NAMASKA R

WELCOME

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Managrement of Preterm Labour

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MANAGEMENT OF PRETERM LABOUR

Prof.Surendra Nath Panda, M.S.
Dept.of OBGYN
M.K.C.G.Medical College Berhampur
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Motherhood…

A dream of every woman … We are obliged to fulfil
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- A Tragic end to this dream …

PRETERM LABOUR
• Delivery between 20 & 37 weeks gestation • Different from LBW –LBW <2500Gm –Very LBW <1500Gm –Extremely LBW <1000Gm • Major cause of foetal, perinatal & Infant death • High cost of survival
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PRETERM LABOUR

THE PROBLEM…      Cause-Uncertain Diagnosis-Elusive Methods-Debatable Results-Unpredictable Cost- Enormous
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MANAGEMENT OF PRETERM LABOUR

DETECT & ELIMINATE / TREAT THE CAUSE:  INFECTION  CERVICAL INCOMPETENCE  PLACENTA PREVIA / ABRUPTION  UTERINE ANOMALIES

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MANAGEMENT OF PRETERM LABOUR

DETECT & ELIMINATE / TREAT THE CAUSE:  PIH  FOETAL ANOMALIES  IMMUNOLOGICAL?  IDIOPATHIC -Cause undetectable
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MANAGEMENT OF PRETERM LABOUR

THREE TYPES OF PATIENS:  PATIENTS AT RISK  THREATENED PRETERM DELIVERY (Active preterm labour)  PRETERM PROM

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IDENTIFYING PATIENTS AT RISK OF PRETERM LABOUR  Poor socioeconomic/ education/ hygiene/ nutritional status  Young or advanced age  Nulliparity or grandmultiparity  Short stature or low weight  Smoking  Medical or surgical illness complicating pregnancy
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IDENTIFYING PATIENTS AT RISK OF PRETERM LABOUR

 History of preterm birth -

After 1st preterm birth - 15% After 2 preterm births - 32-70% If 1st term and 2nd preterm -23%

 Cervical dilatation >20weeks  Pelvic pressure  Low back pain  Uterine contraction
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MANAGEMENT OF PATIENTS AT RISK

GOAL Prevention Of Preterm Labour METHODOLOGY
Multi-component preventive programs
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MANAGEMENT OF PATIENTS AT RISK Multi-component preventive programs

1.Risk assessment:1.Education: Staff  Patients  Public

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MANAGEMENT OF PATIENTS AT RISK Multi-component preventive programs

Support systems:  Home visiting nurses/ midwives  Home help  Family help  Social worker assignment  Stress management classes
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MANAGEMENT OF PATIENTS AT RISK Multi-component preventive programs

Self-monitoring of uterine activity at home: -External tocodynamometer

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MANAGEMENT OF PATIENTS AT RISK Multi-component preventive programs

1.Advice:  Reduce work  Reduce housework & child care  Reduce smoking  Reduce stress  Reduce travel, commuting, moving house
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MANAGEMENT OF PATIENTS AT RISK Multi-component preventive programs

1.Advice:  Reduce / Stop sexual activity  Bed rest at home  Avoid hot & humid climate  Improve nutrition(Sea
Fish+)
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MANAGEMENT OF PATIENTS AT RISK Multi-component preventive programs

1.Antenatal care: -

 Increased frequency of contact  Continuity of care  Facilitated access to tertiary hospital
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MANAGEMENT OF PATIENTS AT RISK Multi-component preventive programs

1.Antenatal care: -

 Over Hydration (1.4 Gallons/day)  High dose calcium  Antioxidants  Regular cervical examinations (No digital Exam.please)
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MANAGEMENT OF PATIENTS AT RISK Multi-component preventive programs

1.Antenatal care: -

 Testing for imminent preterm labour with biological markers-

 Foetal Fibronectin(FFN)  E V Ultrasound of Cx.  Salivary estriol (E3)(SalEst Test).
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MANAGEMENT OF PATIENTS AT RISK Multi-component preventive programs

