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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
Incidence : 6- 10%
Spontaneous : 40-50%

PROM : 25-40%

Obstetrically indicated : 20-

25%
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?
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
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 increased
the risk of preterm delivery
>2-fold .
Risks were higher for those
screened at <16 weeks (odds
ratio, 7.55; 95% CI, 1.80-31.65)
than those at <20 weeks of
gestation (odds ratio, 4.20;
95% CI, 2.11-8.39).
Leitich et al Am J Obstet Gynecol. 2003 Jul;189(1):139 ( Meta-Analysis)
1-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
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
Digital examination is the
traditional method used to
detect cervical maturation, but
quantifying these changes is
often difficult.
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%


Delivery within 1 Week 71% 89%
Delivery within 2 Week 67% 89%
Delivery within 3 Week 59% 92%
Leitich & Kaider ,BJOG. 2003 Apr;110 , 20:66-70. Meta-Analysis 40 studies
Preventio
n
Women at increased risk
of preterm delivery may
be identified by various
risk factors in the
obstetric history and
treated.

American Academy of Pediatrician & ACOG 1997


Prophylactic use of 17 hydroxy
progesterone caproate to prevent
preterm labor revealed a
significant decrease in preterm
birth .
However, it has not successfully
inhibited active preterm labor.
Keirse. Br J Obstet Gynaecol 1990;97:149-54. Meta-anlysis of 6RCTs.

Meis et al. N Engl J Med. 2003 Jun 12;348(24):2379-85.RCT (19 centers )


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


Diagnosi
s
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.
2- Cervical dilatation > 1 cm
>
3- Effacement _ 80%.
American Academy of Pediatrician & ACOG 1997
Suspected preterm labor with
no cervical changes :
Negative fetal fibronectin +
Cervical length > 30 mm
the likelihood of delivering in the next
week is less than 1%.
Thus most women with a negative test can
safely be sent home without treatment.

Goldenberg , Obstetrics &Gynecology 11-2002


Inhibition of labor
Corticosteroid
Antibiotics
Others.
Bed rest :DVT
Hydration
&sedation
Tocolytics
Until effective strategies are found, efforts
should be aimed at preventing newborn
complications by :
Corticosteroids
Antibiotics against group B strep
Avoiding traumatic deliveries.
Delivery in a center with experienced
resuscitation teams and neonatal intensive
care

ACOG NEWS RELEASE: November 2002


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
It is reasonable not to use tocolytic
drugs, as there is no clear evidence
that they improve outcome. However,
tocolysis should be considered if the
few days gained would be put to good
use, such as completing a course of
corticosteroids, or in utero transfer

RCOG Guideline Grade A recommendation 2002 (Valid:2005)


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
B Sympathomimetic
(Ritodrine)
Magnesium sulphate
Indomethacin

Nifedipine = Epilate
Atosiban= Tractocile
Useof 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
There is insufficient evidence for any
firm conclusions about whether or
not maintenance tocolytic therapy
following threatened preterm labor
is worthwhile. Therefore
maintenance therapy cannot be
recommended for routine practice.

RCOG Guideline Grade A recommendation 2002 (Valid:2005)


Antenatal corticosteroids are associated
with a significant reduction in rates of
RDS, neonatal death and
intraventricular haemorrhage,
although the numbers needed to treat
increase significantly after 34 weeks'
gestation.

RCOG Guidelines : Grade A Recommendation


The optimal treatment-
delivery interval for
administration of antenatal
corticosteroids is after 24
hours but < 7 days after the
start of treatment.
RCOG Guidelines : Grade A Recommendation
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.

SOGC Recommendation Jan. 2003


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


All patients in preterm labor
are considered at high risk
for neonatal GBS sepsis and
should receive prophylactic
antibiotics regardless of
culture status.

Goldenberg , Obstetrics &Gynecology 11-2002


The goal of this
strategy is to prevent
neonatal sepsis, and
not to prevent
preterm birth.
Goldenberg , Obstetrics &Gynecology 11-2002
Have not been shown to
significantly prevent
periventricular haemorrhages
in preterm infants.

Crowther & Henderson-Smart (Cochrane Review Novemb. 2000 ) In:The


Cochrane Library, Issue 1 2003. Oxford: Update Software

Crowther & Henderson-Smart (Cochrane Review May 2003 ) In:The


Cochrane Library, Issue 1 2003. Oxford: Update Software

Goldenberg , May 2003


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
.
If a tocolytic drug
is used, ritodrine
no longer seems
the best choice.
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
Maintenance tocolytic
therapy has no proven
effect.
It cannot be
recommended for routine
practice.
Thank You

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