Definition
Preterm labor is the presence of
contractions of sufficient strength
and frequency to effect
progressive effacement and
dilation of the cervix between 20
and 37 weeks' gestation
WHO
Preterm Labor
Incidence : 6- 10%
Spontaneous
: 40-50%
PROM
: 25-40%
Preterm Labor
Most mortality and
morbidity is experienced
by babies born before 34
weeks.
Death
Respiratory distress syndrome
Hypothermia
Hypoglycaemia
Necrotising enterocolitis
Jaundice
Infection
Retinopathy of prematurity
Goldenberg , Obstetrics &Gynecology 11-2002
Can preterm
labor be
predicted?
Prediction
1. Assessment of risk factors
2. Vaginal examination to assess the
cervical status
3. Ultrasound visualization of
cervical length and dilatation
4. Detection of foetal fibronectin in
cervicovaginal secretions
1-Risk Factors
While the exact cause of
preterm labor is often
unknown, there is strong
evidence that intrauterine
infection may play a role in
very early preterm labor.
ACOG NEWS RELEASE November 2002
1-Risk Factors
Bacterial Vaginosis
Bacterial vaginosis increased the
risk of preterm delivery >2-fold .
1-Risk Factors
Other Risk Factors
Multiple pregnancy: risk >50%
Previous preterm delivery: risk 20- 40%
Cigarette smoking: risk 20-30%
Cervical incompetence
Uterine abnormalities
MOH Sing. Guideline Grade C Recommendation 2001
1-Risk Factors
Other Risk Factors
Young age of mother - less than 16 years of age.
Lower socioeconomic class.
Reduced body mass index (BMI) - BMI less than
19.0.
Antiphosphlipid syndrome.
Obstetric complications, including hypertension in
pregnancy,antepartum haemorrhage, infection,
polyhydramnios, foetalabnormalities.
MOH Sing. Guideline Grade C Recommendation 2001
2-Vaginal examination
3-Vaginal U/S
Vaginal ultrasonography
allows a more objective
approach to examination
of the cervix.
Goldenberg , Obstetrics &Gynecology 11-2002
4-Fibronectin Test
Outcome
Sensitivity specificity
Delivery <37
52%
85%
Delivery <34
53%
89%
71%
89%
67%
89%
59%
92%
Prevention
Treatment Of Vaginosis
Treatment of asymptomatic abnormal
vaginal flora and bacterial vaginosis
with oral clindamycin early in the
2nd trimester significantly reduces
the rate of late miscarriage and
spontaneous preterm birth.
Ugwumadu et al. Lancet. 2003 Mar 22;361:983-8. ) RCT
Diagnosis
Diagnosis
3 criteria to document PTL(20-37w)
1-Regular uterine contractions occur
at 4/20 min. or 8/60 min. Plus:
progressive change in the cervix.
Treatment
Inhibition of labor
Corticosteroid
Antibiotics
Others.
Inhibition Of Labor
Bed rest :DVT
Hydration &sedation
Tocolytics
Hydration
Intravenous hydration does not seem
to be beneficial, even during the
period of evaluation soon after
admission,
Women with evidence of dehydration
may, however, benefit from the
intervention.
Stan et al (Cochrane Review 2000). In:
The Cochrane Library, Issue 1 2003. Oxford
Tocolytics
Most authorities do not
recommend use of tocolytics
at or after 34 weeks' .
There is no consensus on a
lower gestational age limit for
the use of tocolytic agents.
Goldenberg , Obstetrics &Gynecology 11-2002
Nifedipine = Epilate
Atosiban= Tractocile
B -Sympathomimetic Agents.
Use of beta-agonists should be
restricted to the management of
preterm labour between 20 and
35 completed weeks, including
women with ruptured membranes.
(Grade A)
RCOG Guideline Grade A recommendation 1997
B -Sympathomimetic Agents.
Maternal: pulmonary edema, myocardial
ischemia, arrhythmia, and even maternal
death.
Fetal : arrhythmia, cardiac septal
hypertrophy , hydrops, pulmonary edema,
and cardiac failure. hypoglycemia,
periventricular-intraventricular
hemorrhage, and fetal and neonatal death.
