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PRETERM LABOR - David Muscan

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David Muscan

on 19 June 2013

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Transcript of PRETERM LABOR - David Muscan

Preterm Labor
David Muscan
James Madison University
06/18/13

Preterm Labor - Highlights
uterine contractions before 37 weeks gestation and associated with uterine changes
one of the greatest obstetrical syndromes
multiple etiologies
chronic in nature
associated with significant neonatal mortality and morbidity
Preterm Labor - Significance
Preterm Labor - Causes
Preterm Labor - Risk Factors
Multifetal gestation
Prior history of preterm birth
Preterm uterine contractions
Premature rupture of membranes (PROM)
African-American race
Cervical insufficiency: Primary or secondary to surgery
Infections: urinary, bacterial vaginosis, intra-amniotic
Excessive uterine enlargement: polyhydramnios; multiple gestation
Uterine distortion: leiomyomas; septate uterus; uterine didelphys
Placental abnormalities: placental abruption, placenta previa
Maternal smoking
Induction of labor
Preterm Labor - Assessment
11-12% of the premature babies account for 75% of all perinatal mortality, and 50% of long term neurologic impairment in children in the US.
40-50% of preterm births with intact membranes; 23-40% from premature rupture of membranes.
The remaining 20-30% births occur following deliberate interventions for maternal complications.
Four pathogenic processes, which lead to uterine contractions and cervical changes:

1. Stress - maternal or fetal: activation of the maternal or fetal hypothalamic-pituitary-adrenal axis
2. Infection: which causes decidual-chorioamnionic or systemic inflammation
3. Decidual hemorrhage
4. Pathologic uterine distension (multifetal pregnancy; polyhydramnios; uterus abnormality)

A combination of the following is the most useful diagnosis tool:

1. fFN (fetal fibronectin) levels in cervicovaginal secretions.
2. Cervical length, with transvaginal ultrasound: <3 cm
Excellent negative predictive value

Also:
3. Early asymptomatic dilation and effacement of the cervix. Treated with prophylactic cervical cerclage.
4. Bacterial vaginosis (BV): occurs in 40% of women. Treatment only beneficial for symptomatic patients.
(DiRenzo et al., 2011)
Preterm Labor - Assessment (cont.)
immediate tocodynamometer (fetal status)
gentle speculum examination or gentle digital examination (periodical)
urine analysis and culture (GBS, C&G)
culture: vaginal and rectal
ultrasound (fetal age, fluid volume, presentation, placental location)
amniocentesis (WBC, lactate, glucose, fetal pulmonary maturity)
ferning test (PROM)
Preterm Labor - Management
major challenge for modern obstetric medicine
goal is to prolong pregnancy for as long as possible to allow fetal maturation and development
Corticosteroids: dexamethasone and betamethasone: some of the most useful tools in reducing preterm mortality and morbidity (ACOG, 2003)
enhance fetal pulmonary maturity
from 24 to 36 weeks gestation
maximal benefit w/in 7 days of delivery
weekly courses not recommended due to potential negative fetal effects
Preterm Labor - Management (cont.)
Antibiotics reduce the risk of birth w/in 48 hrs in patients with PROM, but they do not reduce the risk of sepsis and RDS in patients with intact membranes (Denney, Culhane, & Goldendberg, 2008)
Bacterial vaginosis: Metronidazole PO 500mg twice daily X7 days; Clindamycin 300mg twice daily X7 days
Group B Strep sepsis: Ampicillin 2mg, IV, q6hrs for 48hrs. (Sayres, 2010)

Avoid Amoxicillin-Clavulanate due to risk of neonatal necrotizing enterocolitis. (Gibson, 2011)
Antibiotics do not affect preterm labor in patients with intact membranes. (ACOG, 2009)

Preterm Labor - Tocolytics
(Greek: tokos = childbirth, lytic= capable of dissolving)
extend pregnancy only 2-7 days; potential fatal adverse effects
Magnesium sulfate: relatively safe; competes with Ca++ for entry into cells; S/E: flushing, headaches, respiratory and cardiac depression; ; not for pt. with hypoglycemia or myasthenia gravis.
Indomethacin: decreases prostaglandin production; S/E: premature constriction of ductus arteriosus
Nifedipine: Ca++ channel blocker; prevents Ca++ entry into muscle cells; S/E: HTN, headaches, decreased in uteroplacental flow, fetal hypoxia, hypercarbia
Beta-adrenergics (Ritodrine, Terbutaline): increase cAMP cell concentration; S/E: HTN, tachycardia, anxiety, chest pain, EKG changes, pulmonary edema.
Terbutaline: not FDA approved; SQ, q20min to 3hrs; for 48hrs; S/E: serious CV effects, death

