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PretermPreterm LabourLabour
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DefinitionsDefinitions
LabourLabour is preterm when it occurs in ais preterm when it occurs in apatient whose period of gestation ispatient whose period of gestation isless than 37 completed weeks(lessless than 37 completed weeks(lessthan 259 days) from the first day ofthan 259 days) from the first day ofthe last menstrual period.the last menstrual period.
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IncidenceIncidence
ApproxApprox 55--6% in Australia6% in Australia
More than 10% in the USAMore than 10% in the USA Second leading cause of mortalitySecond leading cause of mortality
after congenitalafter congenital anomaliesanomalies
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DiagnosisDiagnosis
Uterine contractionsUterine contractions-- 4 in 204 in 20 minsmins or 8or 8in 60in 60 minsmins
CervixCervix-- dilated 2 cm or 80% effaceddilated 2 cm or 80% effaced
Serial examinations, preferably by theSerial examinations, preferably by thesame observer, reveal changes in thesame observer, reveal changes in the
cervixcervix
Membranes are rupturedMembranes are ruptured
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Risk Factors (1)Risk Factors (1)
StressStress
Occupational fatigueOccupational fatigue Smoking/substance abuseSmoking/substance abuse
Poor antenatal carePoor antenatal care
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Risk FactorsRisk Factors
Excessive or impaired uterine distension:Excessive or impaired uterine distension:
Multiple pregnancyMultiple pregnancy PolyhydramniosPolyhydramnios
FibroidsFibroids
Uterine anomalyUterine anomaly
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Maternal FactorsMaternal Factors
Maternal diseaseMaternal disease PIHPIH Renal diseaseRenal disease
AppendicitisAppendicitis
Uterine anomaliesUterine anomalies Cervical incompetenceCervical incompetence
History of pretermHistory of preterm labourlabour-- 1 pre term1 pre term-- 2525--50%50%increased riskincreased risk
History of abortionHistory of abortion Socioeconomic statusSocioeconomic status-- Poor nutrition,Poor nutrition,
inadequate prenatal care, low maternal age,inadequate prenatal care, low maternal age,heavy workheavy work
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Risk FactorsRisk Factors
Cervical factors:Cervical factors:
History of second trimester lossHistory of second trimester loss
Cervical surgeryCervical surgery
Premature cervical dilatationPremature cervical dilatation ororeffacementeffacement
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Risk FactorsRisk Factors
Infections:Infections:
Systemic infectionsSystemic infections
STD'sSTD's
PyelonephritisPyelonephritis
BacteriuriaBacteriuria Periodontal diseasePeriodontal disease
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Risk FactorsRisk Factors
Fetal & placental factors:Fetal & placental factors:
Congenital anomaliesCongenital anomalies-- polyhydramniospolyhydramnios (1/3(1/3rdrd
have PTL),have PTL), oligohydramniosoligohydramnios
IUGRIUGR Multiple pregnancyMultiple pregnancy-- 261 days for twins, 246261 days for twins, 246
days for triplets, 236 days for quadrupletsdays for triplets, 236 days for quadruplets
PROMP
ROM
AbruptionAbruption
VaginalVaginal bleedingbleeding
PlacentaPlacenta previaprevia
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Causes of PretermCauses of Preterm LabourLabour
Major focus of O & G research.Major focus of O & G research.
