preterm postterm prom1
DESCRIPTION
ob - prom pretermTRANSCRIPT
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Rex M. Poblete, M.D.,FPOGS
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PRETERM LABOR
POST-TERM PREGNANCY
PROM(Premature Rupture of Membranes)
IUFD (Intrauterine Fetal Demise)
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PRETERM LABOR
Single largest cause of perinatal morbidity and mortality in infants without anomalies in developed nationsRepresent more than 70% of all perinatal mortality and morbidity40% of preterm births follow preterm laborPrevalence: US = 11% Phil = 11.44% (POGS CNS)
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PRETERM LABOR
PRETERM – refers to a fetus, a pregnancy, or a neonate, that is less than 37 weeks gestation (WHO, ACOG) and more than 20 weeks gestation
2 categories: Indicated = 20%
Spontaneous = 80%
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PRETERM LABOR: categories
INDICATED*Follow medical or obstetric
disorders that place the mother or the fetus at risk.
*Preeclampsia (42%)
Fetal distress (26.7%)
Intrauterine growth restriction (10%)
Abruptio placenta (6.7%)
Fetal demise (6.7%)
SPONTANEOUS*Occur when there is no
underlying maternal or fetal illness
*Typically follow premature rupture of membranes, incompetent cervix, chorioamnionitis…
*Any prior spontaneous preterm delivery carries a 2.5 fold increased risk in a current gestation and even a 10.6 fold increase in preterm delivery <28 weeks AOG
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PRETERM LABOR: risk factors
Previous preterm delivery
Low socioeconomic status
Vaginal bleeding
Nonwhite race
Multiple gestation
Low body mass index
Bacteriuria
Extremes of age (≤18 or ≥40 years)Genital colonization or infectionAbsent/inadequate prenatal careCervical injury or abnormalitySmokingUterine abnormality
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PRETERM LABOR: risk factors
Previous preterm deliveryLow socioeconomic status
Vaginal bleeding
Nonwhite race
Multiple gestation
Low body mass index
Bacteriuria
Extremes of age (≤18 or ≥40 years)
Genital colonization or infection
Absent/inadequate prenatal care
Cervical injury or abnormality
Smoking
Uterine abnormality
* Nearly 50% of women with preterm deliveries have no identifiable risk factors…
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PRETERM LABOR: diagnosis
CERVICAL CHANGES*Characteristic cervical changes before delivery: shortening, softening, progressive dilatation*Digital examination: failed to predict preterm labor because of the great variation between examiners *Transvaginal UTZ of the uterine cervix is a better predictor of preterm delivery
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PRETERM LABOR: diagnosis
Preterm Prediction Trial, 1996*2 findings consistently associated with an
increase in preterm birth:
1. Cervical length <25 mm (10th percentile) to 30 mm (25th percentile)
2. Appearance of a funnel that comprises 50% or more of the total cervical length
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PRETERM LABOR: diagnosis
BIOCHEMICAL/ ENDOCRINE MARKERS1. FETAL FIBRONECTIN (Ffn)
• A glycoprotein produced by the fetal chorion and localized to the maternal decidua basalis
• When disruption of the choriodecidual junction occurs, it is extravasated into cervical and vaginal secretions
• Rarely identified after 21 weeks gestation• Presence after 21 weeks AOG is strongly
associated with preterm delivery
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PRETERM LABOR: diagnosis
2. SALIVARY ESTRIOL* estriol – “estrogen of pregnancy”* salivary estriol levels mirror the level of biologically active (unconjugated) estriol in the circulation* elevated levels of maternal salivary estriol (≥2.1 ng/ml) is predictive of preterm delivery in high risk women* studies show increased levels 2-4 weeks before delivery, whether term or preterm
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PRETERM LABOR: diagnosis
3. CORTICOTROPIN-RELEASING
HORMONE (CRH)
* a hypophysiotrophic hormone that
stimulates ACTH production in the
pituitary
* demonstrated to increase 100-fold in
maternal serum in the 3rd trimester before
parturition
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PRETERM LABOR: management
TOCOLYTIC THERAPY
ANTIBIOTICS
STEROIDS
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TOCOLYTIC THERAPY
Mainstay of hospital therapy once preterm labor is suspected
Cannot be expected to prevent prematurity because they treat the symptom (contractions), not the underlying pathology
PRETERM LABOR: management
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TOCOLYTIC THERAPYMain benefit: temporarily delay delivery (48-72
hours) to allow:
1. Administration of glucocorticoid therapy to improve neonatal outcome
2. Transfer of the mother to a tertiary facility that can best take care of a premature infant
3. Time to allow other treatments to work (e.g. antibiotics)
PRETERM LABOR: management
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TOCOLYTIC AGENTS:1.Beta-mimetics:
Terbutaline sulfate (Bricanyl)
Ritodrine hydrochloride
Isoxuprine hydrochloride (Duvadilan/Isoxilan)
**consistently demonstrated an ability to prolong gestation by about 24-48 hours
**side effects include maternal pulmonary edema and neonatal intravascular hemorrhage
PRETERM LABOR: management
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TOCOLYTIC AGENTS:2.Magnesium sulfate
**nonspecific calcium antagonist
**studies show no significant differences in delay in delivery when compared to beta-mimetics
**1st line of treatment in the US
**side effects include maternal hypocalcemia
**monitor for signs of magnesium toxicity
.