1.Specific obstetric interventions:-

 Bed rest in hospital  Cervical suture  Progestogens
Dydrogesterone 17-H P C Progesterone V/O
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MANAGEMENT OF PATIENTS AT RISK Multi-component preventive programs

1.Specific obstetric interventions:-

 Tocolytics (Oral)?B-mimeticsRitodrine 1x4-6 Isoxsuprine 40mgx2 Terbutaline 1x3 Salbutamol 1x3
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Nifedipine 20mgx4
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MANAGEMENT OF PATIENTS AT RISK Multi-component preventive programs

1.Specific obstetric interventions:-

 Antibiotics  Urinary Infection
(Asymptomatic Bacteriuria)

 Local Infection  Bact.Vaginosis  Occult infection
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MANAGEMENT OF THREATENED PRETERM DELIVERY (Active preterm labour) Definitions of preterm labor vary, but the research criteria commonly hold it to be contractions occurring between 20 and 36 weeks' gestation at a rate of four in 20 minutes or eight in 1 hour with at least one of the following-: cervical change over time or dilatation greater than or equal to 2.0 cm.
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MANAGEMENT OF THREATENED PRETERM DELIVERY •HOSPITALISATION •COUNSELLING •LIASION WITH NEONATOLOGIST •HYDRATION- Oral / IV •SEDATIVES
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MANAGEMENT OF THREATENED PRETERM DELIVERY

•ANTIBIOTICS:- The array of agents, routes of administration, and durations of therapy preclude making any recommendation but Erythromycin appears to be a good choice

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MANAGEMENT OF THREATENED PRETERM DELIVERY • STEROIDS(after 28 weeks) :- Beyond a shadow of doubt Two Inj. of Betamethasone 12 mg IM at 12 –24 hours interval OR Six inj. of Dexamethasone 4 mg IM 8 hourly
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MANAGEMENT OF THREATENED PRETERM DELIVERY

•ACUTE TOCOLYSIS: Potentially hazardous side effects  Close monitoring essential  Effectiveness ?  Use is debatable  Combinations may be better
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MANAGEMENT OF THREATENED PRETERM DELIVERY

•ACUTE TOCOLYSIS: Must be given parentrally for 1848 hours  Risk/benefit ratio for both the mother and fetus must be reevaluated on an ongoing basis  Should be used selectively  Never after 33 weeks
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ACUTE TOCOLYSIS

Exclusion criteria : Maternal factors Diabetes Hyperthyroidism Cardiac disease Severe PIH Eclampsia  Abruptio Placenta  Hydramnios  Chorioamnionitis  Cervical dilation more than 3 cm 
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Managrement of Preterm Labour

ACUTE TOCOLYSIS

Exclusion criteria : Foetal factors Severe IUGR Foetal Anomaly incompatible with life Foetal distress

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ACUTE TOCOLYSIS

METHODS

Beta Mimetic:Ritodrine -(150mg
in 500 ml DS)

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 Start 100 mcg /min, go up to 350 mcg, in increments of 50 mcg, until 12 hours of cessation of contractions, then switch to 10mg tab 2 hourly & maintain at 10-20 mg 2-6 hourly  High Cost, Side effects
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ACUTE TOCOLYSIS

METHODS

Beta Mimetic:Isoxsuprine 60mg in 500ml 0.2-1mg / minute IV drip for 12 hours of cessation of contractions – 10mg IM/6hourly for 48 hours – then switch to oral 20mg X 3-4 / 40mg x 2 times  Low cost, Moderate side effects,widely used in India since long
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ACUTE TOCOLYSIS

METHODS

Beta Mimetic:Terbutaline250 mcg IV / SC for 12
hours of cessation of contractions followed by

Oral 5 mg 2/4/6 hours Low cost, widely used,
Moderate side effects
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ACUTE TOCOLYSIS