80% spontaneous onset80% spontaneous onset
5050% PTL% PTL
3030% PPROM% PPROM
20% due to20% due to toto intervention forintervention formaternal ormaternal or fetal indicationsfetal indications
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Four Major CategoriesFour Major Categories
Activation ofActivation ofhypothalamic/pituitary/adrenal axis:hypothalamic/pituitary/adrenal axis:
maternal or fetalmaternal or fetal
InflammationInflammation
DecidualDecidual hemorrhagehemorrhage
Uterine overUterine over--distentiondistention
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Activation ofHPAActivation ofHPA
AxisAxis Maternal physical/emotional stressMaternal physical/emotional stress
PlacentalPlacental vasculopathyvasculopathy
Increased secretion of CRHIncreased secretion of CRH fetalfetalACTHACTH
Increased secretion placentalIncreased secretion placentalestrogenestrogen
Increased secretion of placental PG'sIncreased secretion of placental PG's
Activation of myometriumActivation of myometrium
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InflammationInflammation
Both systemic and genital tract infectionsBoth systemic and genital tract infections
ChorioamnionitisChorioamnionitis in 50% of pretermin 50% of preterm labourslabours before 30 weeks' gestationbefore 30 weeks' gestation
Can occur with intact membranesCan occur with intact membranes
Raised cytokines (interleukins, TNF, GSF)Raised cytokines (interleukins, TNF, GSF) Enhanced prostaglandin productionEnhanced prostaglandin production
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BacteriaBacteria
Some organisms have a direct role inSome organisms have a direct role in PTLPTLindependentindependent of inflammatory mediatorsof inflammatory mediators
PseudomonasPseudomonas, staph, strep,, staph, strep, bacteroidesbacteroides,,enterobacterenterobacter produce proteases that canproduce proteases that canbreak downbreak down fetal membranesfetal membranes
Can also produce phospholipase A2Can also produce phospholipase A2 andandendotoxinsendotoxins, stimulating uterine, stimulating uterinecontractionscontractions
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BacteriaBacteria
Increased rates of PTL noted inIncreased rates of PTL noted inwomen withwomen with
GBS, chlamydia and syphilisGBS, chlamydia and syphilis
Risk of PTL reduced by treating:Risk of PTL reduced by treating:
AsymptomaticAsymptomatic bacteriuriabacteriuria
GonorrheaGonorrhea
BV in high risk patients for PTLBV in high risk patients for PTL
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Oral BacteriaOral Bacteria
Increased rates of PTL noted inIncreased rates of PTL noted inwomenwomen with periodontalwith periodontal diseasedisease
? intrauterine infection following? intrauterine infection followingdescent fromdescent from oral cavityoral cavity
CaseCase report:report: BergeyellaBergeyella bacteriumbacterium
isolated fromisolated from both the mouth andboth the mouth andamniotic fluidamniotic fluid of patientof patient with intactwith intactmembranes having PTLmembranes having PTL at 24at 24 weeksweeks
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DecidualDecidual hemorrhagehemorrhage
Vaginal bleeding in more than oneVaginal bleeding in more than onetrimester increasestrimester increases risk of PTL 7risk of PTL 7--foldfold
Placental histopathology: occultPlacental histopathology: occultdecidualdecidual hemorrhagehemorrhage noted in 36noted in 36--38%38%of cases of PTBof cases of PTB
PPROM may be related to highPPROM may be related to highconcentrationsconcentrations of tissueof tissue factorfactor
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DecidualDecidual hemorrhagehemorrhage
DecidualDecidual TF combines withTF combines with FVIIaFVIIa totoactivate FXactivate FX, to generate thrombin, to generate thrombin
Thrombin is a potent inducer ofIL8,Thrombin is a potent inducer ofIL8,causingcausing localisedlocalised inflammatory reactions.inflammatory reactions.
Leads to degradation of fetalLeads to degradation of fetal membranemembrane
extracellularextracellular matrix, PPROMmatrix, PPROM
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Uterine OverUterine Over--distentiondistention
UpUp--regulation of oxytocin receptorsregulation of oxytocin receptors
Formation of gap junctionsFormation of gap junctions
PGE2 andPGE2 and PGFPGF
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UterineUterine OverOver--distensiondistension
PolyhydramniosPolyhydramnios
Multiple pregnancyMultiple pregnancy
