Management of preterm labor

Management of preterm labor : Overview of NSAIDs as Tocolytic : 

Management of preterm labor : Overview of NSAIDs as Tocolytic IG : Cheong Tan Fong Tutor : Michelle Chan Man

Definition: 

Definition Preterm labor is defined as regular uterine contraction with associated cervical changes at less than 37 wks gestation ( between 24 and 37 wks). Symptoms may include : abdominal cramps (with or without diarrhea), vaginal bleeding, ruptured membranes, increase in low back pain, pressure sensation in pelvis/vagina, change in vaginal discharge.

Risk factor: 

Risk factor The exact mechanism(s) of preterm labor is largely unknown : Decidual hemorrhage : ( eg , abruption, multiple gestation or polyhydramnios ) Cervical incompetence ( eg , trauma, cone biopsy) Uterine distortion : ( eg , müllerian duct abnormalities, fibroid uterus) Cervical inflammation : ( eg , resulting from bacterial vaginosis ) Maternal inflammation/fever ( eg , urinary tract infection) Hormonal changes : ( eg , mediated by maternal or fetal stress) Uteroplacental insufficiency : ( eg , hypertension, insulin-dependent diabetes, drug abuse, smoking, alcohol consumption)

Neonatal Morbidity and Mortality by Gestational Age: 

Neonatal Morbidity and Mortality by Gestational Age

Management of Threatened Preterm Labor: 

Management of Threatened Preterm Labor PURPOSE : 1. Prolong pregnancy to provide benefit of administering antenatal glucocorticoids for fetal lung maturity. 2. Tocolytic therapy may play a role in the safe transportation of the mother diagnosed with preterm labor to the tertiary care facility.

Protocol for management: 

Protocol for management Bed Rest Corticosteroids Tocolytic drug Antibiotics

Tocolytic Agents: 

Tocolytic Agents Beta-Mimetic Adrenergic Agents Magnesium Sulfate Prostaglandin Synthase Inhibitors Indomethacin Diclofenac Calcium Channel Blockers Nifedipine

Prostaglandin Synthase Inhibitors-- Diclofenac: 

Prostaglandin Synthase Inhibitors-- Diclofenac PHARMACOLOGY It is a non-steroidal anti-inflammatory that acts by inhibition of prostaglandin synthesis. It is completely absorbed after oral or rectal administration. Peak serum levels are seen within 2 hours of administration; the half-life is 3-11 hours.

Contraindications: 

Contraindications Maternal pre-existing gastrointestinal lesions (ulcers) known allergies to NSAIDS or salicylates coagulation disorders or thrombolytic therapy renal or hepatic dysfunction Fetal ≥32 weeks gestation pre-existing oligohydramnios fetal compromise, including IUGR, and fetal anomalies

Side Effects: 

Side Effects Maternal Nausea/vomiting Coagulation disturbances Thrombocytopenia Renal failure Hepatits Elevated blood pressure in hypertensive patients Fetal Oligohydramnios Pulmonary hypertension Postpartum patent ductus arteriosus Premature constriction of ducts arteriosus in utero Increased risk for necrotizing enterocolitis and intraventricular hemorrhage

Doseage: 

Doseage Diclofenac 100 mg pr q12h Maximum of 4 doses Maximum length of treatment is 48 hours If used for greater that 72 hours, must be able to perform obstetrical ultrasound and Doppler flow. Study to assess patency of the fetal ductus arteriosus . Because of the potentially serious fetal effects, many centers limit to infants less than 32 wks’ EGA and its duration of use to less than 48 hours.

References: 

References Tocolysis for the Prevention of Preterm Labour . Calgary Regional Health Authority Maternal Newborn Services Policies & Procedures, August 1999. Abramov Y, Nadjari M, Weinstein D, Ben- Shachar I, Plotkin V, Ezra Y. Indomethacin for Preterm Labor: A Randomized Comparison of Vaginal and Rectal-Oral Routes. Obstet Gynecol 2000; 95:482-486. Marjoribanks , J.; Proctor, M.L.; Farquhar, C.;Derks . R.S. Nonsteroidal anti-inflammatory drugs for primary dysmenorrhoea . Cochrane Database Syst. Rev. 2010, 1, CD001751. Gyetvai K, Hannah ME, Hodnett ED, Ohlsson A. Tocolytics for preterm labor: a systematic review. Obstet Gynecol. Nov 1999;94(5 Pt 2):869-77. Katz M, Goodyear K, Creasy RK. Early signs and symptoms of preterm labor. Am J Obstet Gynecol. May 1990;162(5):1150-3.

PowerPoint Presentation: 

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Results of Tocolytic Therapy: 

Results of Tocolytic Therapy With all tocolytics , a point may be reached where further therapy is not indicated. This may be due to adverse maternal or fetal response to the progress of labor. Thus, if cervical dilatation reaches 5 cm, the treatment should be considered a failure and abandoned. Conversely, if labor resumes after a period of quiescence, treatment should be carefully considered because the recrudescence of contractions may be a sign of intrauterine infection. In some cases, therapy may be reinstituted using the same or a different drug.

General Contraindications to Tocolysis: 

General Contraindications to Tocolysis Inappropriate gestational age: <23 wks or >34 wks gestation Internal medical disease, such as: severe gestational hypertension uncontrolled diabetes mellitus cardiac disease chorioamnionitis Active antepartum hemorrhage. Fetal complications: intrauterine fetal demise or non-viable condition fetal compromise (which may include fetal anomalies and/or suspected intrauterine growth restriction)