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Preterm Labor and Birth

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Prevention of Preterm Birth. Supplemental progesterone ... Use of progesterone to reduce preterm birth. Obstet Gynecol 2008; 112:963. ... – PowerPoint PPT presentation

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Title: Preterm Labor and Birth


1
Preterm Labor and Birth
  • Patricia B. Gotsch M.D.
  • St. Lukes Family Medicine Residency
  • Bethlehem PA

2
Objectives
  • Define preterm labor
  • Discuss trends in epidemiology
  • Review risk factors
  • Discuss diagnosis, treatment, and prevention

3
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 lt28 weeks

4
  • PTB increased 20 from 1990 to 2006

5
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

6
Complications of Prematurity
  • RDS
  • IVH
  • Feeding difficulties/NEC
  • Apnea
  • PDA
  • Infection
  • Jaundice
  • Hypothermia
  • Neurobehavioral
  • ROP
  • Anemia

7
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

8
Pathogenesis
  • Premature activation of maternal or fetal HPA
    axis
  • Decidual hemorrhage
  • Inflammation/infection
  • Pathological uterine distention

9
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

10
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

11
Sonographic Cervical Length
  • 10th 25mm (20 to 30 wks gestation)
  • 80-100 of women who deliver early have cervix
    lt30mm
  • 15 mm or less 50 delivery rate within one week

12
Fetal Fibronectin
  • 99 negative predictive value for delivery within
    2 wks
  • Positive predictive value worse, about 30
  • 22 to 35 weeks
  • Sample collection issues

13
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

14
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

15
Tocolysis
  • Risk/benefit ratio for continuation of pregnancy
  • 34 weeks
  • Risk/benefit ratio of various treatments

16
Tocolysis
  • Nifedipine
  • Low cost
  • Oral
  • Low incidence of side effects (hypotension,
    dizziness, flushing)
  • Often considered first line

17
Tocolysis
  • Beta agonists (ritodrine, terbutaline)
  • Tachycardia, hypotension, tremor, palpitations,
    chest discomfort, hypokalemia, hyperglycemia
  • Magnesium sulfate
  • Nausea, flushing, fatigue, diaphoresis, loss of
    DTRs, respiratory depression, cardiac arrest
  • Indomethacin
  • Maternal GI SE, premature closure of ductus,
    oligohydramnios
  • Atosiban
  • Possible increase in fetal/neonatal
    morbidity/mortality not available in US
  • CAUTION when combining tocolytics

18
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

19
Prevention of PTB
  • Reduce/eliminate risk factors, if possible
  • Not proven to be effective bedrest, home uterine
    monitoring, prophylactic tocolytics, prophylactic
    antibiotics, abstinence

20
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

21
References
  • www.cdc.gov
  • www.marchofdimes.com
  • UpToDate online
  • Use of progesterone to reduce preterm birth.
    Obstet Gynecol 2008 112963.
  • Prevention of Preterm Delivery. Simhan HN et al.
    N Engl J Med 2007 Aug 2 357(5)477-87.

22
Questions?
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