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Cervical IncompetenceCervical Incompetence
In most cases a secondary effectIn most cases a secondary effect
CervicalCervical cone biopsycone biopsy
LLETZLLETZ, laser cone, laser cone
Increased risk of PTLIncreased risk of PTL --
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Prevention of PretermPrevention of PretermLabourLabour
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Potentially effectivePotentially effective
interventionsinterventions Progesterone supplementsProgesterone supplements
Smoking cessationSmoking cessation
Avoidance of drugs & alcoholAvoidance of drugs & alcohol
Reduce rate of multiple pregnancyReduce rate of multiple pregnancy
CervicalCervical cerclagecerclage Reduce occupational stressReduce occupational stress
NutritionNutrition
Early diagnosis & treatment of infectionEarly diagnosis & treatment of infection
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Progesterone supplementsProgesterone supplements
Most trials useMost trials use 1717--alphaalpha--hydroxyprogesteronehydroxyprogesteronecaproatecaproate, weekly IMI, weekly IMI
Reduction in PTL rates by 15
Reduction in PTL rates by 15--70%70%
Most effective in women with previous PTLMost effective in women with previous PTL atat
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Stop smokingStop smoking
Cigarette smoking has aCigarette smoking has a dosedose--dependent relationshipdependent relationship with pretermwith preterm
labourlabour
Partially due to smokingPartially due to smoking--relatedrelatedcomplicationscomplications
Cessation of smoking likely to beCessation of smoking likely to bebeneficial,beneficial, but notbut not proven in RCTsproven in RCTs
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Avoidance of drugs andAvoidance of drugs and
alcoholalcohol CocaineCocaine
AlcoholAlcohol
? Cannabis? Cannabis
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Reduction in multipleReduction in multiple
pregnanciespregnancies Multiple pregnancies six times moreMultiple pregnancies six times more
likelylikely to deliverto deliver pretermpreterm
Risk increases with increasing no. ofRisk increases with increasing no. offetusesfetuses
Valid indication before starting ARTValid indication before starting ART
Limit no. of embryosLimit no. of embryos transferrredtransferrred
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CervicalCervical CerclageCerclage
Cervical incompetence based on historyCervical incompetence based on history ororultrasoundultrasound findingsfindings
RCOG study of 1292 womenRCOG study of 1292 women Significant reduction in pretermSignificant reduction in preterm births
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Reduction of WorkReduction of Work
FatigueFatigue Excessive physical demands relatedExcessive physical demands related toto
increasedincreased risk (OR 1.63)risk (OR 1.63)
Working > 42Working > 42 hrshrs/week/week
Standing > 6Standing > 6 hrshrs/day/day
Low job satisfactionLow job satisfaction
No RCTs availableNo RCTs available
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Nutritional interventionsNutritional interventions
No fish consumption linked to excess riskNo fish consumption linked to excess riskof PTLof PTL (OR 19.6)(OR 19.6)
Fish oil supplements: one multiFish oil supplements: one multi--centrecentreRCTRCT in highin high risk women showed arisk women showed asignificant reductionsignificant reduction in PTL (OR 0.54)in PTL (OR 0.54)
Trial withTrial with docosahexanoicdocosahexanoic acidacid
supplements: significantsupplements: significant prolongation ofprolongation ofpregnancypregnancy
CARRDIP trial: marked reduction in riskCARRDIP trial: marked reduction in risk ofofpretermpreterm labourlabour (1/141(1/141 vsvs 11/14911/149
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Early detection and treatment ofEarly detection and treatment of
infectioninfection
AsymptomaticAsymptomatic bacteruriabacteruria: treatment: treatmentsignificantly reducessignificantly reduces risk of PTL or LBWrisk of PTL or LBW
infants (OR 0.60)infants (OR 0.60) ChlamydiaChlamydia, gonorrhea, BV: routine, gonorrhea, BV: routine
screeningscreening not indicatednot indicated
WomenWomen with previous PTL and +with previous PTL and +veve for BVfor BVmay benefitmay benefit from treatmentfrom treatment
TrichomonasTrichomonas: treatment of asymptomatic: treatment of asymptomaticwomenwomen may increasemay increase risk of PTLrisk of PTL
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Tests for Prediction ofTests for Prediction of
