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Preterm Labor

Feb 03 | 1:30 PM

There are many etiologies for preterm labor like stress, infection, placental abruption, substance use, history of preterm birth or abortion, inadequate prenatal care, smoking, maternal age <18 or >40, to name a few. However, there are a few common reasons patients present with preterm labor in clinical settings. With this session with Dr. Uttara Aiyer Kohli, let us discuss types of preterm labor, review the common presentations of preterm labor, and summarize optimal management strategies for the condition!

[Music] welcome everyone good evening i dr rucha welcome you all on behalf of team netflix uh we have an interesting faculty today uh to talk about pre-term labor what are the consequences on uh the baby as well as murder let's understand starting from the signs and symptoms to its management so i'll just introduce mom uh we have doctors she's senior consultant gynecologist uh with 20 years of experience she has served in armed forces for 24 years before uh taking vrs in 2021 she's currently practicing in bangalore uh mom has exporters uh she's actually pg teacher and has served at command hospital in bangalore or till last year her areas of interest are high risk obstetrics and she will be talking about preterm labor today welcome mom and thank you for giving us this opportunity thank you richard so good evening everybody it's uh nice to be able to present in this forum and discuss with you all uh today i will be discussing about pre-term labor uh it holds a lot of importance because of the effect that it will have on the newborn and the consequences and it is one of the major causes of preterm births and low birth baby and neonatal morbidity and mortality and if it is diagnosed on time and we do some timely interventions we can improve the outcome also because of the art procedures because of the availability of intensive monitoring there are so many times that we are doing preterm deliveries to improve the outcomes for the mother and the baby so the objectives of today's presentation would be that i would like to just give you an overview of the preterm labor and its causes diagnosis management and how do we assess for the risk and interventions and tap more on the clinical aspects of it rather than only be theoretical so i'll just go through the theoretical my presentation is generally based on the recent guidelines by foxy american college as well as rcog i've just put them all together and collated for you for day to day practice so as we all know pre-term labor is the presence of uterine contraction of sufficient frequency and intensity resulting in the important part here is resulting in the cervical changes that is effacement which is measured by the shortening of the cervix taken up of the service and the dilatation of the cervix and before 37 completed weeks so if it's 36 weeks five days it is preterm labor and also after period of viability now this period of viability of course is slightly different in different places but after 20 weeks and some places 22 so the period between 20 to 24 weeks is one of those what we call threshold of viability periods which becomes a gray area for management so the main management generally is between 24 to 36 weeks six days so if your trend contractions are perceived however there is no cervical change then we may treat it as something called a threatened preterm labor and we need to observe the patient in case they have any cervical changes subsequently now the incidence of preterm birth ranges worldwide between 10 to 15 percent of all deliveries and it is the leading cause of penetrative mobility and mortality leading to a increased requirement for us to be aware of it as well as know how to treat it it is nowadays you have a lot of hydrogenic or induced preterm labors because of say maternal diseases severe preeclampsia so or abruption has taken place and uh other is spontaneous and of course if the delivery takes place before 34 completed weeks of gestation we call it early preterm delivery and after between 34-36 is late freedom now this period of late freedom is something that is coming into a lot of uh consideration because earlier it used to be like okay these babies do well but sometimes because they do not get enough attention they may not fare as well as we expected them to now when we see why we do induce freedom mainly for maternal and fetal indications primarily preeclampsia maternal chronic diseases and antipartum hemorrhage just to name a few and fetal indication fetal growth restriction oligohedramnes non reassuring fetal status are one of the important etiological factors coming to spontaneous preterm labor it ranges right from the uh things causing over distension of the uterus like multiple pregnancy polyhedramnes then infections like urinary tract infections vaginal infections chorioamnionitis even abdominal infections have been seen to stimulate uterus and lead to preterm labor of course preterm premature rupture of membranes is one of the causes that ends up in preterm labor and that is a topic by itself so i have not uh i'm not going to be covering a lot on it of course the management some of it overlaps with that of preterm labor abruption a retroplacental hematoma or placental abruption leads to preterm labor so that's something that should be ruled out if anybody ever presents in preterm labor then an anomalous uterus say awkward uterus or a uterus unicorn uterus bicarnate uterus these tend to go into preterm labor so any distortion of the uterus because of the presence of a fibroid cervical incompetence which could be a congenital or it may be because of damage to the cervical canal because of recurrent abortions or it could be because of a cervical surgery that has been done earlier then a maternal trauma maternal hormone imbalances caused by diabetes or other hormonal problems and of course a high risk behaviors like smoking then genetic predisposition based on ethnicity and of course demography low socioeconomic status extremes of age may also be responsible now primarily the pathogenesis involved a premature activation of the fetal hypothalamic pituitary axis which is generally aggravated by maternal and fetal stress and also an exaggerated inflammatory response which may be because of infections deceitful hemorrhages pathological uterine distension cervical insufficiency which we've already covered these so as we all know that generally uterine questions is maintained by progesterone and for the initial part of the pregnancy this is what takes place the maternal immune tolerance and all this supports the quiescence and at the onset of partition this dynamic changes and the withdrawal of progesterone leads so certain