Preterm labor

Flint Womens Clinic

Introduction

Preterm birth is the leading cause of neonatal mortality in the U.S. Preterm labor precedes preterm birth in 40-50% of cases 467,000 preterm births in U.S. yearly 11.5% of deliveries are prior to term
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Introduction

Preterm births are responsible for 75% of neonatal mortality Preterm birth is responsible for 50% of the long term neurologic impairment in children The incidence of preterm birth has changed little in 40 years

Introduction

Preterm labor is defined as defined by regular uterine contractions that occur before 37 weeks gestation and are associated with cervical change, birth prior to 20 weeks is an abortion.

Perinatal Morbidity

Pulmonary- RDS bronchopulmonary dysplasia Cardiovascular: PDA, persistent fetal circulation CNS: IVH, cerebral palsy, seizures, sensory deficits GI: NEC Metabolic: hypoglycemia, hypocalcemia, jaundice
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Perinatal morbidity

Infections: GBS, E. Coli SIDS Psychosocial:> prevalence of child abuse

Symptoms of preterm labor

None Pelvic pressure Increasing discharge Contractions (painless or painful) Back ache Menstrual cramps

Traditional Treatment

Bed rest Abstention from intercourse and orgasm Hydration

Risk factors for preterm delivery

Prior preterm delivery(15-30%) Non white race Age over 35 or under 17 Low socioeconomic status Low pre-pregnant weight(<50kgs) Vaginal bleeding in more than one trimester Smoking
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Risk factors for preterm delivery

Physically stressful jobs may increase risk (greater than 40 hour per week of standing) Uterine anomolies Second trimester abortion Preterm rupture of membranes

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Risk factors for preterm delivery

Multiple first trimester abortions Cervical conization Fibroids Polyhydramnios DES exposure Anemia Narcotic and cocaine use Periodontal disease
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Causes of preterm delivery

Placental abruption Uterine over distension Cervical incompetence Infections (chorioamnionitis), associated infections BV, ureaplasma, mycoplasma, peptostreptococcus, and bacteroides
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Causes of preterm delivery

Ruptured membranes Placenta previa Placental abruptions Diabetes HTN Connective tissue disorders Pyelonephritis

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Assessment of patients in preterm labor

History (Prior PTL, membrane status, discharge, fevers, number or size of fetus, associated medical problems) Tocodynamometer and FHR monitoring Physical exam- fundal height and tenderness,
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Assessment of patients in preterm labor

Labs-CBC, UA +/- culture, electrolytes Sterile speculum exam obtaining cultures for group B strep, BV, GC, Chlamydia, obtain fetal fibronectin Cervical length measurement The last thing is the cervical digital exam
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Biologic markers for predicting preterm birth

Home uterine monitoring- no evidence that it is of any benefit ACOG does not recommend it Salivary estriol- still considered investigational by ACOG BV-the most recent evidence does not support screening women for BV as treatment has not affected outcomes (treat symptomatic pts)
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Biologic markers for predicting preterm birth

Cervical length measurementmany studies have confirmed an association with cervical shortening and preterm delivery. When combined with positive fetal fibronectin and length less than 2.5 cm, this is a strong predictor of preterm delivery

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Biologic markers for predicting preterm birth

Fetal fibronectin- need intact membranes, less than 3 cm dilated, not useful before 24 weeks or after 34 weeks 6 days Negative fetal fibronectin gives about a 95% chance of the pregnancy continuing 14 days or more. A positive test is not as predictive.
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Predicting preterm birth

Use history, cervical length less than 2.5 cm (some authors 3.0 cm), fetal fibronectin positive, cervix 80% effaced, and or dilation above 2cm (some authors 3 cm), or a 1 cm change in cervical dilation.

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Treatment of preterm labor

IV hydration Treat any infections (usually start IV antibiotics empirically) Terbutaline 0.25 mg sub Q, can be given q 20 min, keep pulse under 120 MGSO4 4-6 gram bolus then run at 2-3 grams per hour
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Treatment of preterm labor

Calcium channel blockers 30 mg loading dose then 10-20 mg every 4-6 hours (nifedipine) avoid using MGSO4 at the same time Indomethacin 50 mg rectally or 50100 mg orally then 25-50mg every 6 hours only for a 48 hour period also use only less than 32 week

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Treatment of preterm labor

Betamethasone 12mg IM 2 doses 24 hours apart or Dexamethasone 6mg IM q 12 for 4 doses Do not use prior to 24 weeks and after 34 weeks

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Why use steroids

Decreased risk of RDS Decreased risk of Necrotizing enterocolitis Decreased risk of intra ventricular hemorrhages

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Down side of steroids

Decreased ability to fight infection Occasionally increases contractions Increased risk of pulmonary edema

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Management

First determine if it is truly labor Monitor contraction and assess cervical change If fetal fibronectin is negative no treatment needed, unless the cervix is less than 2.5cm Once a patient contracts regularly consider bed rest
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Management

Treat infections Treat asymptomatic bacturia Decrease activity Decrease or eliminate smoking or drugs Because of unknown group B strep status give penicillin until cultures are back
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Management

No method of treatment has proven to work Increased maternal surveillance does make a difference

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Contraindications of tocolysis

Severe PIH Abruption Chorioamnionitis Fetal death Severe IUGR Severe bleeding Fetal compomise 5cm dilated or more
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Outcomes

23 weeks 24 25 26 27 28

0-7% 0-50% 0-29% 56-67% 56-100% 88-91%

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Outcomes

Most NICUs report near 100% survival in the absence of major anomolies Malformations are the number one cause of neonatal death, #2 is prematurity (in blacks prematurity is #1)

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Review

There are risk factors for preterm delivery but the associations are weak. Assess each patient individually Act quickly- collect information and labs and check the cervix for dilation and length Start tocolytics and antibiotics
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Review

If gestation is prior to 34 weeks transfer to tertiary care center is indicated if time permits No therapy is proven superior or to work at all The combination of fetal fibronectin and cervical length are very good negative predictors
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Review

Many patients will have contractions but if no cervical change it is not preterm labor

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Introduction

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Topics of Discussion

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Topic One

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Topic Three

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Real Life

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What This Means

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Next Steps

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