Preterm DeliveryPreterm Delivery CervicoCervico--vaginalvaginal fibronectinfibronectin
Ultrasound measurement of cervicalUltrasound measurement of cervicallengthlength
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Treatment of PretermTreatment of Preterm
LaborLabor No generally accepted criteriaNo generally accepted criteria forfor
startingstarting tocolysistocolysis
AboutAbout 3030--50% of threatened50% of threatened pretermpretermlabourslabours spontaneously resolvespontaneously resolve
TreatTreat the underlying cause if possiblethe underlying cause if possible
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General MeasuresGeneral Measures
No proven benefits forNo proven benefits for::
Bed restBed rest
HydrationHydration
SedationSedation
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Objectives ofObjectives of TocolysisTocolysis
Delay delivery so that steroids mayDelay delivery so that steroids may bebegivengiven
AllowAllow safe transport of the mothersafe transport of the mother ififpossiblepossible
ProlongProlong pregnancy when there arepregnancy when there are selfself
limitinglimiting causescauses ofof labourlabour e.g. sepsise.g. sepsis
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Contraindications toContraindications to
TocolysisTocolysis APHAPH with hemodynamic instabilitywith hemodynamic instability
Severe preSevere pre--eclampsiaeclampsia//eclampsiaeclampsia
ChorioamnionitisChorioamnionitis
Severe IUGRSevere IUGR
Evidence of fetal compromiseEvidence of fetal compromise Lethal fetal anomalyLethal fetal anomaly
Fetal demiseFetal demise
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Benefits of AntenatalBenefits of Antenatal
SteroidsSteroids Reduce riskReduce risk of:of:
RDSRDS (RR 0.66)(RR 0.66)
NEC (RR
0.46)NEC (RR
0.46) IVH (RR 0.54)IVH (RR 0.54)
Severe bruisingSevere bruising Systemic infection in the first 48Systemic infection in the first 48 hrhr ofof
life (RR
life (RR
0.56)0.56) Admission to NICU (RR 0.80)Admission to NICU (RR 0.80) Neonatal mortality (RR 0.69)Neonatal mortality (RR 0.69)
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Antenatal SteroidsAntenatal Steroids
Effective in women with SROM andEffective in women with SROM andPETPET
MaximumMaximum effect at 48effect at 48 hrshrs
Betamethasone 12Betamethasone 12 mg IMmg IM 2424 hrshrs apartapart
Beneficial effects wear off after 2Beneficial effects wear off after 2weeksweeks
No significant maternal side effectsNo significant maternal side effects
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TOCOLYTICAGENTSTOCOLYTICAGENTS
BetamimeticBetamimetic agentsagents
NifedipineNifedipine
NSAIDSNSAIDS
AtosibanAtosiban
MagnesiumMagnesium sulphatesulphate
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BETABETA--ADRENERGICADRENERGICRECEPTORAGONISTSRECEPTORAGONISTS
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Mechanism of action:Mechanism of action:
CauseCause myometrialmyometrial relaxation byrelaxation bybinding withbinding with betabeta--2 receptors and2 receptors and
increasing intracellularincreasing intracellular adenyladenyl cyclasecyclase..
DropDrop in intracellular calciumin intracellular calcium
TargetTarget cells eventually becomecells eventually become
desensitized todesensitized to the effect of betathe effect of beta--adrenergicadrenergic agonists (agonists (tachyphylaxistachyphylaxis).).
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BETABETA--ADRENERGICRECEPTORADRENERGICRECEPTORAGONISTS : EFFICACYAGONISTS : EFFICACY
MetaMeta--analyses:analyses:
ReductionReduction in no. of births within 48in no. of births within 48 hrshrs((RR 0.63RR 0.63).).
NoNo decrease in no. of births within 7decrease in no. of births within 7daysdays
NoNo change in perinatal mortalitychange in perinatal mortality
MarginalMarginal decrease in RDS casesdecrease in RDS cases
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BETABETA--ADRENERGICRECEPTORADRENERGICRECEPTORAGONISTS: MATERNALAGONISTS: MATERNAL SIDEEFFECTSSIDEEFFECTS
TachycardiaTachycardia
PalpitationsPalpitations
Lowered blood pressureLowered blood pressure
Shortness of breathShortness of breath
Myocardial ischemiaMyocardial ischemia
PulmonaryPulmonary edemaedema (0.3%)(0.3%)
Hyperglycemia, hypokalemiaHyperglycemia, hypokalemia
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BETABETA--ADRENERGICRECEPTORADRENERGICRECEPTORAGONISTS:AGONISTS:FETALFETAL SIDEEFFECTSSIDEEFFECTS
TachycardiaTachycardia
NeonatalNeonatal hypoglycemiahypoglycemia
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TERBUTALINE:TERBUTALINE:
