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Objectives
Define preterm labor Discuss trends in epidemiology Review risk factors Discuss diagnosis, treatment, and prevention
Preterm Birth
Term pregnancy - 37 to 42 weeks gestation 12.5 % of deliveries/yr are preterm About 500,000 71.2% 34-36 weeks 13% 32-33 weeks 10% 28-31 weeks 6% <28 weeks
26 wks 80% 27 wks 90% 28-31 wks 90 to 95% 32-33 wks 95% 34-36 wks approaches term survival rates
Complications of Prematurity
RDS IVH Feeding difficulties/NEC Apnea PDA Infection Jaundice Hypothermia Neurobehavioral ROP Anemia
Preterm Birth
Spontaneous preterm labor 30-50% Multiple gestation 10-30% PPROM 5-40% Preeclampsia/eclampsia 12% Antepartum bleeding 6-9% Fetal growth restriction 2-4% Other 8-9%
Pathogenesis
Premature activation of maternal or fetal HPA axis Decidual hemorrhage Inflammation/infection Pathological uterine distention
Previous PTB Multiple gestation Polyhydramnios Uterine anomalies Infection Placental pathology Smoking Substance abuse
Maternal age extremes Anemia Low BMI Hx cervical surgery Hx 2nd TM loss Severe stressors Short interpregnancy interval
Labor = regular, painful uterine contractions that produce cervical dilation and/or effacement Uterine contractions are seen in normal pregnancies at early gestational ages Up to 50% of women hospitalized for PTL go on to deliver at term
10th% = 25mm (20 to 30 wks gestation) 80-100% of women who deliver early have cervix <30mm 15 mm or less = 50% delivery rate within one week
Fetal Fibronectin
99% negative predictive value for delivery within 2 wks Positive predictive value worse, about 30% 22 to 35 weeks Sample collection issues
Tocolysis often halts contractions only temporarily Allow 48 hr+ for steroids to be given Allow for transport to delivery location with NICU capability Allow for correction of reversible causes
Steroids
Reduce incidence of RDS, IVH, NEC, sepsis, and mortality by about 50% Intact membranes: 24-34 weeks GA PPROM: 24-32 weeks GA Betamethasone 12 mg q 24 hr x 2 Dexamethasone 6 mg q 12 hr x 4
Tocolysis
34 weeks
Tocolysis
Nifedipine
Low cost Oral Low incidence of side effects (hypotension, dizziness, flushing) Often considered first line
Tocolysis
Magnesium sulfate
Indomethacin
Atosiban
If maternal and fetal conditions are stable, can be managed at home Avoid excessive physical activity; most advocate pelvic rest Continued tocolytics have not shown definite benefit
Prevention of PTB
Reduce/eliminate risk factors, if possible Not proven to be effective: bedrest, home uterine monitoring, prophylactic tocolytics, prophylactic antibiotics, abstinence
Supplemental progesterone
Women with previous spontaneous preterm delivery at less than 34 weeks gestation Weekly 17OHprogesterone IM or daily vaginal progesterone suppositories Start at 16-20 wks gestation, continue through 36 weeks
References
www.cdc.gov www.marchofdimes.com UpToDate online Use of progesterone to reduce preterm birth. Obstet Gynecol 2008; 112:963. Prevention of Preterm Delivery. Simhan HN et al. N Engl J Med 2007 Aug 2; 357(5):477-87.
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