.
Magnesium Sulfate
Magnesium sulphate is ineffective
Indomethacin
Compared with ritodrine there is
insufficient evidence for any
differential effect on delay in
delivery, but indomethacin does
seem to have fewer maternal
adverse effects than the betaagonists
RCOG Guideline Grade B Recommendation 2002 (Valid:2005)
Indomethacin
Fetal risk:
Premature closure of the ductus.
Renal and cerebral vasoconstriction.
Necrotising enterocolitis
Common with high dose and
prolonged exposure.
RCOG Guideline Grade B Recommendation 2002 (Valid:2005)
Indomethacin
Indomethacin therapy for
< 48 hours
< 30-32 weeks' gestation)
Not > 200mg/day.
appears to be a relatively safe and
effective tocolytic agent
Goldenberg , Obstetrics &Gynecology 11-2002
Indomethacin
Indomethacin can be
used as a second-line
tocolytic agent in early
gestational age preterm
labors.
Goldenberg , Obstetrics &Gynecology 11-2002
Indomethacin
Indomethacin may be a firstline tocolytic in:
Associated polyhydramnios :
( to have renal effects of
indomethacin)
Newton eMedicine 2002
Indomethacin
Capsule
Amp
Rectal Supp
25mg oral
50mg
100 mg
50 mg Loading dose
Atosiban: Tractocil
Atosiban, a synthetic
peptide, is a competitive
antagonist of oxytocin at
uterine oxytocin
receptors.
Atosiban: Tractocil
Atosiban - compared with beta-agonists-
has:
Little difference in the effect of these agents on
delayed delivery
Fewer maternal adverse effects than beta-agonists,
such as chest pain, palpitations , tachycardia ,
hypotension , dyspnoea ,vomiting , and headache.
Worldwide Atosiban Vs Beta-agonists Study Group. BJOG 2001;108:13342(
RCT)
Nifedipine
Nifedipine- compared with ritodrine -
has:
Higher delaying of delivery for >48 H.
Lower risk of RDS &Neonatal jundice.
Lower admission to NN ICU
Fewer maternal adverse effects
Tsatsaris et al, . Obstet Gynecol 2001;97:8407. (Meta-analysis)
Nifedipine
When tocolysis is indicated for women in
Nifedipine
20mg initial
10-20 mg /4-6 h
Epilate capsule
:10mg
Corticosteroids
Antenatal corticosteroids are associated
with a significant reduction in rates of
RDS, neonatal death and
intraventricular haemorrhage, although
the numbers needed to treat increase
Corticosteroids
The optimal treatment-delivery
interval for administration of
antenatal corticosteroids is
after 24 hours but < 7 days after
Corticosteroids
Two 12 mg doses of betamethasone
given IM 24 hours apart, Or
Four 6 mg doses of dexamethasone
given IM 12 hours apart (I-A).
There is no proof of efficacy for any
other regimen.
Antibiotics
There is no evidence of clear
overall benefit from
prophylactic antibiotics for
preterm labour with intact
membranes on neonatal
outcomes.
King & Flenady (Cochrane Review August 2002). In: The
Cochrane Library, Issue 1 2003. Oxford: Update Software.
ACOG Advises
Screening All
Pregnant Women
for Group B Strep.
ACOG NEWS RELEASE November 2002
Conclusions
Various strategies that have been
used to prevent or treat preterm
labor, haven't proven effective.
Tocolysis should be considered only
for 2 days- if needed - for
corticosteroids thereby , or in utero
transfer to a tertiary center .
Conclusions
If a tocolytic drug is
used, ritodrine no
longer seems the
best choice.
Conclusions
Other drugs with fewer adverse effects and
comparable effectiveness are now
recommended
Atosiban or nifedipine have been
recommended by RCOG
endomethacin may be used as a 2nd line
tocolytic or if there is polyhydramnous
Conclusions
Maintenance tocolytic
therapy has no proven
effect.
It cannot be recommended
for routine practice.
Thank You