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Preterm Labor and Birth

Patricia B. Gotsch M.D. St. Lukes Family Medicine Residency Bethlehem PA

Objectives

Define preterm labor Discuss trends in epidemiology Review risk factors Discuss diagnosis, treatment, and prevention

Preterm Birth

Term pregnancy - 37 to 42 weeks gestation 12.5 % of deliveries/yr are preterm About 500,000 71.2% 34-36 weeks 13% 32-33 weeks 10% 28-31 weeks 6% <28 weeks

PTB increased 20% from 1990 to 2006

Survival in Premature Infants

26 wks 80% 27 wks 90% 28-31 wks 90 to 95% 32-33 wks 95% 34-36 wks approaches term survival rates

Complications of Prematurity

RDS IVH Feeding difficulties/NEC Apnea PDA Infection Jaundice Hypothermia Neurobehavioral ROP Anemia

Preterm Birth

Spontaneous preterm labor 30-50% Multiple gestation 10-30% PPROM 5-40% Preeclampsia/eclampsia 12% Antepartum bleeding 6-9% Fetal growth restriction 2-4% Other 8-9%

Pathogenesis

Premature activation of maternal or fetal HPA axis Decidual hemorrhage Inflammation/infection Pathological uterine distention

Risk Factors for PTD

Previous PTB Multiple gestation Polyhydramnios Uterine anomalies Infection Placental pathology Smoking Substance abuse

Maternal age extremes Anemia Low BMI Hx cervical surgery Hx 2nd TM loss Severe stressors Short interpregnancy interval

The Challenge: Identification

Labor = regular, painful uterine contractions that produce cervical dilation and/or effacement Uterine contractions are seen in normal pregnancies at early gestational ages Up to 50% of women hospitalized for PTL go on to deliver at term

Sonographic Cervical Length

10th% = 25mm (20 to 30 wks gestation) 80-100% of women who deliver early have cervix <30mm 15 mm or less = 50% delivery rate within one week

Fetal Fibronectin

99% negative predictive value for delivery within 2 wks Positive predictive value worse, about 30% 22 to 35 weeks Sample collection issues

Goals of Treatment of PTL

Tocolysis often halts contractions only temporarily Allow 48 hr+ for steroids to be given Allow for transport to delivery location with NICU capability Allow for correction of reversible causes

Steroids

Reduce incidence of RDS, IVH, NEC, sepsis, and mortality by about 50% Intact membranes: 24-34 weeks GA PPROM: 24-32 weeks GA Betamethasone 12 mg q 24 hr x 2 Dexamethasone 6 mg q 12 hr x 4

Tocolysis

Risk/benefit ratio for continuation of pregnancy

34 weeks

Risk/benefit ratio of various treatments

Tocolysis

Nifedipine
Low cost Oral Low incidence of side effects (hypotension, dizziness, flushing) Often considered first line

Tocolysis

Beta agonists (ritodrine, terbutaline)

Tachycardia, hypotension, tremor, palpitations, chest discomfort, hypokalemia, hyperglycemia


Nausea, flushing, fatigue, diaphoresis, loss of DTRs, respiratory depression, cardiac arrest Maternal GI SE, premature closure of ductus, oligohydramnios Possible increase in fetal/neonatal morbidity/mortality; not available in US

Magnesium sulfate

Indomethacin

Atosiban

CAUTION when combining tocolytics

Management after Tocolysis

If maternal and fetal conditions are stable, can be managed at home Avoid excessive physical activity; most advocate pelvic rest Continued tocolytics have not shown definite benefit

Prevention of PTB

Reduce/eliminate risk factors, if possible Not proven to be effective: bedrest, home uterine monitoring, prophylactic tocolytics, prophylactic antibiotics, abstinence

Prevention of Preterm Birth

Supplemental progesterone
Women with previous spontaneous preterm delivery at less than 34 weeks gestation Weekly 17OHprogesterone IM or daily vaginal progesterone suppositories Start at 16-20 wks gestation, continue through 36 weeks

References

www.cdc.gov www.marchofdimes.com UpToDate online Use of progesterone to reduce preterm birth. Obstet Gynecol 2008; 112:963. Prevention of Preterm Delivery. Simhan HN et al. N Engl J Med 2007 Aug 2; 357(5):477-87.

Questions?