Done by : –Mazen Basheikh Done by : –Mazen Basheikh

11/2/2015copyright (your organization) Definitions & Statistics Preterm labor Vs. Preterm birth. Incidence of preterm labor: 5-15 % of all pregnancies. Mortality rate. 30% of preterm births are due to preterm labor. Preterm labor Vs. Preterm birth. Incidence of preterm labor: 5-15 % of all pregnancies. Mortality rate. 30% of preterm births are due to preterm labor.

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11/2/2015copyright (your organization) Previous history of preterm birth: the relative risk increase to 3.9, and it increase to 6.5 with 2 previous preterm deliveries. 2 nd trimester abortions. Previous history of preterm birth: the relative risk increase to 3.9, and it increase to 6.5 with 2 previous preterm deliveries. 2 nd trimester abortions.

11/2/2015copyright (your organization) Uterine / vaginal infections: e.g. bacterial vaginosis, Chlamydia and gonorrhea.

11/2/2015copyright (your organization) Short cervix: the relative risk increase from 2.4 for 3.5 cm ( 50 th percentile ) to 6.2 for 2.5 cm ( 10 th percentile ) Placental causes. Short cervix: the relative risk increase from 2.4 for 3.5 cm ( 50 th percentile ) to 6.2 for 2.5 cm ( 10 th percentile ) Placental causes.

11/2/2015copyright (your organization) Psychological factors: Why ?? Socioeconomic status: Why ?? Psychological factors: Why ?? Socioeconomic status: Why ??

11/2/2015copyright (your organization) Other risk factors: UTI, multiple gestation, uterine anomalies, polyhydramnios, and incompetent cervix. Other risk factors: UTI, multiple gestation, uterine anomalies, polyhydramnios, and incompetent cervix.

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11/2/2015copyright (your organization) ) Documented uterine contractions. 2) Documented cervical changes. 1) Documented uterine contractions. 2) Documented cervical changes.

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11/2/2015copyright (your organization) CBC. Random blood glucose. U&E. Urine analysis. Urine culture & sensitivity. CBC. Random blood glucose. U&E. Urine analysis. Urine culture & sensitivity.

11/2/2015copyright (your organization) Vaginal swab for : Culture. PH. 10% KOH test. Vaginal swab for : Culture. PH. 10% KOH test.

11/2/2015copyright (your organization) Cervical & vaginal fetal fibronectin: Detected when Fetal membrane disruption occurs in : –Repetitive uterine activity or cervical shortening. –Presence of infection. A positive fetal fibronectin test at 22 to 24 weeks predict more than half of the spontaneous preterm births that oocur before 28 weeks. Cervical & vaginal fetal fibronectin: Detected when Fetal membrane disruption occurs in : –Repetitive uterine activity or cervical shortening. –Presence of infection. A positive fetal fibronectin test at 22 to 24 weeks predict more than half of the spontaneous preterm births that oocur before 28 weeks.

11/2/2015copyright (your organization) Ultrasound To assess fetal weight. To document presentation. To assess cervical length. To rule out the presence of any congenetal malformations. To assess fetal weight. To document presentation. To assess cervical length. To rule out the presence of any congenetal malformations.

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11/2/2015copyright (your organization) Initial assessment : Hx &General examination. Pelvic examination : 1-cervix evaluation ( length, effacement and dilatation) 2-presenting part and station. Utrine activity. investigations for correctable causes ( e.g. UTI, vaginal infection, chorioamnionitis ……. ) Initial assessment : Hx &General examination. Pelvic examination : 1-cervix evaluation ( length, effacement and dilatation) 2-presenting part and station. Utrine activity. investigations for correctable causes ( e.g. UTI, vaginal infection, chorioamnionitis ……. )

11/2/2015copyright (your organization) % -During this assessment oral or IV fluid + bed rest should be started, as in 20 % of the patients the uterine contractility cease. doesn't tocolytic no contraindicationIf the patient doesn't respond to bed rest and hydration, then tocolytic therapy should be initiated if there is no contraindication to it. 20 % -During this assessment oral or IV fluid + bed rest should be started, as in 20 % of the patients the uterine contractility cease. doesn't tocolytic no contraindicationIf the patient doesn't respond to bed rest and hydration, then tocolytic therapy should be initiated if there is no contraindication to it.

11/2/2015copyright (your organization) Tocolytics : 1- Magnisum Sulfate. 2- Nifidipine. 3- prostaglandin synthetase inhibitors Tocolytics : 1- Magnisum Sulfate. 2- Nifidipine. 3- prostaglandin synthetase inhibitors

11/2/2015copyright (your organization) First : First : Magnisum Sulfate : Drug of choice for initiating tocolytic therapy. Mechanism of action :Mechanism of action : Act by competing with calcium for entry into the cell during depolarization. So, low calcium intracellular lead to muscle relaxation. First : First : Magnisum Sulfate : Drug of choice for initiating tocolytic therapy. Mechanism of action :Mechanism of action : Act by competing with calcium for entry into the cell during depolarization. So, low calcium intracellular lead to muscle relaxation.

