การเจ ็บครรภ์คลอดกอ่นกำาหนด

การเจ็บครรภ์คลอดก่อนกำาหนดDefinition

การเจ็บครรภ์ที่อายุครรภ์ตั้งแต่ 20 สัปดาห์ (28 สัปดาห์ในไทย) ถึงก่อนครบ 37 สปัดาห์หรือ 259 วันนับจาก LMP

การเจ็บครรภ์คลอดก่อนกำาหนดRisk factors

Maternal factorsFetal factorsPlacental factors

การเจ็บครรภ์คลอดก่อนกำาหนดMaternal factors

Preterm premature rupture of membranes

Infection : Amnionitis, cervicitis, BV

Over-distended uterusIncompetent cervixUterine anomalies

การเจ็บครรภ์คลอดก่อนกำาหนดMaternal factors

Previous preterm delivery or late abortion

Retained IUDSerious maternal diseaseSubstances abuseExtreme ages

การเจ็บครรภ์คลอดก่อนกำาหนดFetal factors

Fetal deathFetal anomalies

Placental factorsPlacenta abruptionPlacenta previa

Risk scoring for preterm laborUse at first ANC,GA 22 wks, and

GA 26 wksScore 0 – 5 : low risk

6 – 9 : intermediate risk 10 : high risk

PRETERM LABOR

Diagnosis1. Regular uterine contraction

4 in 20 mins or 8 in 1 hr Duration ≥ 30 sec

2. Cervical dilatation ≥ 1 cm and effacement 80%

PRETERM LABOR

Sterile speculumBiochemistryFetal evaluationRuling out infections

Sterile speculumInfectionRupture of membrane

PRETERM LABOR

PRETERM LABOR

BiochemistrypHCulture for Gonorrhea and Chlamydia

(cervix)Wet smear & Whiff testGroup B Streptococci (vagina &

rectum)Fetal fibronectinTransvaginal ultrasonography

Fetal evaluationUltrasonography

GAEstimated fetal weightAFIOther abnormalities e.g. multifetal

pregnancy, polyhydramnios, congenital anomalies, placental abnormalities

Antepartal fetal assessment

PRETERM LABOR

Ruling out infectionsFever ≥ 38 °C2/5

WBC >15,000/mm3Maternal tachycardiaFetal tachycardiaUterine tendernessFoul-smelling leukorrhea

PRETERM LABOR

PRETERM LABOR Management

Work-up for causes General management Tocolytics Glucocorticoids Antibiotics in PPROMทั้งนีแ้บง่ตาม GA Early preterm: < 34 wks Late preterm: ≥ 34 wks

PRETERM LABORLate preterm : Expectant management

General managementRestMonitor FHR, UCRisk factor identification + treatment

U/S (Fetal well-being, GA, amniotic fluid, placenta)

ObserveAntibiotics in PPROM

PRETERM LABOR

Early preterm : InhibitionGeneral managementTocolyticsDexamethasone : prevent RDS,

IVHAntibiotics in PPROM

TOCOLYTICS

IndicationsHealthyPretermContraction presentEffacement < 80%

& cervical dilatation < 4 cmNo rupture of membrane unless

inhibition for corticosteroid administration

TOCOLYTICS Contraindication

Effacement > 80% & cervical dilatation > 4 cm

PPROMSevere complications e.g. preeclampsia,

eclampsia, CVS diseaseObstetric complications e.g. placental

abruption, polyhydramnios, chorioamnionitisFetal complications e.g. death, major

anomalies, growth retardation, fetal distress, Rh immunization

Contraindicated health conditions e.g. uncontrolled DM, hypertension, severe liver disease, CVS disease, thyrotoxicosis

TOCOLYTICS Beta adrenergic receptor agonists

Terbutaline Ritodrine Fenoterol

Magnesium sulfate Antiprostaglandins

Salicylate Endomethacin Naproxen

Calcium channel blockers Nifedipine Verapamil

TOCOLYTICS Beta-2 agonist

Terbutaline (Bricanyl)5 mg in NSS 500 ml15 ud/min then add 15 ud/min q 10 min (max120 ud/min)

C/I: CVS diseases, hyperthyroidism, uncontrolled DM

Side effects: hyperglycemia, hypokalemia, lactic and ketoacidosis

Tachycardia, hypotension, arrhythmia, heart failure

TOCOLYTICS

MgSO4 4 g loading dose

with 2 g/hr maintenance dose IVWhen Bricanyl cannot be usedMonitor urine output, DTR, RRAntidote: 10% Calcium gluconate 1 g

IV

TOCOLYTICS MgSO4

Side effectsMaternal: flushing, lethargy, headache, muscle weakness, diplopia, dry mouth, pulmonary edema, cardiac arrest

Fetal: lethargy, hypotonia, respiratory depression

C/I : MG

NifedipineSide effects

Maternal: flushing, headache, dizziness, nausea, transient hypotension

Fetal:-C/I: Maternal hypotension, cardiac diseases, concomitant use with MgSO4, caution use with renal diseases

TOCOLYTICS

Antenatal glucocorticoids Lower incidence of respiratory distress

syndrome Significant in GA < 34 wks Increase phospholipid surfactants which

promotes lung maturity Highest effect at 24 hours after injection

which lasts for 7 days afterwards May repeat every week until 36 wks GA 6 mg IM q 12 hrs * 4 doses Maternal pulmonary edema, infection,

hyperglycemia

Preterm Labor Care Fetal heart rate monitoring & external

tocography Sedative drug avoidance Wide episiotomy Cesarean section when

Fetal distressBreech presentationTransverse/Oblique lieOther obstetric indications e.g. placenta

previa, prolonged labor Resuscitation and intensive neonatal care

preparation Watch out for fetal hypotension, hypoglycemia,

hypocalcemia

PRETERM LABOR PREVENTION

Diet advice (to avoid malnutrition)Smoking cessationBed rest in high risk pregnancy—

multifetalNo intercourse in high risk

pregnancy—history of recurrent preterm labor

PREMATURE RUPTURE OF MEMBRANE

PREMATURE RUPTURE OF MEMBRANE

Rupture of membrane before labor pain

Term 95% / preterm 5%Usually followed by labor pain

within 6 hrs≥ 18 hrs = prolonged PROM

PREMATURE RUPTURE OF MEMBRANE Causes and risk factors

Chorioamnionitis Cervical/vaginal infections Lack of tensile strength of amnion Intercourse—prostaglandins in semen Cervical incompetence History of mutifetal pregnancy Polyhydramnios Placental abruption, placenta previa Low socioeconomics Smoking

PREMATURE RUPTURE OF MEMBRANE

Diagnosis confirmationNitrazine paper testFern test (arborization)

Check GA

PREMATURE RUPTURE OF MEMBRANE

Term—delivery Augmentation C/S when OB indication

Late preterm If infected/fetal distress—delivery Otherwise—expectant

Early preterm If infected/fetal distress—delivery Otherwise—inhibition

ROLE OF ANTIBIOTICS IN PROM

Prolonged PROM Ampicillin 2 g IV q 6 hrs until delivery

SUMMARY

Preterm labor Early Late

Premature rupture of membrane Term Preterm

Infected/distress/prolonged

THANK YOU