maternal and lifestyle factors like stress and nutrition environmental factors all these may contribute to the premature activation of these signals leading to preterm labor now when a patient presents to us with preterm labor what are our goals of management so they would depend most important on early identification of risk factors timely diagnosis identifying what is the etiology and trying to treat that evaluating the fetal well-being because that will decide when do we have to intervene and how soon we have to intervene then providing prophylactic pharmacological therapy that we will discuss as to do we need to prolong the pregnancy what do we need to use to prolong the pregnancy then of course reducing the incidence of respiratory distress syndrome which is one of the most common problems that we face if there is a preterm labor and a pre-term birth preventing of intra-amniotic infections specifically if the membranes have ruptured then this becomes a major cause and major problem and establishing a maternal fetal surveillance to improve neonatal outcomes so while we are waiting or whenever we are waiting or we're transferring the patient we need to monitor so that the outcome is good now how do we before we go into management suppose a patient comes to us for the first time how do we predict which patient is at increased risk so now people have come up with various tests and tried it and not found it successful but what i have highlighted in red is as you can see a very important is a good history taking so if the patient belongs to a high ethnic high-risk ethnic group like in they have found that in western countries the colored races are at higher risk or if they belong to lower socioeconomic status or if they are extremes of age then if the patient has a pre-existing disease patient has a chronic hypertension patient has diabetes patient has thyroid disorders a patient has kidney diseases or autoimmune disorders these patients again become high-risk patients then if the patient is a smoker or has sexually transmitted diseases patient who has had a previous history of a preterm birth or a previous history of a mid-trimester abortion again becomes a very high risk candidate for a subsequent so these are the things in the initial history we can pick up if the patient is a high risk patient right from the time the patient first reports for antenatal checkup of course uh those who are high risk they tried these the other two these people tried that home uterine activity monitoring which was not found to be of much benefit and a given our circumstance our clientele it is not going to work much salivary israel uh was found to be raised if preterm labor was to be predicted again not found very uh just 70 specificities are not very useful now fetal fibronectin testing has had a predictive value in identified patients who will or will not deliver in the subsequent one or two weeks now this uh specifically if a patient is very high risk or presence with suspected or threatened preterm labor if it is raised it gives us a we need to be more careful chances that the patient may progress to preterm labor however it is negative then we may consider discharging the patient and following up the patient bacterial vaginosis has been associated but it is not a specific predictive and cannot be used as a predictive test it's something that should be treated because it has an association with pre-term birth but we cannot use it as a predictor of pre-temper cervical length assessment has also been found to be very useful and this specifically can be carried out in those who are at high risk or have a history suggestive before 24 weeks of gestation anything less than 2.5 uh centimeters or 25 millimeter of the cervical length is then we should consider this patient as a high risk depending on the given circumstances we can consider a prophylactic sludge which i will be discussing subsequently and specifically cervical length say when the patient after 24 weeks or around 30 to 33 weeks presence with a preterm labor an assessment of a cervical length of less than 1.5 centimeter centimeters or 15 millimeter as we put it may be more suggestive of the patient being in labor as compared to if it is more than 15 millimeters now the prediction is improved if we combine the fetal fibronectin testing along with the measurements of cervical length once we have predicted then how do we prevent so prevention can be of two things either it's preconceptional where we have a definitive history of previous uh freedom labor in these cases we assess for the cervical features cervical trauma if it has happened what is britain birth history if there are any genetic infections we try and treat them if there are previous uh mid trimester losses then we have to make a plan for the present to see what was the cause and does an interval is an intervention required we treat chronic diseases say diabetes you keep it under control because uncontrolled diabetes will lead to preterm labors and we modify other high risk behaviors in the current pregnancy once we assess the risk factors we try to modify what we can we assess the cervical length and we can allow if there is a short cervix or there is a history of uh cervical incompetence then we would like to give a prophylactive surplus or put the patient on progesterone so various studies have been carried out over a period of time and some have showed an equal uh equal whether you give a circular or you use vaginal or intramuscular progesterones uh they may have the same effect so it depends on the clinician preference the patient preference ability of the patient to follow up you should also realize that it's not so easy to take a weekly injection and also we have to see how much is the patient compliance when we put on long-term medication and of course if there is any evidence of infection we should treat that now coming to diagnosis has already specified a detailed history whether what are the type when when we are trying to diagnose now the how would the patient patient may have presented to us saying okay i'm having pain abdomen now a detailed history will we have to find out what is the type of pain abdomen the patient is having so is it intermittent pain abdomen continuous pain abdomen is the pain uh like it is coming in at specified intervals it is increasing in frequency and intensity or is it the same or is it a dull backache so sometimes just a persistent dull backache may be a predictor of the patient may be going into preterm labor so we have to take a detailed list of the type of brain then also we need to see what are the other features does she have any associated vaginal discharge a foul smelling discharge does he have any history when she has any history suggestive of