08/01/09 10:05 Am

NAMASKA WELCOME
08/01/09 10:05 AM Managrement of Preterm Labour 2

MANAGEMENT OF PRETERM
LABOUR
Prof.Surendra Nath Panda, M.S.

Dept.of OBGYN
M.K.C.G.Medical College
Berhampur
Motherhood…
A dream of every woman …

We are obliged to fulfil

- A Tragic end to this dream …
PRETERM LABOUR
• Delivery between 20 & 37
weeks gestation
• Different from LBW
–LBW <2500Gm
–Very LBW <1500Gm
–Extremely LBW <1000Gm
• Major cause of foetal,
perinatal & Infant death
• High cost of survival
PRETERM LABOUR
THE PROBLEM…
 Cause-Uncertain
 Diagnosis-Elusive
 Methods-Debatable
 Results-Unpredictable
 Cost- Enormous
MANAGEMENT OF PRETERM LABOUR
DETECT & ELIMINATE / TREAT
THE CAUSE: -
 INFECTION
 CERVICAL INCOMPETENCE
 PLACENTA PREVIA / ABRUPTION
 UTERINE ANOMALIES

DETECT & ELIMINATE / TREAT
THE CAUSE: -
 PIH
 FOETAL ANOMALIES
 IMMUNOLOGICAL?
 IDIOPATHIC -Cause undetectable

THREE TYPES OF PATIENS: -
 PATIENTS AT RISK
 THREATENED PRETERM
DELIVERY (Active preterm labour)
 PRETERM PROM

IDENTIFYING PATIENTS AT RISK OF
PRETERM LABOUR
 Poor socioeconomic/ education/

hygiene/ nutritional status
 Young or advanced age
 Nulliparity or grandmultiparity
 Short stature or low weight
 Smoking
 Medical or surgical illness
complicating pregnancy
IDENTIFYING PATIENTS AT RISK OF
PRETERM LABOUR
 History of preterm birth -

After 1st preterm birth - 15%
After 2 preterm births - 32-70%
If 1st term and 2nd preterm -23%
 Cervical dilatation >20weeks
 Pelvic pressure
 Low back pain
 Uterine contraction
MANAGEMENT OF PATIENTS
AT RISK
GOAL
Prevention Of Preterm Labour
METHODOLOGY
Multi-component
preventive programs

MANAGEMENT OF PATIENTS AT RISK
Multi-component preventive programs
1.Risk assessment:-
1.Education:-
 Staff
 Patients
 Public
Support systems: -
 Home visiting nurses/
midwives
 Home help
 Family help
 Social worker assignment
 Stress management classes
Self-monitoring of uterine
activity at home: -
-External tocodynamometer

1.Advice: -
 Reduce work
 Reduce housework & child
care
 Reduce smoking
 Reduce stress
 Reduce travel,
commuting, moving house
1.Advice: -
 Reduce / Stop sexual
activity
 Bed rest at home
 Avoid hot & humid climate
 Improve nutrition(Sea
Fish+)
1.Antenatal care: -
 Increased frequency of
contact
 Continuity of care
 Facilitated access to
tertiary hospital
1.Antenatal care: -
 Over Hydration (1.4
Gallons/day)
 High dose calcium
 Antioxidants
 Regular cervical
examinations (No
digital Exam.please)
1.Antenatal care: -
 Testing for imminent
preterm labour with
biological markers-
 Foetal Fibronectin(FFN)
 E V Ultrasound of Cx.
 Salivary estriol
(E3)(SalEst Test).
1.Specific obstetric
interventions:-
 Bed rest in hospital

 Cervical suture
 Progestogens
Dydrogesterone
17-H P C
Progesterone V/O
interventions:-
 Tocolytics (Oral)?-
B-mimetics-
Ritodrine 1x4-6
Isoxsuprine 40mgx2
Terbutaline 1x3
Salbutamol 1x3
Nifedipine 20mgx4
interventions:-
 Antibiotics -
 Urinary Infection
(Asymptomatic Bacteriuria)
 Local Infection
 Bact.Vaginosis
 Occult infection
MANAGEMENT OF THREATENED
PRETERM DELIVERY
(Active preterm labour)
Definitions of preterm labor vary, but
the research criteria commonly hold it
to be contractions occurring between
20 and 36 weeks' gestation at a rate of
four in 20 minutes or eight in 1 hour
with at least one of the following-:
cervical change over time or dilatation
greater than or equal to 2.0 cm.
PRETERM DELIVERY
•HOSPITALISATION
•COUNSELLING
•LIASION WITH NEONATOLOGIST
•HYDRATION- Oral / IV
•SEDATIVES
PRETERM DELIVERY
•ANTIBIOTICS:- The array of agents,

routes of administration, and
durations of therapy preclude making
any recommendation but
Erythromycin appears to be a good
choice