DOSAGEDOSAGE ContinuousContinuous iv infusioniv infusion (10(10 mcgmcg/min/min
increasedincreased to max. ofto max. of 5050 mcg/min)mcg/min)
S.C.IS.C.I. 25 mg stat. 25 mg stat
StopStop ifHR>120 or symptomaticifHR>120 or symptomatic
MonitorMonitor K+ andK+ and blood sugarsblood sugars
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CALCIUMCHANNELCALCIUMCHANNEL
BLOCKERSBLOCKERS Block the influx ofBlock the influx of CaCa+ through+ through thethe
cellcell membranemembrane
ReductionReduction of intracellular free calciumof intracellular free calcium
InhibitionInhibition of myosin light chainof myosin light chain kinasekinasephosphorylationphosphorylation
RelaxationRelaxation of uterine muscleof uterine muscle
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EFFICACY OF NIFEDIPINEEFFICACY OF NIFEDIPINE
MetaMeta--analysis of 12 RCTs:analysis of 12 RCTs:
Reduction in no. of births within 7 days (RRReduction in no. of births within 7 days (RR
0.760.76)) Reduction in no. of births before 34 weeksReduction in no. of births before 34 weeks
(RR 0.83)(RR 0.83)
Lower risk ofRD
S (RR
0.63), NEC (RR
Lower risk ofRD
S (RR
0.63), NEC (RR
0.23),0.23), IVHIVH (RR(RR 0.59), jaundice (RR 0.73)0.59), jaundice (RR 0.73)
Fewer maternal side effects (RR 0.14)Fewer maternal side effects (RR 0.14)
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NIFEDIPINE :NIFEDIPINE :
MATERNAL SIDEEFFECTSMATERNAL SIDEEFFECTSPeripheral vasodilator:Peripheral vasodilator:
Nausea, flushing, headacheNausea, flushing, headache
PalpitationsPalpitations
Reduction in MAP, reflex tachycardiaReduction in MAP, reflex tachycardia
Rarely severe hypotensionRarely severe hypotension
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NIFEDIPINE :NIFEDIPINE :
FETAL SIDEEFFECTSFETAL SIDEEFFECTSAnimal studies: reduced uterineAnimal studies: reduced uterine andand
umbilicalumbilical blood flowblood flow
No evidence of toxicity in humansNo evidence of toxicity in humans
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NIFEDIPINE :NIFEDIPINE :
CONTRAINDICATIONSCONTRAINDICATIONS KnownKnown allergyallergy
LV dysfunction or cardiac failureLV dysfunction or cardiac failure
Hepatic dysfunctionHepatic dysfunction
Concomitant use ofConcomitant use of magnesium:magnesium:respiratoryrespiratory paralysisparalysis
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MagnesiumMagnesium sulphatesulphate
Prevents influx of calcium into thePrevents influx of calcium into themyometrialmyometrial cellcell
4 g loading dose in 250 ml RL over 204 g loading dose in 250 ml RL over 20minsmins
MaintenanceMaintenance-- 40 g in 1 l RL40 g in 1 l RL-- 50 ml/50 ml/hrhr
(2g/(2g/hrhr)) Serum levelsSerum levels-- 44--8 mg8 mg
Continued for 24Continued for 24-- 48 hours48 hours
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Side effectsSide effects
MaternalMaternal
Patellar reflexes disappearPatellar reflexes disappear-- 1010 meqmeq/l/l
Respiratory depressionRespiratory depression-- 1212--15meq/l15meq/l
Cardiac arrestCardiac arrest-- 15meq/l15meq/l
FetalFetal-- crosses the placentacrosses the placenta
Loss of beat to beat variabilityLoss of beat to beat variability Respiratory depressionRespiratory depression
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IndomethacinIndomethacin ProstaglandinProstaglandin synthetasesynthetase inhibitorinhibitor
100 mg rectal suppository100 mg rectal suppository
Repeat at 8Repeat at 8--12 hour intervals or 25 mg oral12 hour intervals or 25 mg oral
every 6 hoursevery 6 hours UptoUpto 24 hours24 hours
Side effectsSide effects-- Premature closure ofPremature closure of ductusductusarteriosusarteriosus
NeuronalNeuronal micronecrosismicronecrosis OligohydramniosOligohydramnios
Delay in pulmonary maturationDelay in pulmonary maturation
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ROUTINEANTIBIOTICSINPRETERMROUTINEANTIBIOTICSINPRETERMLABOUR WITHINTACTMEMBRANESLABOUR WITHINTACTMEMBRANES
Results of ORACLE and metaResults of ORACLE and meta--analysis:analysis:
No improvement in neonatalNo improvement in neonatal
outcomesoutcomes
Reduction in maternal infection (RRReduction in maternal infection (RR0.74)0.74)
Uncertainty about optimal antibioticsUncertainty about optimal antibioticsand regimeand regime
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MANAGEMENT FOLLOWINGMANAGEMENT FOLLOWINGSUCCESSFULSUCCESSFUL
TOCOLYSISTOCOLYSIS
Optimal approach unknownOptimal approach unknown limitedlimiteddatadata
ProlongedProlonged hospitalisationhospitalisation probably ofprobably ofno valueno value