a watery discharge which means subject [Music] membrane rupture that has occurred and then we look for other risk factors what she has in her that could uh lead to preterm labor then we look for uh other features like is she perceiving fetal moments is she having any reduced fetal moments is she having any feature does she have any bleeding pv which may be suggestive of abrasion or does she then in the history we also have to take a history which will tell us exactly about her period of gestation or we have to confirm her gestational age because that will determine how we manage her if she's more than 34 weeks how we go about it if it is if she's less now there are different ways to confirm gestational age one would be her first ultrasound if it's done in first trimester and she has a subsequent follow-up ultrasound of her ultrasound and her dates are matching that will tell us her gestation age is accurate because there may be a patient who has a wrong gestational age and we are presuming she's preterm but she's term on the other hand there may be a patient who may by dates be termed but however by her first ultrasound or a second ultrasound she has a delayed conception she actually will be preterm so we must definitely confirm gestational age when a patient presents with these features when we examine the patient a general physical examination will help us rule out other problems like anemia and any chronic disease and her normal bmi and of course features of infection so any fever if she's got any features of sepsis in case it has been prolonged prm then we do a pelvic examination a pelvic examination we do a speculum examination and the speculum examination we have to look for any evidence of uh water discharge or leaking permagenum if you are suspecting as per history and then we look for any presence of infection we may also be able to see if the cervix is dilated or the membranes are bulging and then a pv examination may help us to know if what is the dilatation and the length of the cervix now depending on this we go ahead the next step that we'll do is certain investigations and imaging investigations when we are doing this pelvic examination that time itself we should take a vaginal swab for culture so that we can see if there is any infection we if we have fetal fibronectin testing available readily with us we could take that test and keep it ready so in case when the result comes we'll know how the follow-up has to be for this patient then of course a urine culture a blood count which will tell us about any other existing infection and in patient is a diabetic we need to know how sugar levels now an ultrasound is very important because it will tell us about the fetal wellbeing what is the like a situation so in case there is a suspected uh leaking or we do not uh we are not very clear from the history so a reduced like may be indicative of uh that leaking has occurred or the like membrane rupture has occurred which may be the cause of the freedom labor though not very accurate sometimes a retroplacental clot may be picked up on ultrasound also it will tell us about the fetal condition how's the fetal growth if there's any growth restriction and we along with that and the non-stress testing for the fetus we would know how is the fetal well-being so are we good to uh go conservative or do we need to intervene earlier now whenever a patient presents with pain abdominal pregnancy there are some important differential diagnosis other than labor of course labor should always be your first diagnosis so you rule out labor and abruption that is the premature separation of the placenta is one of the major diagnosis and generally by the feel of the uterus when we palpate the uterus you can make out if it is relaxing in between the contraction unlikely abruption but if it is tense the tone is high then it is likely that it is uh abruption and we need to be very very of that and specifically associated with fetal distress now for your abnormalities again we may have a tender uterus foul smelling discharge so continuous pain tender uterus chorionitis should be high on the cards preeclampsia sometimes presents with pain abdomen in complicated preeclampsia helps syndrome so we have to see where the pain is certain times non-obstetric causes of pain abdominal over a period of time i have encountered cases who had a gastrointestinal infection loose motions typhoid and because of the gastric irritation they had presented with preterm labor so they had a double whammy they had a gastric infection as well as a preterm labor once a patient had disseminated tuberculosis presented only as preterm labor and after she delivered we realized that she had other features like uh plural effusion and other problems and she disseminated tb now once we plan the management of course the first line is always supportive management the patient is anxious she's worried that she's going to have a preterm labor so we need to reassure her rest is an important component but not the only component and as of today complete bed rest has a lot of questions because of the risk of thromboembolisms and everything so of course we give adequate rest a a trial of sedation always helps so what we generally use is whatever situation protocol in your labor room if you have if you're using tramadol you can give tramadol pathetin so you give the patient sedation so in case of false labor pains generally patient will subside and you'll also have a period of observation over which you will know that there are no changes in cervical finding and that will help you decide whether the patient is in labor or not counseling is very important once a patient of preterm labor presence and you are presuming that the slay patient is going to deliver prematurely or there is a risk of premature delivery the patient needs to be counsel about the risk of preterm delivery the risks to the neonate the availability you have of neonatal facilities the requirement in if in in case any of transfer of the patient to a tertiary care center and consent and about this is very important because there have been times when patient has come and then later he will to say or she will say that i didn't know that my baby was at risk nobody informed me so if a patient comes with preterm labor they have to be informed about the neonatal risks there is to the mother and whatever plan of action we are taking whether we are going conservative or progressing with delivery why we are doing it we should inform the patient otherwise these become medical legal issues later and we should also inform the concerned specialist so for us the most important concern specialist of course is the pediatrician and availability of pediatric facilities so they should be available that there's a new uh there is a pre-term neonate on the way so that they are ready to receive it so there are times when they may not be available so you may have to send to a center where the pediatrician is available or the pediatric beds in your or the neonatal beds or ventilators may be booked in your setup so you may need to look for another setup so these things have to be planned well in advance now there are various treatment considerations available to us we have tocolysis to stop the uterine contractions we have corticosteroids to enhance which lung maturity we have to use antibiotics judiciously as they were indicated and four gram group b septococci infection prophylaxis earlier onset of preterm labor that is between 24 to 27 weeks there may be a role of rescue uh insert clutch will be discussing that and of course the role of progesterone's not as in immediately thwarting the preterm episode but in patients or for follow-up following an episode of freedom labor then of course uh the delivery the consideration as to when to deliver or where how long to wait what should be the mode of delivery and where should you deliver the patient now in cases presenting with preterm labor there is no role of conservative management in patients who have evidence of coriolinitis any evidence of fetal compromise or maternal compromise where there is an existing fetal anomaly where you know that the outcome of the fetus is not uh good then there's no role of waiting and in case of severe preeclampsia eclampsia if there's abruption maternal distress there's no role of waiting just a note on what are the features of coriolinitis most of you all must be knowing it is the infection of the the intrauterine infection of the coriander and it is it can very easily spread to sepsis so we have to be very careful about it it occurs in approximately 0.5 to 1 percent of pregnancies of course any feature of maternal tachycardia fever fetal tachycardia uterine tenderness foul smelling discharge a high tlc count for the mother a raised crp these are all features of corionitis and specifically patients of premature rupture of membranes if we are going conservative we do we uh do a closed monitoring for all this to look for any feature of coriolinitis those who have intact membranes may not have but there are incidences of intact membranes with coriamonitis also so we should always we're looking out for these features in a patient of preterm labor who we are managing conservatively now coming to the uh different modes pharmacological therapies that we can offer to this patient so one is stocalytic so tocolytics are drugs used to stop the uterine contractions and the primary purpose as of today optocolytics is to delay the delivery at least for 48 hours to allow maximum benefits of glucocorticoids to decrease the incidence of respiratory distress syndrome this should be very clear because earlier people used to indefinitely use beta mathematics like you would have heard of patients being on divide a lot i have seen patients being on development from first trimester till 36 weeks which is absolutely not indicated as of today and a lot of people in the periphery still practice it and it should be discouraged because we beta sympathetic biometric drugs like the butler have a lot of side effects and they affect the maternal glucose metabolism also when do we prefer to use stockolytics not after 34 weeks period of gestation so between 24 to 34 weeks period of gestation is the most common time that we prefer to use it indications of users first we have to be sure that the patient is in established preterm labor we do not just give it to anybody who complains of pain abdomen because remember if there is an abruption and we give a topolytic we are going to increase the amount of bleeding and increase the risk of the newborn and elite two intrauterine demise so we have to establish that it is labor we have to rule out sinister problems like organitis abruption we have to ensure the fetal well-being that we are planning to wait we have taken the decision to wait and there is no indication to immediately deliver the baby and we have to confirm the gestational age so after 34 weeks there is no indication of using procolytic therapy so frank contraindications of topolytic therapy oligohedra aminos non-reactive non-stress test results positive contraction stress results uh so this is when we do a cardio graphic monitoring of the baby if you find that with the contractions you're getting decelerations or you find a non-reactive nsd loss of b2b variability in fact loss of b2b variability is one of the uh very um okay almost diagnostic of code amnionitis so you should watch out for that and absent or reverse diastolic flow that means basically there is a fetal compromise you will definitely not give any tocolysis and secondly there is maternal compromise in the form of a general bleeding consistent with abruption of placenta previa now ah this is not my own i have also taken from the net but i found it very interesting so when the baby says it's not my time to come out so it's not my time so these are the most commonly used uterine relaxants autopolitics so you have endometriosis and nephidupin magnesium sulphate tepitlin of course i have put it in the order that we prefer to use it so first line as of today mainly most practitioners would prefer nephidupin magnesium sulfate is also got a significant role in domethasin beta sympathy mathematics are avoided as far as possible attack was came up initially was tried to use but fda usa did not approve it and it is not uh it's quite an expensive drug and it's not found to be so effective that we should use the uh that we need to definitely use it so all about a little more about nephi dipping we all know because we have people use it where for the treatment of hypertension but because it's a calcium channel block and in which the contractility of the smooth muscles it it has been found to have a good effect on docolysis it has been found as compared to other topolytics to successfully prolong pregnancy fewer admissions of newborn to neonatal intensive care units low incidence of respiratory stress and also fewer adverse events related to the mother as compared to the other politics the initial dose we generally give a mother a 20 milligrams oral tablet not sublingual mind you oral tablet and we can repeat it if required after 30 minutes if the contraction is still there or we can use it three to eight hourly depending uh uh we do not exceed a maximum dose of 160 milligrams per day but we have to also closely monitor maternal heart rate as well as the maternal bp so as a victim what we follow is the systolic blood pressure of the mother goes below 100 or if maternal heartbeat is more than 120 we