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Preterm delivery Prom Cervical insufficiency (PROM / PPROM (MANAGEMENT…
Preterm delivery
Prom
Cervical insufficiency
Intrauterine infection
Clinical symptoms
fetal tachycardia
maternal tachycardia
maternal body temperature >38°c
uterine pain
uterine contractions
smelly vaginal discharge
laboratory symptoms
leukocytosis
presence of leukocytes in amniotic fluid
positive result of amniotic fluid culture
progressive increase in CRP and procalcytonin concentration
PRETERM DELIVERY
delivery between 22 and 37 weeks of pregnancy
Patomechanism
idiopathic (most common)
infection and inflammation,
intrauterine bleeding,
Uterine muscle ischemia,
Stress and activation of materno-fetal
complications
Early
respiratory distress syndrome (RDS)
intraventricular hemorrhage (IVH)
persistent ductus arteriosus (PDA)
sepsis
necrotizing enterocolitis (NEC)
Late
visual and hearing impairment
mental reatrdation
cerebral palsy
RISK FACTORS
2/3 Organic
1/3 Psychosomatic
MATERNAL
history of preterm delivery or miscarriage
age <17 or >35
underweight or overweight
stimulants, drugs
infections, chronic maternal diseases
metabolic disorders , malformations of the uterus , stress
vaginal bleeding
work overload
low socio-economic status
low educational level
FETAL
fetal malformations
multiple pregnancy
polihydramnios (excessive stretching of the uterine muscle)
IUGR
infections
onset
! gestational age 22-37 weeks
! regular uterine contractions (4 per 20 min or 8 per 60 min)
! > 2 cm cervical dilation and/or 80% cervical shortening or documented cervical changes
Management of preterm uterine contractions
tocolysis
ß –mimetics
calcium channel blockers
prostaglandin inhibitors
progesterone
methylxanthine derivatives (diprophyllinum)
oxytocin antagonists (Atosiban)
NO donors (nitroglycerin – patches)
potassium channel openers (a subject of research)
spasmolytic agents (drotaverin)
sedatives (diazepam)
magnesium sulfate
Contraindications
Absolute
Placental abruptio
Intrauterine infection
Eclampsia
Lethal fetal malformation
Fetal demise
Relative
Vaginal bleeding,
IUGR
Preeclampsia
Fetal distress
Side-effects
Nausea, vomiting, Headache, Ddyspnea,
Tachycardia, transient hypotensia, Lung edema, