIS INVESTIGATIONS PREDICITON AND PREVENTIONS TOCOLYTIC AGENTS MANAGEMENT PPROM(INTRODUCTION, DIAGNOSIS,MANAGEMENT)
POST-TERM LABOUR INTRODUCTION SIGNIFICANCE CLINICAL APPROACH MANAGEMENT
DEFINITIONS
PRE TERM PREGNANCY DELIVERY BEFORE 37 WEEKS OF GESTATION
TERM PREGNANACY GP FROM 37 TO 41 + 6 days WEEKS
POSTERM PREGNANCY GP FROM 42 WEEKS ONWARDS
PRETERM LABOUR
Preterm labour is defined by WHO as Onset of labour prior to the completion of 37 weeks of gestation, in a pregnancy beyond 20 wks of gestation.
Preterm labour is considered to be established if regular uterine contractions can be documented atleast 4 in 20 minutes or 8 in 60 minutes with progressive change in the cervical score in the form of effacement of 80% or more and cervical dialatation >1cm.
CONT’
This condition tends to be over diagnosed and over treated.
Nearly 50-60% of preterm births occur following spontaneous labour.
30% due to preterm premature rupture of membranes
Rest are iatrogenic terminations for maternal or fetal benefit.
Half of all neonatal morbidity occurs in preterm infants.
Inspite of all major advances in obstetric and neonatal care, there has been no decrease in incidence of preterm labour over half a century.
On the contrary , it has been increasing in the developed countries as more and more high risk mothers dare to get pregnant.
Incidence
Preterm birth occurs in 5-12% of all pregnancies and accounts for majority of neonatal deaths and nearly half of all cases of congenital neurological disability, including cerebral palsy.
A neonate weighing 1000- 1500 g today has ten times greater chance of surival then what it had in 1960s.
The focus is hence shifting to early preterm births(<32 weeks) which account for 1-2% of all births but contribute to 60% of perinatal mortality and nearly all neurological morbidity.
One of the major reasons for increase in incidence of premature births is the increase in numbers of multiple pregnancies , particularly higher order pregnancies, resulting from the use of fertility drugs and assisted reproduction.
PRETERM LABOUR
5 -> 4 -> 4
Mildly preterm 32 – 36 weeks
Very preterm 28 – 31 days weeks
Extremely preterm 24 – 27 weeks
AETIOLOGY
INFECTIONSOVER-DISTENSIONVASCULARSURGICAL PROCEDURES AND
INTERCURRENT ILLNESSABNORMAL UTERINE CAVITYCERVICAL WEAKNESSIDIOPATHIC
NON MODIFIABLE(MAJOR AND MINOR)
MODIFIABLE
RISK FACTORS
RISK FACTORS
MAJOR NON MODIFIABLE Last birth preterm: 20% risk Last two birth preterm : 40%risk Twin pregnancy: 50% risk Uterine abnormalities Cervical Anomalies Factors in current pregnancy
Non modifiable , Minor Parity 0 or >5 Ethnicity(Black) Poor socioeconomic status Education Teenagers having second or subsequent babies
Modifiable Smoking :2x risk of PPROM Drug abuse : especially cocaine BMI <20 Inter Pregnancy interval: <1year
DIAGNOSIS
SYMPTOMS WITH CERVICAL WEAKNESS Increased vaginal discharge Mild Lower abdominal pain Bulging membranes on examination
SYMPTOMS WITH INFECTION, ABRUPTION Lower abdominal pain Painful uterine contraction
DIGNOSTIC CRITERIA
1. GESTATIONAL AGE : 24-37 WEEKS2. UTERINE CONTRACATION: ATLEAST 3
CONTRACTIONS IN 30 MINUTES3. CERVICAL CHANGE: CHANGE IN
CERVICAL DIALTATION OR 2CM DILATED CERVIX
DIFFERNTIAL DIAGNOSIS
UTIRED DEGERATION OF FIBROIDPLACENTAL ABRUPTIONCONSTIPATIONGASTROENTERITIS
DIAGNOSTIC APPROACH
HXEXAMINATIONSINVESTIGATIONS
FBC CRP MID STREAM URINE SAMPLE U/S TVS FETAL FIBRONECTIN
PREVENTION
Rx of BV
Cervical Cerclage
Selective Reduction of pregnancy numbers
Progesterone ?
PREDICITON
Cervical length TVS improves diagnostic accuracy Normal length 35 mm In asymptomatic women with singleton pregnancy
Cervix <15 mm long : risk of delivering before 32 weeks is 4%
Cervix <5 mm long: risk of delivering before 32 weeks is 78%
In symptomatic woman with singleton pregnancy Cervix <15mm long : risk of delivering within 7 days is
50% Cervix >15 mm long: risk of delivery within 7 days is
<1%
cont
Fetal Fibronectin(fFn)- glue like protein at choriodecidual interface fFN test offers rapid assessment of risk in
symptomatic women with minimal cervical dilatation, fFN is protein not usually present in cervicovaginal
secretions at 22-36weeks fFN positive test indicates that women is likely to
deliver fFN predicts preterm birth within 7 – 10 days of
testing Implying disruption of choriodecidual interface
TOCOLYTIC AGENTS AND STEROIDS
Used to prevent labour and deliveryMay prolong pregnancy but not more than 72
hours Useful for fetal lung maturity by maternal IM steroids Transportation of mother to a facility with neonatal
intensive care
IMPORTANT TOCOLYTIC DRUNGS
TOCOLYTIC DRUGS SIDE EFFECTS
MAGNESIUM SULFATECompetitive inhibitors of calciumOverdose treated by IV ca gluconate
Resp depressionMuscle weaknessPulmonary edema
Beta- Adrenergic agonistTerbutaline
HTN and tachycardiaHypokalemiaHyperglycemia
cont
Calcium channel BlockerDec. intracellular Calciume.g nifidipine ,
HypotensionMyocardial depressionTachycardia
Prostaglandin synthetase inhibitorDec. smooth muscle contractilitye.g. Indomethacin
Fetal complications like oligohydramnios, premature closure of ductus and necritising enterocolitis have restricted their use.