PRETERM DELIVERY
• STEROIDS(after 28 weeks) :- Beyond a

shadow of doubt
Two Inj. of Betamethasone 12 mg IM
at 12 –24 hours interval
OR
Six inj. of Dexamethasone 4 mg IM 8
hourly

PRETERM DELIVERY
•ACUTE TOCOLYSIS:-
 Potentially hazardous side

effects
 Close monitoring essential
 Effectiveness ?
 Use is debatable
 Combinations may be better

PRETERM DELIVERY
•ACUTE TOCOLYSIS:-
 Must be given parentrally for 18-

48 hours
 Risk/benefit ratio for both the
mother and fetus must be re-
evaluated on an ongoing basis
 Should be used selectively
 Never after 33 weeks
ACUTE TOCOLYSIS
Exclusion criteria : -
Maternal factors -
Diabetes  Abruptio Placenta
Hyperthyroidism  Hydramnios
Cardiac disease  Chorioamnionitis
Severe PIH  Cervical dilation
Eclampsia more than 3 cm


ACUTE TOCOLYSIS
Exclusion criteria : -
Foetal factors -
Severe IUGR
Foetal Anomaly incompatible with life
Foetal distress

ACUTE TOCOLYSIS METHODS
Beta Mimetic:-
Ritodrine -(150mg in 500 ml DS)

 Start 100 mcg /min, go up to
350 mcg, in increments of 50
mcg, until 12 hours of
cessation of contractions,
then switch to 10mg tab 2
hourly & maintain at 10-20 mg
2-6 hourly
 High Cost, Side effects
Beta Mimetic:-
Isoxsuprine-
 60mg in 500ml 0.2-1mg / minute
IV drip for 12 hours of
cessation of contractions –
10mg IM/6hourly for 48 hours –
then switch to oral 20mg X 3-4
/ 40mg x 2 times
 Low cost, Moderate side
effects,widely used in India
since long
Beta Mimetic:-
Terbutaline-
250 mcg IV / SC for 12
hours of cessation of
contractions followed by
Oral 5 mg 2/4/6 hours
Low cost, widely used,
Moderate side effects

Beta Mimetic:-
Salbutamol-
 IV for 12 hours of cessation
of contractions followed by
2/4mg 2/4/6/8 hours– Oral
effects, mostly used in
Australia
Magnesium sulfate:-
 4-6 Gm IV/IM loading dose over
20 minutes, followed by 2-4 Gm
IV/IM every hour for 12 hours
after contractions stop to be
followed by beta agonists
orally
 For IV 40 Gms in one Lit of
5%DS or 0.45% Normal saline
 Watch for hypermagnesemia
 Monitor Mg level
Nifedipine:-
 5mg S/L every 15 minutes for

2 hours-10mg Tab, 8hourly
effects, sporadic use
 Move to ban sublingual
getting wider acceptance,

Indomethacin:-
 Initial loading dose of 50 mg
then 25-50 mg oral every 4 hours
until contractions cease
 Maintenance therapy at 25 mgs
oral every 4 - 6 hours up to 35
weeks
 Not widely accepted because of
side effects
 Can be given for short periods
of <72 hours
Nitroglycerine :-
 It is a nitric oxide
donor
 Good for very short
periods
 Hypotension

 Atosiban(Tractocile) :-
 A Nona peptide oxytocin analog
 Acts as a oxytocin/ADH
antagonist
 Start IV bolus 675 mg, then
300mg/minute IV for 3 hours and
100mg/minute IV thereafter.
 Efficacy same as beta agonists
with lesser side effects
 Not available in India at
present
TOCOLYSIS IN PRETERM
LABOUR
Most tocolytics are effective in stopping

labor for 48-72 hours. None have been
shown to decrease the rate of preterm
delivery. Once the uterus is quiescent and
intravenous tocolytics are stopped,
prolonged use of tocolytics has not been
shown to be effective in preventing
preterm birth.

