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Preterm labor Prepared by the student: Mustafa Shukri University of duhok College of medicine E-mail: email@example.com
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Definition Preterm (premature) labor is that occurring after 20 weeks and before 37 completed weeks of gestation.
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Incidence 5%-10% of all deliveries 85% of neonatal death
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Etiology Multiple pregnancy. APH IUGR Cervical incompetence Amnionitis Uterine abnormality Polyhydramnios Maternal condition: DM, pyelonephritis and past history of premature labor
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Diagnosis Clinically: Presence of uterine contractions Cervical change (initial cervical exam >2cm or >80% effacement) Tests: Fetal fibronectin Vaginal U/S for cervical length
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TRIAGE BASED UPON CERVICAL LENGTH Vaginal U/S If > 30mm, (low risk) Swab for fFN testing 20-30mm Observe for 4-6hrs in the hospital, then discharge and review after 2wks. fFN<50 ng/ml fFN>50 ng/ml Active management <20mm, (hight risk) Active management
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Contra indications to labor inhibiton Intrauterine death. Lethal fetal anomaly. Severe IUGR. Chorioamnionitis. Hemodynamically unstable mother. Severe pre-eclampsia or eclampsia.
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Goals of treatment Delay delivery so that corticosteriods can be administered. Allow safe transport of gravida to a facility that can provide neonatal care. Prolong pregnancy when there are underlying self-limited causes of labor.
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Management Principles of management depends on: State of membranes Dilatation of the cervix Gestational age Cause of preterm labor Frequency of uterine contractions Fetal wellbeing Availability of NICU
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Lines of management Look for a cause for preterm labor If membranes are intact, a vaginal examination should be performed. The fetal heart rate and uterine activity should be electronically recorded continuously. Repeated vaginal examination and obtain endocervical and vaginal swab to rule out gonorrhea, chlamydia & BV.
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Lines of management cont… 5. Urine culture. 6. Vaginal U/S to measure cervical length. 7. Check fibronectin levels in cervical fluid; elevation may indicate imminent labor.
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Treatment Tocolytic drugs. Antibiotics for women with +ve urine culture. Appropriate antibiotics for GBS. Antenatal corticosteroids.
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Tocolysis Magnesium sulfate: competes with calcium at the level of the plasma membrane voltage-gated channels. Dose: 4 to 6 g intravenous loading dose over 20 minutes, followed by a continuous infusion of 2 to 4 g/hour. Contraindications 1. MG 2. Cardiac conduction defects
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Tocolysis cont… Nifedipine: Calcium channel blocker Dose: 30 mg orally, followed by 20 mg orally in 90 minutes, followed by 20 mg orally every six to eight hours. Side effects 1. Maternal: transient hypotension 2. Fetal: ?uterine & umbilical blood flow 3. Should not be used with Mg sulfate
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Tocolysis cont… ß-Agonists: Terbutaline: (decreases free intracellular calcium ions) Dose: 2.5 to 5 µg/min; Increased by 2.5 to 5 µg/min every 20 to 30 minutes to a maximum of 25 µg/min, or until the contractions have abated. 0.25 mg subcutaneously every 20 to 30 minutes for up to four doses or until tocolysis is achieved. 0.25 mg every 3 to 4 hours.
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Tocolysis cont… ß-Agonists (side effects) Hypokalemia Hyperglycemia Hypotension Pulmonary edema Arrhythmias Cardiac insufficiency Myocardial ischemia Maternal death
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Tocolysis cont… Indomethacin: Prostaglandin inhibitor Dose: 50- to 100-mg rectal suppository, then 25 to 50 mg orally every six hours Fetal side effects 1. Premature closure of ductus arteriosus (usually after 32wks of gestation) 2. Oligohydramnios 4. IUGR 3. Necrotizing enterocolitis 5. IVH
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Tocolysis cont… Atosiban: (oxytocin receptor antagonist) Dose: I.V.: Initial: 6.75 mg over 1 minute; followed by 18 mg/hour for 3 hours, then 6 mg/hour for up to 45 hours; maximum duration of treatment: 48 hours
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Glucocorticoids Dexamethasone tow doses of 12mg 12 or 24 hrs apart Benefits: Reduce neonatal RDS by 40%-60% Lower the incidence of neonatal IVH Decrease the risk of necrotizing enterocolitis in the neonate Reduce neonatal mortality and days in NICU
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Antibiotics Prophylactic antibiotics can be given to prevent silent infection progression to clinical amnionitis and the risk of fetal infection. The most common micro-organisms are group B streptococcus and E. coli
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Hypotension in prete...
Balancing Labor Cost...
Cervical length Pre...
Abnormalities of the...
THE BENEFITS OF EARL...
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causes and management of preterm labor and an overview of some tocolytic agents- Slides
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