Download - 32- Preterm Labour
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Preterm labour( PTL) &premature rupture ofmembranes
Rami Kilani
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Defnition De nition : Labour which occurs
rom the viability o the etus( completed 24 weeks !" until thecompletion o #$ weeks o %estation
Incidence : &'$ white )uropean *+ in ! ricans
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,redisposin% actors orpreterm labour
Epidemiological -./0 *1 Low social class black
unmarried3unsupported 3 smoker oun% a%e5 old a%e6 anemia or polycythemia ,revious preterm labour ( the sin%le most
e7ective predictor " 2+ or one ,8L 4+ or 2,8L
Elective delivery ( iatrogenic !") ,)86 maternal /9 R etal
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,8L ( continued risk actors"
#edical R;. *3# .ultiple pre%nancy ,olyhydramnios .edical disorders uired abnormalities o the
uterus(=ervical incompetence bicornuate uterus
fbroids" ?a%inal in ection ( e'%' bacterial va%inosis" !,@ /ntra abdominal sur%ery
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Diagnosis $istory : R;. -ackache crampin% abdominal pain
,elvic pressure increased va%inal dischar%e
E%amination : !bdominal eAam : uterine tenderness abruptio chorioamnionitis'
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Di erential diagnosis 98/ ,lacental abruption
astroenteritis =onstipation Red de%eneration o fbroid
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Investigations 'etal bronectin : %lue like protein bindin%
the choriodecidual membranes' !ny disruption othe choriodecidual inter ace results in release oCC 5 detection in cervico va%inal section ' 8hisdisruption precedes preterm labor
% lengt : measurement by transvaginalultraso und( normal cA len%thE #'& cm" c%s ortening* dilatation* 5 unneling o themembranes down the cA canal
+epeat vaginal e%am ( in * 4 hours" inthe absence o specialiFed tests
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#anagement -ed rest @ydration
.aternal steroids 8ocolytics !ntibiotics Cetal assessment
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,8L ( mana%ement" ,ed rest & ydration : /ncrease uterine blood Bow 5 >uietin% the
uterus' De ydration increased levels o-D$ ' !D@ may cross react with oAytocinreceptors 5lead to contraction so hydrationdecrease !D@ 5 contractions'
Lyin% on her side 5 /? Buid
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#aternal steroids :
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Tocolysis
*' -eta mimetics2' .a%nesium sul ate
#' =alcium channel inhibitors4' ,rosta%landin inhibitors&' ;Aytocin anta%onist
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,eta mimetics : 8wo beta mimetics commonly used or preterm
labor ritodrine ( utopar"5 terbutaline '
2ide e ects : tachycardia headacheshyper%lycemia hypokalemia'
8he most serious is pulmonary edema 5 in rare
cases maternal death Contraindicated : symptomatic cardiac disease
uncontrolled diabetes hyperthyroidism'
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#agnesium sulfate : 2ide e ects : Bushin% headache ati%ue diplopia' !t 8oAic level o .% ( G *+m%3dl" respiratory
depression hypoAia 5cardiac arrest'
Deep tendon reBeAes depressed5 lost at0 *+ m%3dlso rule out .% toAicity with serial reBeA checks
,ulmonary edema may occur
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a3 c annel bloc1ers : ni edipine
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Prostaglandin in ibitors : /ndomethacin
4%ytocin antagonists : atosiban
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-ntibiotics
Routine use o antibiotics in uncomplicatedpreterm labour did not con er benefts
*+ day course o eryt romycin lead toimproved neonatal outcome after P+4#
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'etal assessment 9ltrasound: etal presentation estimated etal
wei%ht !C/'
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.ode o delivery 8he case should be evaluated
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Premature rupture of membranes
( P+4# ) & preterm +4#
Preterm +4# : R;. occurrin%be ore #$ wk'
Premature +4#(P+4# ":R;.be ore the onset o labour'
/ t0o occur to%ether PP+4# Prolonged P+4# : R;. 6 ./ rs
be ore delivery(or 78 rs "
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Preterm +4# =ommon cause o preterm labour 5
chorioamnionitis 9!" %o into labour within ./ rs :9"0it in /8 rs 8hese correlate inversely with ! at
R;. Prolonged PP+4# associated with
increased risk o chorioamnionitisabruption 5 cord prolapse
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linical features $istory : gus o Buid per va%ina ollowed by
continuous dribblin%' Cetal movement may reduced in stren%th or re>uency
E%amination : PR, temp, appearance Abdominal exam : may oli%ohydramnios
uterine tenderness i chorioamnionitis Speculum exam (defnitive DH": pool o amniotic
Buid post va%ina is dA positive cou%h si%n ?isualiFe the cA or dilatation Di%ital eAam should be avoided
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Di erential diagnosis ;rine loss : /ncontinence 5 98/ are common in
pre%nancy
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Investigations
7> ?itra@ine test amniotic Buid is alkalinebut va%inal secretions are acidic' !lkaline ,@ black stick' Calse positive blood semen 5urine
.> 5enital tract s0abs @?< 5 or - #aternal 0ellbeing vital si%ns I-=
=R, early markers o in ection
/> 'etal 0ellbeing serial
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&';ltrasound !C/ oli%ohydramniossupport ,R;.
J' -mniocentesis =5< %ram stain
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#anagement
Preterm +4# : depends on ! -alance risk o prematurity 5 risk o in ection
-etween #2 #4 weeks
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8he use o antibiotics leads to longer latencyperiod prior to onset o labour so ampicillin withor without eryt romycin is recommended in,,R;.
Tocolysis contraindicated
2teroids are recommended
!ny patient who shows si%ns o infection or fetaldistress needs to be delivered
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#aternal & fetal complicationsassociated 0it P+4#
*' =horioamnionitis2' @yaline membrane disease ( @.D"#' ,ulmonary hypoplasia re>uent when ,R;.
occurs be ore 2J wk5 latent period G & wk4' !bruptio placenta&' Cetal distress the most common is variable
deceleration reBectin% umbilical cord
compression caused by oligo ydramniosJ' Cetal de ormities acial 5 skeletal de ormities inprolon%ed ,R;.