TOCOLYSIS IN PRETERM
LABOUR
Long-term use of tocolytics is

difficult to justify at this time

TOCOLYSIS IN PRETERM LABOUR
What is the HOPE FOR THE FUTURE?
A Designer Drug
A selective ß2 –Adrenergic
receptor modulator

PRETERM PROM
Risk Factors
 Vaginal /Cervical infection

 Membrane Physiology
 Nutritional factors
 Incompetent Cervix
 Preterm Labour
PRETERM PROM
Diagnosis
 Patient History
 Fluid Observation
 Ulrasound
 Nitrazine Test
 Ferning Test
 Dye Injection
MANAGEMENT OF PRETERM PROM
GOAL
To Prolong Pregnancy till lung maturity
preferably up to 33weeks
• Hospitalisation
• Monitor for-
Infection → Antibiotics
Labour → Tocolysis(<34 weeks)
Foetal well being → USG
• Promote Lung maturity → Steroids
• Amnio infusion
Intra Partum Managements of
Preterm Labour
Minimise Maternal Hypotension and
Foetal hypoxia and acidosis➝ < RDS
Routine use of prophylactic forceps &
episiotomy not recommended
If Foetal distress- CS?
Below 28 weeks - NO CS
Below 32 weeks - ?
Above 32 weeks - CS
Vertical skin & uterine incision
Survival Rate According to Gestational Age &
Birth Weight
(Oklahoma Medical Center, 1981-1994)
Gest. Age Survivors Birth Weight Survivors

24 weeks 20 <500Gms 0
25 25 501-800 22
26 50
27 75 801-1000 75
28 83 1001-1250 82
29 94 1251-1500 94
30 95
31 95 1501-1750 97
32 97 1751-2500 98
33+ 99 >2500 99
MANAGEMENT OF PRETERM
LABOUR
SLIGHT OVER-REACTION
+
COMMON SENSE
+
JUDGEMENT
= CORRECT MANAGEMENT
FOR THE INDIVIDUAL.

ANY QUESTIONS
PLEASE

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NAMASKA WELCOME

08/01/09 10:05 AM Managrement of Preterm Labour 2

Prof.Surendra Nath Panda, M.S.

A dream of every woman …

08/01/09 10:05 AM Managrement of Preterm Labour 4

08/01/09 10:05 AM Managrement of Preterm Labour 7

 IDIOPATHIC -Cause undetectable

08/01/09 10:05 AM Managrement of Preterm Labour 8

08/01/09 10:05 AM Managrement of Preterm Labour 9

 Poor socioeconomic/ education/

 History of preterm birth -

08/01/09 10:05 AM Managrement of Preterm Labour 12

08/01/09 10:05 AM Managrement of Preterm Labour 15

 Bed rest in hospital

•LIASION WITH NEONATOLOGIST

•ANTIBIOTICS:- The array of agents,

08/01/09 10:05 AM Managrement of Preterm Labour 26

• STEROIDS(after 28 weeks) :- Beyond a

08/01/09 10:05 AM Managrement of Preterm Labour 27

 Potentially hazardous side

08/01/09 10:05 AM Managrement of Preterm Labour 28

 Must be given parentrally for 18-

08/01/09 10:05 AM Managrement of Preterm Labour 30

08/01/09 10:05 AM Managrement of Preterm Labour 31

Ritodrine -(150mg in 500 ml DS)

08/01/09 10:05 AM Managrement of Preterm Labour 34

 5mg S/L every 15 minutes for

08/01/09 10:05 AM Managrement of Preterm Labour 37

08/01/09 10:05 AM Managrement of Preterm Labour 39

Most tocolytics are effective in stopping

08/01/09 10:05 AM Managrement of Preterm Labour 41

Long-term use of tocolytics is

08/01/09 10:05 AM Managrement of Preterm Labour 42

What is the HOPE FOR THE FUTURE?

08/01/09 10:05 AM Managrement of Preterm Labour 43

 Vaginal /Cervical infection

Gest. Age Survivors Birth Weight Survivors

08/01/09 10:05 AM Managrement of Preterm Labour 49

08/01/09 10:05 AM Managrement of Preterm Labour 51

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