Bed rest not proven effectiveBed rest not proven effective
Avoid physically demanding workAvoid physically demanding work
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MANAGEMENT FOLLOWINGTOCOLYSIS:MANAGEMENT FOLLOWINGTOCOLYSIS:SEXUAL ACTIVITYSEXUAL ACTIVITY
Observational data onlyObservational data only
HigherHigher mortality amongst infectedmortality amongst infected
infants associatedinfants associated with recent coitus:with recent coitus:11%11% vsvs 2.4%2.4%
IncreasedIncreased rates or RDS, jaundice, lowrates or RDS, jaundice, lowApgar scoresApgar scores (x 2)(x 2)
EffectEffect stronger among preterm birthsstronger among preterm births
PrudentPrudent to suggest avoidance of coitusto suggest avoidance of coitusafter successfulafter successful tocolysistocolysis
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MANAGEMENT FOLLOWINGTOCOLYSIS:MANAGEMENT FOLLOWINGTOCOLYSIS:MAINTENANCETOCOLYSISMAINTENANCETOCOLYSIS
MostRCTs are smallMostRCTs are small
EndogenousEndogenous prostaglandins mayprostaglandins may
increase oxytocinincrease oxytocin receptor densityreceptor density
CochraneCochrane review of maintenance oralreview of maintenance oralbeta agonists: nobeta agonists: no significant benefitssignificant benefits
MayMay be useful for temporary relief ofbe useful for temporary relief ofpainful contractionspainful contractions
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MANAGEMENT FOLLOWINGTOCOLYSIS:MANAGEMENT FOLLOWINGTOCOLYSIS:REPEATED COURSESOF ANTENATALREPEATED COURSESOF ANTENATAL
STEROIDSSTEROIDS
Repeat courses of steroids improveRepeat courses of steroids improve neonatalneonatalpulmonarypulmonary outcomes, especially inoutcomes, especially in earlierearlier
gestationalgestational agesages EvidenceEvidence of delayed neuronal maturationof delayed neuronal maturation
and increasedand increased risk ofIUGR in animal studiesrisk ofIUGR in animal studies
Humans
Humans: reduced birth weight only with 4: reduced birth weight only with 4 orormoremore coursescourses
CatchCatch--upup growth by time of dischargegrowth by time of discharge fromfromhospitalhospital
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MANAGEMENT FOLLOWINGTOCOLYSIS:MANAGEMENT FOLLOWINGTOCOLYSIS:REPEATED COURSESOF ANTENATALREPEATED COURSESOF ANTENATAL
STEROIDSSTEROIDS
LongLong--termterm neuroneuro--developmental datadevelopmental datanot availablenot available
OptimalOptimal number of courses ofnumber of courses of steroidssteroidsunknownunknown
TwoTwo courses probably safecourses probably safe
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MANAGEMENT FOLLOWINGMANAGEMENT FOLLOWINGTOCOLYSIS: RISKTOCOLYSIS: RISKOF IUGROF IUGR
Threatened PTL may be an indication ofThreatened PTL may be an indication offetal stressfetal stress arising fromarising from unfavourableunfavourableintrauterine environmentintrauterine environment..
PlacentalPlacental pathology: increased incidencepathology: increased incidenceof fetalof fetal or maternal vascular lesionsor maternal vascular lesionswithout inflammationwithout inflammation
RiskRisk of giving birth to SGA infant (ORof giving birth to SGA infant (OR
2.2)2.2) NeedNeed closer surveillance with USS forcloser surveillance with USS for
growth andgrowth and Doppler studiesDoppler studies
bb
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LabourLabour
Premature infants tolerate stress andPremature infants tolerate stress andhypoxia less well than term infantshypoxia less well than term infants
Aims ofAims of manangementmanangement
Adequate fetal oxygenation during deliveryAdequate fetal oxygenation during delivery
Prevention of traumatic deliveryPrevention of traumatic delivery
Skilled resuscitative team present at birthSkilled resuscitative team present at birth
Continuous electronic fetal monitoringContinuous electronic fetal monitoring Scalp blood sampling when indicatedScalp blood sampling when indicated
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DeliveryDelivery
Birth should be gentle and slow toBirth should be gentle and slow toavoid rapid compression andavoid rapid compression anddecompression of the headdecompression of the head
Membranes should not be rupturedMembranes should not be rupturedartificiallyartificially
Episiotomy may be indicatedEpisiotomy may be indicated
Low forceps may be used to guide theLow forceps may be used to guide thehead over the perineumhead over the perineum
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THANK YOUTHANK YOU
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