skip the dose so we delay the dose we do not repeat it and do we follow up the patient by uh monitoring uterine contraction either by the cardiodrop or by your own hand that is very specific to see if the rate of contractions has reduced her pain would reduce and contraindications of course allergy hypotension hepatic dysfunction and concurrent use of other beta mimetics and magnesium sulfate should not be used or transdermal nitrates side effects we all know maternal flushing palpitations tachycardia headache dizziness nausea so the dose modification helps to reduce these side effects continuous monitoring of fetal heart rate and patient contraction obviously when we are doing these and patients pulse and blood pressure should be carefully monitored when we are giving this next is magnesium sulfate now magnesium sulfate has a double effect in pregnancies less than 34 weeks period or 33 weeks period of gestation or less it also has a neuroprotective effect and it has been found to be a good uh locality specifically where we cannot use nephidipin or uh there are um this is uh senefitepin is not acting so we need to use it so uh it is uh used as a loading dose of four to six grams iv and followed by one to two grams for twenty four uh but per hour for 24 hours as a thing whenever we use magnesium sulfate most gynecologists here would know that we have to keep a close watch on the deep tendon jerks the the heart rate the respiratory rate and the urine output so at least 100 ml in 4r should be there but 30 to 50 ml per hour would be better and close monitoring should be there and of course it has the added effect of neural protection but requires intensive monitoring as compared to nephilipin next coming to endomethycin now endometricine is not so widely used but for preterm labor less than 30 weeks it has found to be effective in my personal practice even in twins specifically presenting before 30 weeks where where infection and inflammation is one of the causative factors that we think and it has been found that preterm labor before 30 weeks has a greater inflammatory response as compared to that later so it is useful then freedom never because of polyhydramnios endomethacin has a major role because it also helps in reducing the polyhydramnios being a prostaglandin synthesis inhibitor it reduces the prostaglandin it reduces the inflammation and it also has an effect and reduce fetal renal effects help in reducing the polyhydramnios so we generally start with 100 milligrams per rectal dose followed by 50 milligrams per only every six hours for eight doses side effects of course are oligo hydroaminos because of the fetal renal effects feet rarely fetal and urea renal microcytic lesions neonatal death premature closure of ductus arteriosus so generally this is not given after 32 weeks period of gestation i prefer to be used only prior to this a word on lithuanian territory ness of supreme or wetlands so turbotlene if available is good for a single point two five milligrams subcutaneous that can be given and repeated uh as per the contraction or as for the maternal heart retinol but generally we avoid these if possible specifically if there is maternal tachycard uh so that's the side effects of maternal tachycardia hyperglycemia palpitations pulmonary edema myocardial in ischemia and cardiac arrhythmias so patients who are already in a high um volume state so twins heart disease patients so definitely these have to be avoided coming to etosiban which is a non-peptide oxytocin analog oxygen receptor antagonist uh it came as a it was found to be very effective earlier but however randomized clinical trials failed to show it better than the other process and they some of them found that it was linked to some neonatal morbidity so fda has denied approval now corticosteroids these are very very important drugs and in fact if you see the use of tocolytics is used uh is linked to the uh function of the corticosteroids so we use topolytics till the corticosteroids can act because corticosteroids have been definitely proven to improve uh the fetal lung maturity and prevent or reduce the incidence of respiratory distress syndrome in the newborn and this is given between 24 to 34 weeks definitely we would give and we would like to deliver after 24 to 12 to 24 hours of the last dose of the steroid but recent data and recent guidelines have said that it may be beneficial to give this up to 36 weeks six days to a patient now the the caveat here is that uh we did not localize the patient or we did not wait for the effect of corticosteroids after 34 weeks period of gestation but we should definitely give the patient corticosteroids and if there is enough time for it to act the neonatal outcome would definitely be better the common corticosteroids used of course dexamethasone which is given as 6 milligrams 12 hourly 4 doses and betamethasone 12 milligrams every 24 hours two doses the role of antibiotics has is mainly to treat any evident infection so if the patient has urinary tract infection if she has any gi infection ish if she has infections like even oral infections periodontal uh periodontic infections have been seen to precipitate preterm labor if there is evidence of cardiomyominitis definitely otherwise it has a definite role in gbs infection prophylaxis so and of course the bacterial vaginosis is documented so what generally is dr uh said is that once you put the patient once you have a patient you may and you think that this patient is going into preterm labor then you should initiate the group uh b streptococcus infection prophylaxis which is generally a penicillin based antibiotic so you can either give erythromycin orally or you can give injection ampersand to gram stat one gram iv6 hardly and once you find that either there is no preterm labor or the labor has stopped or there is no evidence of any infection on culture you stop the antibiotic but if the patient is about to deliver in the next 24 hours then you give the antibiotic as groupie streptococcal infection prophylaxis for those who have an allergy to penicillin then other things like caphalosporins or clindamycin may be used now what is the role of risky and circulation risky insect large is the term used for giving an answer class in an emergency condition so one we spoke of giving excel clutch if a patient has a high risk factor so patient is not in labor but patient has a high risk factor like previous preterm delivery previous mid trimester abortion history of a cervical surgery a short cervix diagnosed before 24 weeks period of gestation so there may be a role of giving an answer clutch around 16 to 18 weeks however suppose a patient presents with preterm uterine activity or labor specifically uh before 27 weeks period of gestation