METHODS

Beta Mimetic:Salbutamol IV for 12 hours of cessation of contractions followed by 2/4mg 2/4/6/8 hours– Oral  Low cost, Moderate side effects, mostly used in Australia
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ACUTE TOCOLYSIS

METHODS

Magnesium sulfate: 4-6 Gm IV/IM loading dose over 20 minutes, followed by 2-4 Gm IV/IM every hour for 12 hours after contractions stop to be followed by beta agonists orally  For IV 40 Gms in one Lit of 5%DS or 0.45% Normal saline  Watch for hypermagnesemia  Monitor Mg level
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ACUTE TOCOLYSIS Nifedipine:-

METHODS

 5mg S/L every 15 minutes for 2 hours-10mg Tab, 8hourly  Low cost, Moderate side effects, sporadic use  Move to ban sublingual getting wider acceptance,
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ACUTE TOCOLYSIS Indomethacin:-

METHODS

 Initial loading dose of 50 mg then 25-50 mg oral every 4 hours until contractions cease  Maintenance therapy at 25 mgs oral every 4 - 6 hours up to 35 weeks  Not widely accepted because of side effects  Can be given for short periods of <72 hours
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ACUTE TOCOLYSIS Nitroglycerine :-

METHODS

 It is a nitric oxide donor  Good for very short periods  Hypotension

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ACUTE TOCOLYSIS

METHODS

 Atosiban(Tractocile) : A Nona peptide oxytocin analog  Acts as a oxytocin/ADH antagonist  Start IV bolus 675 mg, then 300mg/minute IV for 3 hours and 100mg/minute IV thereafter.  Efficacy same as beta agonists with lesser side effects  Not available in India at present
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TOCOLYSIS IN PRETERM LABOUR Most tocolytics are effective in stopping labor for 48-72 hours. None have been shown to decrease the rate of preterm delivery. Once the uterus is quiescent and intravenous tocolytics are stopped, prolonged use of tocolytics has not been shown to be effective in preventing preterm birth.
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TOCOLYSIS IN PRETERM LABOUR

Long-term use of tocolytics is difficult to justify at this time

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TOCOLYSIS IN PRETERM LABOUR

What is the HOPE FOR THE FUTURE?

A Designer Drug
A selective ß2 –Adrenergic receptor modulator
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PRETERM PROM

Risk Factors
     Vaginal /Cervical infection Membrane Physiology Nutritional factors Incompetent Cervix Preterm Labour
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PRETERM PROM

Diagnosis
     
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Patient History Fluid Observation Ulrasound Nitrazine Test Ferning Test Dye Injection
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MANAGEMENT OF PRETERM PROM

GOAL
To Prolong Pregnancy till lung maturity preferably up to 33weeks

• Hospitalisation • Monitor forInfection → Antibiotics Labour → Tocolysis(<34 weeks) Foetal well being → USG

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• Promote Lung maturity → Steroids • Amnio infusion
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Intra Partum Managements of Preterm Labour

Minimise Maternal Hypotension and Foetal hypoxia and acidosis¨ < RDS
Routine use of prophylactic forceps & episiotomy not recommended If Foetal distress- CS? Below 28 weeks - NO CS Below 32 weeks - ? Above 32 weeks - CS Vertical skin & uterine incision
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Survival Rate According to Gestational Age & Birth Weight
(Oklahoma Medical Center, 1981-1994)

Gest. Age Survivors 24 weeks 20 25 25 26 50 27 75 28 83 29 94 30 95 31 95 32 97 33+ 99
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Birth Weight <500Gms 501-800 801-1000 1001-1250 1251-1500 1501-1750 1751-2500 >2500
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Survivors 0 22 75 82 94 97 98 99
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MANAGEMENT OF PRETERM LABOUR
SLIGHT OVER-REACTION + COMMON SENSE + JUDGEMENT = CORRECT MANAGEMENT FOR THE INDIVIDUAL.

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ANY QUESTIONS PLEASE
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