Preterm Labor - Tocolytics (cont.)
fetus >34 weeks gestation
severe anomalous fetus
intrauterine infection or chorioamnionitis
significant vaginal bleeding
severe preeclampsia, placental abruption
advanced cervical dilatation (>4cm)
evidence of fetal compromise, placental insufficiency.
Contraindications
A new designed combined marker by dividing cervix length by neutrophil-lymphocyte ratio
increased sensitivity to 64.2% & specificity to 88.3% for prediction of preterm delivery, when compared to compared to cervix length or systemic inflammatory markers alone
(Min-A, Byung Seok, Yong-Won, & Kyung, 2011)
Preterm Labor - Progesterone
P4 - micronized natural progesterone, and 17 0-hydroxy progesterone caproate (17 OHP-C) - a synthetic compound
- efficient in preventing PTB recurrence in single pregnant, nulliparous pts. with short cervix (OHP-C 250mg/weekly IM or P4 vaginally)
- no prevention in multiple pregnancies (either twins or triplets)
- concern about 3rd trimester fetal death and higher incidence of diabetes mellitus with OHP-C. (Coombs, Garite, Maurel, Das, & Porto, 2010)
Preterm Labor - ANP Role
sudden onset of PTL and PTB caused state of crisis
parents were frightened, disoriented
importance of early identification and treatment of acute stress disorder (ASD) and post traumatic stress disorder (PTSD)
obstetrical and neonatal healthcare providers need to be educated about the symptoms of ASD and PTSD. (Lasiuk, Comeau, & Newburn-Cook, 2010)
surveillance is the predominant APN function for women with high-risk pregnancies.
treatments and procedures comprised less than 1% of APN total functions.
a great need for surveillance and teaching, guidance, and counseling of women at risk of having a preterm or low birthweight infant
help distinguish between real labor and B-Hicks contractions
the importance of matching APN clinical specialization with the patient population under their care wherever possible for optimal outcomes. (Brooten et al., 2007)

Preterm Labor - APN Role
(Beckman, Barzansky, Ling, Laube, & Smith, 2013)
(Beckman, Barzansky, Ling, Laube, & Smith, 2013)
(Beckman, Barzansky, Ling, Laube, & Smith, 2013)
(Beckman, Barzansky, Ling, Laube, & Smith, 2013)
(Beckman, Barzansky, Ling, Laube, & Smith, 2013)
References
ACOG Committee on Practice Bulletins. (2003). ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologist. Obstet Gynecol, 43(101), 1039-1047
ACOG Committee opinion no. 445: Antibiotics for preterm labor. Obstet Gynecol, 114, 1159.
Beckman, C. R. B., Barzansky, B. M., Ling, F. W., Laube, D. W., & Smith, R. P. (2013). Obstetrics and Gynecology (7th ed.). Lippincott & Wilkins. ISBN: 978-1451144314
Brooten, D., Youngblut, J. M., Donahue, D., Hamilton, M., Hannan, J., & Neff, D. (2007). Women with high-risk pregnancies, problems, and APN interventions. Journal Of Nursing Scholarship, 39(4), 349-357. doi:10.1111/j.1547-5069.2007.00192.x
Combs, C. A., Garite, T., Maurel, K., Das, A., Porto, M. (2010) Obstetrix Collaborative Research Network. Failure of 17-hydroxyprogesterone to reduce neonatal morbidity or prolong triplet pregnancy: a double-blind, randomized clinical trial. Am J Obstet Gynecol, 203, 248.
Denney, J. M., Culhane, J. F, Golendberg, R. L, (2008). Prevention of preterm births. Womens Health, 4, 625-638.
Di Renzo, G., Roura, L., Facchinetti, F., Antsaklis, A., Breborowicz, G., Gratacos, E., & ... Ville, Y. (2011). Guidelines for the management of spontaneous preterm labor: identification of spontaneous preterm labor, diagnosis of preterm premature rupture of membranes, and preventive tools for preterm birth. Journal Of Maternal-Fetal & Neonatal Medicine, 24(5), 659-667.
Gibson, J. L. (2011). Pharmacologic management of preterm labor and prevention of preterm birth. US Pharm, 36(9). 13-16.
Lasiuk, G., Comeau, T., & Newburn-Cook, C. (2013). Unexpected: an interpretive description of parental traumas' associated with preterm birth. BMC Pregnancy & Childbirth, 13, 1-10. doi:10.1186/1471-2393-13-S1-S13
Min-A, K., Byung Seok, L., Yong-Won, P., & Kyung, S. (2011). Serum markers for prediction of spontaneous preterm delivery in preterm labour. European Journal Of Clinical Investigation, 41(7), 773-780. doi:10.1111/j.1365-2362.2011.02469.x
Sayres, W. G., (2010). Preterm labor. Am Fam Physician, 81, 477-484.
Slotkin, T. A., & Seidler, F. J. (2012) Terbutaline impairs the development of peripheral noradrenergic projections: Potential implications for autism spectrum disorders and pharmacotherapy of preterm labor. Neurotoxicology and Teratology 3, 91-96. doi.org/10.1016/j.ntt.2012.07.003

QUESTIONS
(and possibly answers)
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