and on diagnosis we find that the membranes are intact but the cervix is short or the cervix is slightly dilated so there is a role to give a rescue and surcludge in which case we may either be able to give a mcdonald's which is a burst string or we may give something called a womb suture in which we give cross suturing anterior to posterior post sideways now this is a very controversial thing because of course there is always a risk of the membranes rupturing during the procedure and there is a risk of ascending infection now definitely there is a contraindication to giving this infection if there is evidence of infection if there is any bleeding if there is already an existing fetal compromise so the patient has to be counseled accordingly if we are planning a resequence of clutch and this has to be given along with uh tocolysis and antibiotic in case uh we want to give this now coming to progesterone therapy now progesterone has been known to help in maintaining uterine voices and so in patients who are at risk of preterm labor there is a definite role as per different studies of giving a patient uh progesterone therapy generally up till 34 weeks period at gestation not later and this can be given in the form of an injectable hydroxyprogesterone capital 500 milligram injection weekly or we can give vaginal progesterone gels you have eight percent gel or you have tablets micronutrient tablets or even given orally now different studies have shown some say that vaginal progesterone is better than injectable some say that injectable so the debate continues some have also compared and circulates to now if a patient actually presents with preterm labor there is no definitive thing saying that you give a progesterone injection and the patient will stop but because it kind of suppresses inflammatory response in the myometrium and it also makes it more uh says it improves its receptivity to the tocolysis so we could give a single dose of progesterone when the patient presents with preterm labor and we are planning to go conservative or giving crocolisis but it's not a definitive proven therapy but of course say if the patient's preterm labor activity subsides and she's less than 34 weeks period of this station so there may be a role of continuing her on some progesterone therapy up till 34 weeks and then stopping it now once a patient presents with preterm labor now what do we do depending on the period of the station at which the patient has presented we'll decide as to whether we want to go conservative or whether we want to deliver the patient or let the preterm labor progress so if the patient is what we call threshold or viability less than 24 weeks period of gestation 22 to 24 weeks periods association we have to take an informed decision and also depending on what is the dilatation how much are we going to be able to prevent this labor what uh what are we going to what is the evidence of infection and what are the facilities available with us the main period of action for us is between 24 to 34 weeks period of this station but after 34 weeks period of gestation remember there is no role of giving any tocolysis you have you can give corticosteroids and you can prepare for a vaginal delivery you can treat if there is any infection and the only time which you may want to use a short period of topolysis maybe in case you need to transfer a patient to a tertiary care center say you are in a peripheral setup you have no pediatrician available or no uh you find that there is so once you rule out the sister things like coriandous or abruption you may give a short course of tocolysis say for six hours or 12 hours till the patient reach reaches a center where the mother and the baby now between 26 to 34 weeks our aim would be to try to at least gain try to stop the preterm labor and at least gain 48 hours to enhance the fetal lung maturity and plan for a place a suitable place for the patients delivery where the maternal and neonatal outcome can be taken care of so in such cases after ruling out the contraindications for topolysis and contraindications for uh like conservative like we said infection bleeding maternal fetal compromise we can start docolysis and immediately start steroid dosage and then we monitor the patient we give the patient rest and if we are able to successfully stop the preterm labor that we know that the contractions go away there is no further change in the cervical findings then we closely follow up this patient if the patient is comfortable fetal well-being is established there is no more preterm labor we can even consider discharging the patient home and weekly follow-up or after 48 hours we stop the tocolysis observe for some more time if the patient goes into labor we allow the patient to deliver now once a patient is in labor there are certain considerations that we need to know how to deliver this patient so the mode of delivery would depend on the presentation of the baby the maternal fetal conditions and the period of gestation preterm breach fetal non-reassuring status abruption contraindications of a general delivery obviously will indicate a cesarean there have been documentation we need to actually free term newborns are at increased risk of intraventricular hemorrhage so we need to ensure that there is no sudden compression decompression of the head so there was there are people who uh say that a prophylactic outlet forces may prevent this and the vacuum should definitely be avoided before 34 weeks we may want to use an episiotomy again to prevent the saturn compression decompression if the patient is in prolonged labor augmentation of labor should be done the place of delivery should be preferably a tertiary care center with nic facilities here a word of question that a lot of people in the in a particular setup may not want to lose their patient or they may not want to lose the thing let's not get into that and remember that what is best for the patient is what we should do so a patient should definitely be given the benefit and be transferred to a facility which has an ic facility which has a pediatrician available and somebody who can look after so we should avoid delivering freedom babies in very small setups where we do not have facilities to look after the baby and remember the baby does not a new neonate a preterm neonate does not handle transfer very well outside of the maternal body so a intrauterine transfer is always better than extra uterine so if we can timely transfer a neutral to a center where the baby will get a better chance of survival we should do that during delivery we should have if it's a preterm delivery we should have an obstetrician and pediatrician in attendance once we know that this patient is going to progress to delivery and it