MATERNAL STEROIDS
Reduces the rates of respiratory distress, intraventricular hemorrhage and neonatal death
Given as IM injection two doses 12-24 hrs apart.
Maximum benefit is seen after 48 hours.
MANAGEMENT OF PRETERM LABOUR
Confirm labour using three criteria listed above.
Rule out contraindications of tocolysisAdminister IV lineStart MgSO4 tocolysis with 5g IV for 20 min,
then 2g/hAdminster maternal IM betamethasone to
stimulate type II pneumocyte
Clear plan about Mode of delivery Monitoring in labour Presence of pediatrician In antibiotics in labour
PRETERM PRELABOUR OF MEMBRANES (PPROM)
Rupture of fetal membranes occurring before 37 wks of gestation.
It complicates about 3 % of pregnancies and contributes to one third of preterm births
RISK FACTORS
Ascending infection of lower genital tract-most common
Multiple pregnancyPolyhydramniosAntepartum hemorrhagePlacental abruptionCervical weaknessIdiopathic
Diagnosis of PPROM
History of sudden escape of watery amnoitic fluid. Oligohydramnios on US Pooling of amniotic fluid in posterior vagina
A sterile speculum examination confirms that the fluid is coming through the os.
Nitrazine test: turns blue from yellow if amniotic fluid leak.
Fern test Ultrasound examination shows oligohydramnios Amnisure test(immunochromatographic method)
detects trace amounts of placental microglobulin (PAMG-1)
Differential diagnosis
It needs to be differentiated from stress urinary incontinence
and profuse normal vaginal discharge. UTI Vaginal Infection
Management of PPROM
Correct and prompt diagnosis is imperative for optimum management.
PPROM remote from term: Conservative management is advisable, provided acute cord complications like prolapse and compression, placental abruption and fetal distress have been excluded. Oligohydramnios is not an indication. Antibiotics: help to prolong latency and improve
perinatal outcomes. Corticosteroids: should be given to patients between 24
and 34 weeks of gestation.
PPROM nearer to term(34-36 wks):
It is preferable to induce labour unless fetal lung maturity or gestational age is doubtful
Serial transabdominal amnioinfusions in<26 wks pregnancies with PPROM and severe oligohydramnios in selected women reduce the risk of pulmonary hypoplasia and improve neonatal survival.
POST-TERM PREGNANCY
Any pregnancy that exceeds 42 weeks from the first day of last menstrual period in women with regular 28 day cycles
Aka Postdate pregnancy and prolonged pregnancy
INCIDENCE
The generally quoted incidence of PT pregnancy is 10%
Incidence is decreasing b/c of better estimation of duration of gestation and timely induction of labour.
RISK FACTORS
Past history of prolonged pregnancyFamily historyRace (White>black)AnencephalyCongenital adrenal hyperplasiaExtra uterine pregnancy
COMPLICATION
FETAL COMPLICATION Macrosomia Syndrome Dysmaturity Syndrome
MATERNAL COMPLICATION Anxiety Prolonged labour C-section
Fetal Complications
Macrosomia Syndrome Occurs when placental function is maintained(80%
cases) Results in healthy but large fetus Amniotic fluid is normal Inc risk of C-section b/c of prolonged and arrested
labour Shoulder dystocia
Dysmaturity syndrome When placental function deteriorates (20% cases) Placental insufficiency results in reduction of
metabolic and respiratory support to fetus Amniotic fluid is decreased Inc risk of C-section b/c of non reassuring fetal heart
rate patterns Oligohydramnios results in umbilical cord
compression
MATERNAL COMPLICATIONS
Anxiety Is commonly seen postdate pregnancy b/c of worry of
inc. in gestation period from the EDDProlonged labour
Chances increases significantly and also the risk of instrumental delivery
C-section Risk of C-section is also greatly increased
MANAGEMENT
It depends on the Confirmation of gestational age Favorability of cervix
CONFIRAMTION OF GESTATIONAL AGE
In a booked case confirmation of gestational age is easily determined
In an unbooked case , diagnosis of post term pregnancy poses a major challenge.
DETERMINATION OF GESTATIONAL AGE
HISTORY LMP EARLY U/S FAMILY HISTORY HX OF NTDs
EXAMINATION SFH BISHOP SCORING
INVESTIGATIONS
U/SNSTAFI After confirmation of gestational age
management plan is decided
CONSERVATIVE MANAGEMENT
50% women going beyond 42 weeks of gestation experience spontaneous labour in 4-5 days
Poor bishop scoreGood fetal health + adequate placental
function
INDUCTION OF LABOUR
1. Favorable cervix2. Oligohydramnios3. Fetal macrosomia4. Non reactive NST
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