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,FPOGS
PRETERM LABOR
POST-TERM PREGNANCY
INDICATED SPONTANEOUS
*Follow medical or obstetric *Occur when there is no
disorders that place the underlying maternal or fetal
illness
mother or the fetus at risk.
*Typically follow premature
*Preeclampsia (42%) rupture of membranes,
Fetal distress (26.7%) incompetent cervix,
Intrauterine growth chorioamnionitis…
restriction (10%) *Any prior spontaneous
preterm delivery carries a
Abruptio placenta (6.7%)
2.5 fold increased risk in a
Fetal demise (6.7%) current gestation and even
a 10.6 fold increase in
preterm delivery <28
weeks AOG
PRETERM LABOR: risk factors
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
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
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
PRETERM LABOR: management
TOCOLYTIC THERAPY
ANTIBIOTICS
STEROIDS
PRETERM LABOR: management
TOCOLYTIC THERAPY
TOCOLYTIC THERAPY
Main 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
TOCOLYTIC AGENTS:
1.Beta-mimetics:
Terbutaline sulfate (Bricanyl)
Ritodrine hydrochloride
Isoxuprine hydrochloride (Duvadilan/Isoxilan)
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
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
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
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
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
POST-TERM PREGNANCY
ULTRASOUND:
*Fetal biometry/
fetal aging
*Amniotic fluid
assessment
POST-TERM PREGNANCY: diagnosis
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
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:
management
Preterm PROM
Rupture of the membranes before 37 weeks
PREMATURE RUPTURE OF
MEMBRANES: diagnosis
Diagnosis of membrane rupture is
mainly clinical
2. Ferning
false positive result:
if the specimen is contaminated with
cervical mucus (sample should be taken
from the cul de sac or lateral vaginal
walls)
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
PREMATURE RUPTURE OF
MEMBRANES: management
* Gestational age should be established as
soon as possible
Clinical history and UTZ – estimate the gestational age,
fetal weight, fetal position & residual amniotic fluid