is less than 33 weeks period of this station there is a definite role of using injection magnesium sulfate for neuro protection effect for the newborn so magnesium sulfate in the same dose that we had already said four to six grams four grams iv over two of twenty percent over twenty minutes and followed by one gram per hour till delivery there are again there are two three protocols you can have the continuous delivery dosage or you can even give a single dose say at least two hours prior to delivery say you are taking a patient for an elective preterm delivery because of severe preeclampsia you can always give on severe fgr absent diastolic flow you can always give to us prior to delivery injection magnesium sulfate preferably six hours prior to delivery a single dose may also be given because sometimes we don't want to continue the magnesium sulfate right up till delivery because there are cases that the uterus then refuses to contract and pph marker now steps to prevent intracranial hemorrhage already described either prophylactic forceps use of episiotomy um another thing important is delay cord clamping if the if the baby does not require urgent resuscitation it is better to delay cord clamping so that we can have um the baby's hematocritus improve now a short small word of complications of preterm labor and but the most important complication is we are handing over a preterm baby which is not completely mature to come out so there are a lot of risks for the baby right from respiratory distress syndrome to low birth weight to hypothermia hypoglycemia hyperbolic nuclear necrotizing hydrocolitis just to name a few i'm not going to this forum it is more for a pediatrician to discuss but we have to be aware of this and that is the reason why we need to avoid it or at least deliver in a place where the pediatrician can take over the baby and maternal of course risk of maternal infection if there was a pre-existing maternal infection risk of intervention because of the thing and of course psychological impact whenever you have a preterm baby the mother requires a lot of psychological counseling because it may lead to prolonged admission for the mother because the baby is in an icu fear so there are a lot of psychological implications of rate of birth for the mother once the patient uh has either delivered preterm and gone off so we need to follow up her for the future for the baby for the current if there was any high risk factor and for her future pregnancies we have to advise her if a patient or preterm labor we managed to prevent the labor in such cases uh follow-up would involve home monitoring of contractions up to the patient we tell them about all the danger signs we tell them to monitor the fetal movements we call them back for frequent reviews we can do uh sonographic monitoring of the cervical length or also and we can keep the patients on progesterone up to 34 weeks so i have almost covered everything so to just summarize once more that suppose a patient presents to us with history suggestive of preterm labor so that would be patient would have intermittent pain abdomen and she may have a cervical changes so we would like to admit the patient give her rest reassure her establish preterm labor we establish it by monitoring the contractions and also seeing if there is any serial change in the cervical findings or if there is a significant change in cervical findings depending on her period of gestation and associated complications we rule out conditions that may require immediate delivery and we start off with giving her steroids for enhancing fetal lung maturity we start antibiotic if there is evidence of infection or evidence of immediate delivery we start off tocolysis if it is less than 34 weeks and there is no contraindication to tocolysis we monitor the patient through the tocolysis to see that there are no adverse effects of localism there is no evidence of progressing infection and we are able to gain that 48 to 72 hours following which we will stop the tocolysis watch for the patient's progress in case she still progresses to labor we let the patient deliver in a tertiary care center with the pediatrician available and if not if she is asymptomatic the labor has imported we will send her home and follow her hub closely thank you for a patient hearing and now i would take your questions if any yeah thanks a lot it was really wonderful session so dr basu has asked uh could you please explain the ffn test okay so fetal fibronectin is a basement membrane protein generally when there is a breakdown of the basement membrane because of inflammation and all this is released so it's actually like a card test you take a swab card so if you find that it is higher than a particular cut off values more than 20 nanogram then you uh if it is positive if fetal fibronectin is increased that means this patient is more likely to go into preterm labor and if this is negative it is basically predictive for a period of over one to two weeks so it will tell us that okay this patient is less likely to go into preterm labor if it is negative because that means the basement membrane breakdown has not taken place dr maya has asked if babies three term most likely that the baby is underweight and the weight is on lower side basically so what is the need for apg so exactly what i said was that of course you have to this is where we as certain the maternal see if it is a multi gravida where there is the vagina is lags and everything so what i said a preterm baby's head is soft a sudden compression and decompression of the head leads to intraventricular hemorrhage so specifically that's why i mentioned to prevent this sudden compression and decompression of the head we need to give an episode me so that there is enough room for the baby to smoothly come out so a term head is able to push the vagina better and it can sustain the the con the pressure of the vagina whereas a pre-term head may not be able to do that and may end up with a sudden compression decompression leading to intraventricular hemorrhage right uh role of usg in monitoring patients with uh past history of ptl so uh of course in the initial trimester doing the cervical length uh monitoring or looking for any fetal any uterine malformation say a biconnection tutor's unicorn a tutorial that is very conceptional or early gestation then if there is a definite uh history suggestive of preterm labor we do a cervical length monitoring specifically if we can catch a small short cervix before 20 weeks so before 24 weeks period of gestation we can give the patient a prophylactic cancer class or put them prophylactically or progesterones which will help in prolonging pregnancy but remember one thing whenever we do any of these interventions we have