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Diagnosis and Management of
Preterm Labor
James Ducey MDStaten Island University Hospital
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Making The Diagnosis
Labor is a retrospective diagnosisOnce vaginal delivery has occurred wecan be sure the woman was in labor
There are a variety of methods we use todiagnose labor
None of them are foolproof
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Clinical Factors Used to PredictPreterm Labor
Risk assessment is a concept firstproposed by Papiernik (Presse Med 1969)
The hope was that identification ofwomen at increased risk to give birth
early prior to the onset of labor wouldlead to interventions that would preventpreterm birth
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Risk Assessment
The frequency of a large # ofdemographic and epidemiologicalmarkers in women who did and did notgive birth were compared
Scoring systems to predict which womenwere at increased risk for preterm birth
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Economic
Poor Unemployed
Father is either
Not insured No access to care
Not well fed
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Behavioral
Poor education Not compliant with prenatal care
Substance abuse
Old or young Life stresses
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Medical
Mom was small at birth Short
Underweight or overweight?
Chronic illnesses
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Obstetric
Previous preterm birth Multiple birth
Acute infections
Hypertensive disorders of pregnancy Uterine anomalies
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Risk Assessment
Creasy and co-workers have published anumber of more simplified scoringsystems(ObGyn 1980,1982,Birth Defects 1983)
Prospective studies have reported
sensitivities of 40
60% Positive predictive values between 15
30%
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History
Pain-abdominal,back,pelvic,vaginal,gasVaginal bleeding, staining
Pelvic pressure
Urinary frequency
Diarrhea or constipation
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History
Many normal women who deliver at termhave similar symptoms
Iams etal (ObGyn 1990) reported that 1/3 ofthe women they studied that developed
preterm labor had no symptoms at all
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Physical Examination
Asymptomatic effacement and dilation of thecervix frequently occurs prior to labor
It may be the first sign of labor, cervicalincompetence or normal variation especially inmultiparous women
Buekens ( Lancet 1994) in a randomized study ofover 5000 women showed no difference inoutcome when cervical exam was performed atevery visit
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Uterine Activity
Frequency and duration of uterinecontractions can be monitored accuratelyin an ambulatory setting
There is an increase in uterine activity in
24 hours prior to preterm labor (Katz ObGyn1986)
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Uterine Activity
Initial studies were promising In addition to uterine activity monitoring
there was a lot of nursing contact
Much controversy ensued
May diagnose preterm labor sooner
Not clinically significant
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Biochemical Markers
Estrogen
Progesterone
Prostaglandins and their metabolites
Activan
Inhibin
Collagenase
Tissue inhibitors of metaloproteinases
Fetal Fibronectin
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Fetal Fibronectin
Component of extra cellular matrix Lockwood (NEJM 1991) found that levels
were elevated in cervicovaginalsecretions in women who delivered early
AHRQ published a review of the data
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Fetal Fibronectin
7 Days
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Fetal Fibronectin AT SIUH
81 Test in 71 women
20 have delivery data
13 Negatives 8 were term 5 preterm (all 35 36
weeks) None within 7 days
7 positives 3 were term 4 preterm (all
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Endovaginal Ultrasound
Cervix visualized in great detail Funneling of the internal cervical os
Length of the cervix
Sensitivity, specificity, positive andnegative predictive values similar to fetalfibronectin
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Correction of UterineMalformations
Women with defects in lateral fusion ofthe Mullarian ducts appear to be atincreased risk for preterm labor
Surgery is usually reserved only for
habitual abortion
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Cervical Incompetence
History of cervical trauma or surgery
Two subsequent pregnancies thatterminated spontaneously in the latesecond or early third trimester and the
loss was characterized by days of pelvicpressure followed by spontaneousrupture of the membranes and quickpainless labor
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Cerclage
Has become the standard treatment Large prospective randomized study was
carried out by RCOG 1992(BJOG 1993)
A heterogeneous group of women felt to
be at increased risk for preterm birth
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Cerclage
A very safe operation There was a significant decrease in
delivery prior to 35 weeks in women whounder went cerclage
25 operations to prevent 1 preterm birth
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Pharmacological Agents
TocolyticsGlucocorticoids
Thyrotropin-releasing hormone
Antibiotics
Others
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Tocolytics
Magnesium sulfate
Beta adrenergic agonists
Prostaglandin inhibitors
Calcium channel blockers
Oxytocin-receptor antagonistEthanol
Progesterone
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Tocolytics
All these drugs seem to delay delivery 48hours
None is superior in efficacy
Delay of 48 hours improves neonatal
outcome when corticosteroids are used inconjunction
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Magnesium Sulfate
Maternal side effects are nausea,uncomfortable sensation of heat,weakness, pulmonary edema(1%) andrespiratory arrest
Fetal side effects are hypotonia andhypocalcemia
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Beta Adrenergic Agonists
Ritodrine and Terbutaline
Maternal side effects include myocardialischemia, pulmonary edema(4%),hypotension, tachycardia, hypokalemia,
hyperglycemia and acidosisFetal effects include hypotension,tachycardia, hypoglycemia andhyperbilirubinemia
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Prostaglandin SynthetaseInhibitors
IndomethacinMaternal side effects include GI upset,rash, headache and interstitial nephritis
Fetal effects include oliguria,
oligohydramnios, premature closure ofthe ductus arteriosus and pulmonaryhypertension
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Calcium Channel Blockers
NifedipineMaternal side effects include headache,nausea,flushing,hypotension,tachycardiaand hepatotoxicity
Fetal effects are not clear
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Oxytocin Receptor Blockers
Atosiban new drug that appears to beeffective
Causes nausea, headache, chest pain,arthralgias and may inhibit lactation
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Ethanol
No longer used Caused acute intoxication in the mother
May be toxic to the fetus
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Progesterones
Has been used for many years to preventmiscarriage without proven efficacy
Keirse (BrJObGyn 1990) found that whenused routinely on initial registrationresulted in a significant decrease inpreterm labor and birth
No effect on neonatal morbidity ormortality however
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Antenatal Steroids
Crowley etal(BrJObGyn 1990
) meta-analysisof 12 controlled studies
There was a significant decrease inRDS,IVH,NEC and NND
NIH conference 1995 concluded that allwomen at risk for preterm birth between24 and 34 weeks are candidates
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Antibiotics
Several studies have looked at the use ofvarious drugs to treat subclinicalinfections and prevent neonatal sepsis
Results have been inconsistent
Has not gained acceptance
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Behavioral Changes
Bed restCoitus
Substance abuse
Obesity
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Obesity
Will kill more Americans in the next 50years than cancer, cigarette smoking andHIV combined
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Obesity
Schieve etal (Epid 1999
) women withincreased weight gain during pregnancywere at increased risk for preterm birth
Rothacker etal (ADA2000) mean weight
gain of women 20
30 years of age from1992 to 1997 increased 12.1 kg
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The Future
Tocolysis will only impact on
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The Future
Reproductive endocrinologist need tolimit the # of embryos they implant
Iatrogenic prematurity continues in someplaces despite many of our best efforts