11/2/2015copyright (your organization) Side effect :Side effect : Short term : Short term : For the mother : Warmth & flush. Respiratory distress at serum level of mg / dl Cardic arrest at higher level For the baby : Decrease muscle tone Drowsy ( ….. and this can lead to low abgor score …..) Long term : Long term : Osteoporosis Vertebral fracture ( As a prophylactic to these side effects we add calcium supplement ) Side effect :Side effect : Short term : Short term : For the mother : Warmth & flush. Respiratory distress at serum level of mg / dl Cardic arrest at higher level For the baby : Decrease muscle tone Drowsy ( ….. and this can lead to low abgor score …..) Long term : Long term : Osteoporosis Vertebral fracture ( As a prophylactic to these side effects we add calcium supplement )

11/2/2015copyright (your organization) Second : Second : Nifidipine : Very effective with less side effects and gradually replace IV magnisum sulfate. Mechanism of action :Mechanism of action : Inhibit slow calcium infusion during the action potential which lead to muscle relaxant. Second : Second : Nifidipine : Very effective with less side effects and gradually replace IV magnisum sulfate. Mechanism of action :Mechanism of action : Inhibit slow calcium infusion during the action potential which lead to muscle relaxant.

11/2/2015copyright (your organization) Side effects : Flushing Headache Hypotension Tachycardia ( …. And the last 2 can be corrected by good hydration & TED hose stocking ) Side effects : Flushing Headache Hypotension Tachycardia ( …. And the last 2 can be corrected by good hydration & TED hose stocking )

11/2/2015copyright (your organization) Third : Third : prostaglandin synthetase inhibitors : Indomethacin Most commonly drug used is Indomethacin but it used for short term only due to: it's side effects And short 1/2 life of prostaglandin. ( for example it's used in preterm lapor associated with fibroid ) Third : Third : prostaglandin synthetase inhibitors : Indomethacin Most commonly drug used is Indomethacin but it used for short term only due to: it's side effects And short 1/2 life of prostaglandin. ( for example it's used in preterm lapor associated with fibroid )

11/2/2015copyright (your organization) Side effects : Oligohydraminos Premature closure of PDA Decrease renal function Increase the risk of necrotizing enterocolitis Increase the risk of IVH. Side effects : Oligohydraminos Premature closure of PDA Decrease renal function Increase the risk of necrotizing enterocolitis Increase the risk of IVH.

11/2/2015copyright (your organization) What is the efficacy of tocolytic therapy in the management ?? Although the tocolytic agent has failed to decrease preterm birth in large population studies but it has an effect in : prolongation of the gestational age neonatal survival ( by decreasing the incidence of RDS and increasing the birth weight of the infant ) What is the efficacy of tocolytic therapy in the management ?? Although the tocolytic agent has failed to decrease preterm birth in large population studies but it has an effect in : prolongation of the gestational age neonatal survival ( by decreasing the incidence of RDS and increasing the birth weight of the infant )

11/2/2015copyright (your organization) what are the contraindications for tocolytics therapy ?? severe preeclampsia. severe bleeding from placenta previa or abrubio. chorioamnionitis. IUGR. fetal anomaly incompatible with life fetal demise. what are the contraindications for tocolytics therapy ?? severe preeclampsia. severe bleeding from placenta previa or abrubio. chorioamnionitis. IUGR. fetal anomaly incompatible with life fetal demise.

11/2/2015copyright (your organization) what are the role of : Antibiotics and Glucocorticoid ?? First : First : Antibiotics : It's found that 15 % of those who have Idiopathic P.T.L, have colonizing of pathogens in the amniotic fluid. So, it's reasonable to use prophylactic antibiotics to prevent further complications. what are the role of : Antibiotics and Glucocorticoid ?? First : First : Antibiotics : It's found that 15 % of those who have Idiopathic P.T.L, have colonizing of pathogens in the amniotic fluid. So, it's reasonable to use prophylactic antibiotics to prevent further complications.

11/2/2015copyright (your organization) Second : Second : Glucocorticoid : It should be used in the gestational age of 24 to 34 weeks to those at risk of P.T.L To reduce : mortality rate. incidence of RDS IVH Drugs : Drugs : Betmethasone : 2 doses of 12 mg given IM 24 h apart or Dexamethazone : 4 doses of 6 mg givin IM 12 hours apart … the benefits begins 24 h after initiation of therapy and last 7 days. Second : Second : Glucocorticoid : It should be used in the gestational age of 24 to 34 weeks to those at risk of P.T.L To reduce : mortality rate. incidence of RDS IVH Drugs : Drugs : Betmethasone : 2 doses of 12 mg given IM 24 h apart or Dexamethazone : 4 doses of 6 mg givin IM 12 hours apart … the benefits begins 24 h after initiation of therapy and last 7 days.

11/2/2015copyright (your organization) what if the patient does not respond to tocolytic therapy ?? some patients will not respond to tocolytics therapy so the goal in these patients to deliver the baby ( but not less than 24 weeks of gestation or 500 g due the viability ) with vertex presentationwith vertex presentation, vginal delivary is preferred with breech presentation,with breech presentation, neonatal outcome improved by cesarean section what if the patient does not respond to tocolytic therapy ?? some patients will not respond to tocolytics therapy so the goal in these patients to deliver the baby ( but not less than 24 weeks of gestation or 500 g due the viability ) with vertex presentationwith vertex presentation, vginal delivary is preferred with breech presentation,with breech presentation, neonatal outcome improved by cesarean section

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