PRETERM LABOR: management
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TOCOLYTIC AGENTS:3.Calcium-channel blockers (Nifedipine)
**contraindicated in maternal hypotension (<90/50)
4. Prostaglandin synthetase inhibitors:
Indomethacin
Sulindac
Ketorolac
5. Oxytocin antagonist – Atosiban
.
PRETERM LABOR: management
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ANTIBIOTICS*Studies have linked urinary tract infections, intrauterine
infections, and vaginal microflora including bacterial vaginosis, with an increased risk for spontaneous preterm birth
*Proposed pathogenesis of infection-induced preterm labor: ascent of microorganisms from the cervix or vagina colonization of fetal membranes and decidua release of toxins production of cytokines production of prostaglandins which stimulate myometrial contractionPRETERM LABOR
PRETERM LABOR: management
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ANTIBIOTICS*In PTL with intact membranes:
*shown to be of no beneficial effect
DISCOURAGED
*In PTL with Premature Rupture of Membranes
*shown to improve outcome for both mother and fetus
*beneficial in prolonging pregnancy and in decreasing
neonatal infectious morbidity
.
PRETERM LABOR: management
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STEROIDS
*Use prior to preterm delivery has been shown to significantly decrease respiratory distress and neonatal mortality
*There is not enough evidence to evaluate the utilization of repeated doses of corticosteroids
*Present recommendation is only for a single course
*Dexamethasone, Betamethasone
PRETERM LABOR: management
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POST-TERM PREGNANCY
TERM gestation: 37-42 weeks
POST-TERM: >294 days or 42 weeks• Frequency: 4-14% (2-7% at 43 weeks)• Parturition occurs at 280 days (40 weeks)
after 1st day of last menses only in 5%• Associated with increased perinatal morbidity
and mortality
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POST-TERM PREGNANCY: diagnosis
Reliability of the Last Menstrual Period (LMP)
Use of ultrasound measurements (early = done <24 weeks gestation)
Assessment of amniotic fluid:*Volume – oligohydramnios?
* Character – stained?
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ULTRASOUND:
*Fetal biometry/ fetal aging
*Amniotic fluid assessment
POST-TERM PREGNANCY: diagnosis
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OLIGOHYDRAMNIOS:*AFI is below 5 cm*Associated with higher rates of intrapartum fetal distress and cesarean section*Meconium-staining: occurs in 37% of post-term pregnancies with normal AFI;increase to 71% when AFI is diminished
POST-TERM PREGNANCY: diagnosis
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FETAL COMPLICATIONS:• Aberrations in fetal growth:
• Postmature-dysmature syndrome – wasting of subcutaneous tissue, meconium-staining, peeling of skin (undernourished neonate)
• Macrosomia - >4000 grams birth injuries
• Meconium-staining & pulmonary aspiration• 3-fold higher increased incidence in post-term
POST-TERM PREGNANCY
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If (+)favorable cervix: labor induction between 41-42 weeks
If (+)unfavorable cervix: (a) do cervical ripening followed by labor induction; or (b) do twice weekly fetal monitoring DELIVERY if with fetal compromise
Use of UTZ: Biophysical Profile/ Score
POST-TERM PREGNANCY: management
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PREMATURE RUPTURE OF MEMBRANES (PROM)
Spontaneous rupture of the membranes that occur before the onset of labor
Preterm PROMRupture of the membranes before 37 weeks
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PREMATURE RUPTURE OF MEMBRANES: diagnosis
Diagnosis of membrane Diagnosis of membrane rupture is mainly clinicalrupture is mainly clinical
*other causes of vaginal discharge must be excluded
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PREMATURE RUPTURE OF MEMBRANES: diagnosis
Diagnostic tests:1. Nitrazine paper – insert a sterile cotton tip applicator deep into the vagina touch it to the nitrazine paper
pH > 6.5pH > 6.5 consistent with ruptured membranes
False positive nitrazine paper test:False positive nitrazine paper test: increased pH such as in cases contaminated by blood, semen or alkaline substance, or if with bacterial vaginosis
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PREMATURE RUPTURE OF MEMBRANES: diagnosis
2. Ferning
false positive result:false positive result: if the specimen is contaminated with cervical mucus (sample should be taken from the cul de sac or lateral vaginal walls)
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PREMATURE RUPTURE OF MEMBRANES: diagnosis
3. Ultrasound evaluation
Ultrasound finding of oligohydramnios without fetal urinary tract malformation or fetal growth restriction highly suggestive of membrane rupture
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* Gestational age should be established as soon as possibleClinical history and UTZ – estimate the gestational age, fetal weight, fetal position & residual amniotic fluid
* Evaluate for presence of advanced labor, chorioamnionitis, abruptio placenta, fetal distress
Expeditious delivery regardless of ageExpeditious delivery regardless of age
PREMATURE RUPTURE OF MEMBRANES: management
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* If conservative management is pursued, patient must be admitted to a tertiary hospital
* Provisions for 24-hour neonatal resuscitation & intensive care
PREMATURE RUPTURE OF MEMBRANES: management
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GOOD DAYGOOD DAY