to counsel the patient that none of it is sacrosanct because we've had sad cases of where we have had insure clutch failures failures instead of progesterone we have cases where we have given abdominal insulin and still had failures because some uterus just are not able to hold the fetus for some reason which is say genetic or it's feminine and whatever so we're not able to so we should always counsel the patient they should not think that okay now i've got this so nothing can happen to me so that's where counseling has a major role okay so dr narayana has asked we have eight mg dexamethasone and one ampule do you give 1.5 ml or the whole 8 mg no we have to give 6 milligrams 12 hourly so you have to accordingly give 1.5 ml so 6 milligrams 12 hourly 4 doses is the main disk okay so earlier we used to give 12 milligrams 12 hourly so sometimes when we have we see as uh in clinical practice we may not always go by the book sometimes when we have we feel that this patient may not even wait 24 hours we want to give you know as much dose we can give earliest so we've also given 12 milligrams 12 hourly and said okay let us get maximum effect but there are no proven studies on that so if we go by the prescribed dose it is 6 milligrams 12 hourly phobos okay so aim is to give it over 24 hours to get the maximum benefit in the 24 hours yeah yeah so dr kaushik das is asking what is the role of prophylactic uh cervical and circulation uh he's saying that he has seen prophylactic cervical and circular around 40 to 15 weeks in twins but what is the rule so so like i said i've already partly covered it so avoid it in in a no but like uh his question may be more specific there are certain people say post diagram pregnancy twins where there are existing uterine anomalies like you know that patient has a biconnect uterus or a septic uterus so there are some advocates of giving an answer clutch irrespective of the cervical leg so the cervical length is normal but they would still give a answer clutch so that is a very debatable topic and uh so there are pros and cons so generally we say we should not intervene because any surgical procedure we do by just passing the needle to the cervix maybe we may be generating an inflammatory response and we actually may end up causing uterine contractions so uh we avoid it but there are people who would say a very high risk pregnancy but when i said with the prophylactic surcharge i was trying to speak of was in patients who've had a classical history of mid-trimester abortion features suggestive of cervical incompetence have a short cervix less than 2.5 or have features of funneling or are at very high risk have had cervical surgeries earlier are definitely candidates for insect large right and mom which material do you prefer so uh so so again um it's again a experience and your what is your clinical experience what is available to you so the maximum that i have given ever is mcdonald's suture which we use a uh non-absorbable suture like proline earlier we used to use silk but silk increases chances of infection so proline is what nowadays we use number one proline and we give a mcdonald's suture that is a purse string switch i go all around the cervix and tie the knot i can see in the comments he's using about merceling tape so there is a shirt method in which mercelin tape is to be used so what happens whenever we put a circle as remember we have to take it out also at 36 weeks so when we put a muslin tape and all it is something that you know you cut then you put the tape then so removing it becomes equally troublesome and that removing it at 36 weeks so where you think that you need a more permanent solution see when you do abdominal length class you put a tape and then at that time you counsel the person that if the delivery has to take place it has to be done by cesarean because now you put a permanent kind of tape around the so steroids technique uses muscle intake but then again removing it becomes a problem so you may end up doing a cesarean so we have to uh so we for people who have recurrent uh abort preterm labors or abortions or mid travis abortion specifically more than preterm labor and those who had failure of previous classes where the length of the postal vision analysis of cervix is very less in those cases definitely there may be a rule of doing uh you know dissecting out and putting a tape okay all right so dr karshik ma'am as well explained your question i hope uh this helps you um there is one more question try me gravida at 32 weeks of uh with pprom uh what is the management and how long can we prolong the pregnancy okay so uh as this is so once we've diagnosed that their membranes are ruptured so we have to uh look out for any evidence of coriondonitis we have to do an ultrasound to see how much lycra is available inside to the baby is there severe oligohedram neurons or house the fetal well-being feed there should be no fetal distress if we have ruled out coriandous we've ruled out fetal distress we would definitely attempt to gain 48 hours by giving corticosteroids so we would give steroids and we would ah give antibiotic prophylaxis to prevent infection and do a closed monitoring for any evidence of infection and try to gain 48 hours at least and in this 48 hours so after 12 hours of the last dose of steroid we can allow the patient or maybe even induce the patient to be delivered if the leaking is demonstrable and in case and earlier there is any evidence of uterine tenderness foul smelling discharge there is a rise in tlc the crp raises we should immediately terminate the pregnancy and in this time that we gain we would have uh we should be able to take the patient to a center which has a pediatrician available now here a little question comes over should we or should we not use docolysis so upfront we would not use tocolysis but however if everything else is ruled out and you find that there is some uterine activity some people may consider giving a little tocolysis for 48 hours just to get the fetal language already provided there is no contraindication in the form of infection or maternal or fetal compromise right it's really great to have you with us it was an interesting session wonderful session yeah i also had i also had a nice time thank you thank you everyone good night

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dr. Uttara  AiyerKohli

Dr. Uttara AiyerKohli

Senior Consultant Gynecologist | Ex- Professor AFMC, Pune

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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dr. Uttara  AiyerKohli

Dr. Uttara AiyerKohli

Senior Consultant Gynecologist | Ex- Professo...

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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