Post on 29-Jun-2015
description
Preterm labor and PROM
Dr. Wisit Woranitat
Preterm labor• What is preterm labor
• How dose labor start
• What can happen if my baby is born too early
• What factors increase the risk of preterm labor
• What are the signs and sympto ms of preterm labor
• How can preterm labor be diagnosed
Preterm labor• If I am at risk of preterm la
bor, what can I do to decr ease the risk
• How do I monitor myself f or contraction
• What medications are use d to slow or stop per term
• What are the special need s of preterm babies
What is preterm labor
• 37The labor begin start before weeks
• 1 10About in babies born in USA
• 75% of neonatal mortality
• 50% of the long term neurologic impairment in children
How does labor start
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What can happen if my baby is born too
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• Eyes
• Ears
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• Nervous system
Perinatal Morbidity
- Pulmonary RDS bronchopulmonary dyspRRRRR
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Perinatal morbidity
Infections: GBS, E. Coli SIDS Psychosocial:> prevalence of child abuse
PathogenesisPathogenesis• 80% of Preterm births are spontaneous
• 50% Preterm labor
• 30% Preterm premature rupture of the membraRRR
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RRRRRR RRRRRRRRR RRRR• RRRRRRRRR• RRRRRRRR RRRRRRRRRR• Pathologic uterine distention
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Previous History Smoking
Cocaine use & DES Multiple pregnancy
Abn Cx & Ut Surgery
Bleeding 2 half Hydramnios
Infection Poor ANC
What are the signs a nd symptoms of pre
term labor Vaginal discharge Pelvic&Abd pressure
Backache Abd cramps
Ut contraction PROM
How can preterm labor bediagnosed
• Cervical change
• Regular contraction
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• Fetal mornitoring
Biologic markers for predicti ng preterm birth
• - Cervical length measurement many studRRR RRRR RRRRRRR RR RR RRRRRRRRRRR R RRR RR
rvical shortening and preterm delivery. When combined with positive fetal fibron
2 .5 ,ectin and length less than cm this isR RRRRRR RRRRRRRRR RR RRRRRRR RRRRRRRR
Biologic markers for predicti ng preterm birth
• - Fetal fibronectin need intact membranes 3, less than cm dilated, not useful befor 24 34 6e weeks or after weeks day
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• Negative fetal fibronectin gives about a 9 5 1% chance of the pregnancy continuing
4days or more. A positive test is not as predictive.
What can I do to dec rease the risk of pre
term labor• Early ANC
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• Progesterone
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How do I monitor m yself for contraction
• Monitor for sign of uterine activity
• 4 20times in minutes
• 8 60times in minute
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• PROM
What medications a re used to slow or st
op preterm• Tocolysis agents
•Corticosteroid
• - Anti biotic agent
Bricanyl Calcium Chanel blocker
• NSAIDS• Oxytocin antagonist
Assessment of patients in pr eterm labor
- - Labs CBC, UA +/ culture, electrolytes RRRRRRR RRRRRRRR RRRR RRRRRRRRR RRRRRRR
s for group B strep, BV, GC, Chlamydia, oRRRRR RRRRR RRRRRRRRRRR
Cervical length measurement RRR RRRR RRRRR RR RRR RRRRRRRR RRRRRR
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What are the special needs of preterm babies
•NICU
• Breathe
• Eat
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Premature rupture o f membrane
•Definition
• Incidence
•Diagnosis
• Risk factors
•Management
Definition Premature rupture of membranes (PROM)
Rupture of the chorioamnionic membrane pri or to the onset of labor at any stage of gestati
on
Preterm premature rupture of membra nes (PPROM)
- PROM prior to 37 wk. gestation
Incidence PROM – 12% of all pregnancies PROM – 8% term pregnancies PPROM – 30% of preterm deliveries
Diagnosis History
“ Gush” of fluid Steady leakage of small amounts of fluid
Physical Sterile vaginal speculum exam
Minimize digital examination of cervix, regardl ess of gestational age, to avoid risk of ascendi
ng infection/amnionitis Assess cervical dilation and length Obtain cervical cultures (Gonorrhea, Chlamydi
a) Obtain amniotic fluid samples
Findings Pooling of amniotic fluid in posterior vaginal for
nix Fluid per cervical os
Diagnosis• Test or investigation
• Nitrazine test
• Fern test
• Nine blue test
• Ultrasound
• - Indigo carmine Amnioinfusion
Nitrazine test
Fluid from vaginal exam placed on strip of nitrazin
e paper Paper turns blue in prese
nce of alkaline (pH > 7.1) amniotic fluid
Fern test
Fluid from vaginal e xam placed on slide
and allowed to dry Amniotic fluid narro
w fern vs. cervical mucus broad fern
Nile blue tests
• >32 wks. Fetal fat cell can discover in amniotic fluid
• Strained with Nile blue sul phate. Become to red colo
r
Fetal Fibronectin (AmniSure)
• Newer test
• Point of Care test
• - Cost up to $50 each
• - -Sensitivity 98.7 98.9%
• - -87510Specificity .0%
• RRRRRRRR RRRRRRR RRRRRR g pr i or t o r ecommendat ions
UltrasoundRRRRRR RR RRRRRR RRRRR RRRRR RRR RRR RRR
ibility with PROM
- Indigo carmine AmnioinfusionR RRRRRRRRR RRRRRR RRRRRR RRRR RRR RRR
amnioinfusion (“Blue tap”) Observe for passage of blue fluid from va
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Risk factor of PROM Prior PROM or PPROM Prior preterm delivery Multiple gestation Polyhydramnios Incompetent cervix Vaginal/Cervical Infection
Gonorrhea, Chlamydia, GBS, S. Aureus Antepartum bleeding (threatened abortion) Smoking Poor nutrition
Effect to mother and fetus
• - Feto maternal infection
• Placenta abruptio
• - Premature infant: 30% 40% of premature la bour is associated with premature rupture of
membrane
• Cord prolapse, cord compression
• Poor fetal lung development and fetal compre ssion syndrome
Management
PROM at term:
1( ) Awaiting the onset of spontaneous labor
-1224for h
2 24( ) Termination of pregnancy after hourr
PROM before term Termination of pregnancy
1( ) Evidence of fetal rrrrrrrrr rrrrrrrrrr (2 ) Evidence of intrauterine infection
Expectant therapy Indication : (1) Evidence of fetal pulmonary immaturation r rrrrrr rrrrrrrr rr rrrrrrrrrrrr rrrrrrrrr 2
Management: 1( )To enhance fetal pulmonary maturation 2( ) Antibiotic 3( ) Tocolysis
Management: Rationale
Antibiotics Prolong latency period Prophylaxis of GBS in neonate Prevention of maternal chorioamnionitis and neonatal se
psis
Corticosteroids Enhance fetal lung maturity Decrease risk of RDS, IVH, and necrotizing enterocolitis
Tocolytics Delay delivery to allow administration of corticosteroids Controversial, randomized trials have shown no pregnan
cy prolongation
Management: Surveillance
Maternal: Monitor for signs of infect ion
Temperature Maternal heart rate Fetal heart rate Uterine tendernessContractions
Management: Surveillance
-Fetal: Monitor for fetal well being Kick counts Nonstress tests (NST’s) Biophysical profile (BPP)
Im m ediate Delivery Intrauterine infection Abruptio placenta Repetitive fetal heart rate decelerations Cord prolapse.
Thank you For your attention