Preterm Labor:

Dr : Alia Abdullah Shoib

Evidence Based Sources:

PubMed Cochrean library RCOG Guidelines ACOG Issues Guidelines National Guideline Clearinghouse MOH Sing. Guideline

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 PROM : 40-50% : 25-40%

Obstetrically indicated : 20-25%

Preterm Labor
Most mortality and
morbidity is experienced by babies born before 34 weeks.

Major Risks Of Preterm Delivery

Death Respiratory distress syndrome Hypothermia Hypoglycaemia Necrotising enterocolitis Jaundice Infection Retinopathy of prematurity

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.

1-Risk Factors
Bacterial Vaginosis
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).

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

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.

2-Vaginal examination

Digital examination is the traditional method used to detect cervical maturation, but quantifying these changes is often difficult.

3-Vaginal U/S
Vaginal ultrasonography allows a more objective

approach to examination of the cervix.

4-Fibronectin Test
Outcome
Delivery <37 Sensitivity specificity 52% 53% 71% 67% 59% 85% 89% 89%

Delivery <34
Delivery within 1 Week Delivery within 2 Week Delivery within 3 Week

89%
92%

Prevention

Prevention of Preterm Labor

Women at increased risk of preterm delivery may be identified by various risk factors in the obstetric history and treated.

17 Hydroxy -Progesterone Caproate

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.

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.

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.

2- Cervical dilatation > 1 cm 3- Effacement > 80%. _

Vaginal U/S+ Fibronectin Test

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.

Inhibition of labor Corticosteroid Antibiotics Others.

Treatment

Inhibition Of Labor
Bed rest :DVT Hydration &sedation Tocolytics

Most Efforts to Prevent Preterm Labor Not Effective

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

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.

Is Tocolysis Better Than No Tocolysis For Preterm Labour?

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

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.

Choice Of Tocolytic Drug

B Sympathomimetic (Ritodrine) Magnesium sulphate Indomethacin

Nifedipine = Epilate Atosiban= Tractocile

Choice Of Tocolytic Drug

If a tocolytic drug is used, ritodrine no

longer seems the best choice.

Atosiban or nifedipine appear

preferable as they have fewer adverse effects and seem to have comparable effectiveness.

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
Dose

Side effect

Nitric Oxide Donors

There is insufficient evidence to

support the routine

administration of nitric oxide donors (nitroglycerin )in the treatment of preterm labor.

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

Indomethacin
Fetal risk: Premature closure of the ductus. Renal and cerebral vasoconstriction. Necrotising enterocolitis Common with high dose and prolonged exposure.

Indomethacin
Indomethacin therapy for < 48 hours < 30-32 weeks' gestation) Not > 200mg/day. appears to be a relatively safe and effective tocolytic agent

Indomethacin
Indomethacin can be used as a second-line tocolytic agent in early gestational age preterm labors.

Indomethacin
Indomethacin may be a firstline tocolytic in: Associated polyhydramnios : ( to have renal effects of indomethacin)

Indomethacin
Capsule Amp Rectal Supp 25mg oral 50mg 100 mg

50 mg Loading dose

Then 25-50mg /6hs

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.

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

Nifedipine
When tocolysis is indicated for women in

preterm labor, calcium channel blockers

are preferable to other tocolytic agents

compared, mainly betamimetics.

Further research should address the effects of different dosage regimens and formulations

Nifedipine
20mg initial 10-20 mg /4-6 h

Epilate capsule

:10mg

Epilate retard Tablet: 20 mg

Maintenance Tocolysis Is Not Recommended For Routine Practice.

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.

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

significantly after 34 weeks' gestation.

Corticosteroids
The optimal treatment-delivery interval for administration of

antenatal corticosteroids is
after 24 hours but < 7 days after

the start of treatment.

Corticosteroids
Two 12 mg doses of betamethasone given IM 24 hours apart, Or Four 6 mg doses of dexamethasone given IM 6 hours apart 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.

Screening for GB Strep.

ACOG Advises Screening All Pregnant Women for Group B Strep.

Group B Streptococci (GBS) Prophylaxis

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

Group B Streptococci (GBS) Prophylaxis

The goal of this strategy is to prevent neonatal sepsis, and not to prevent preterm birth.

Prophylactic Vitamin K Or Phenobarbital

Have not been shown to significantly prevent periventricular haemorrhages in preterm infants.

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.

THANKS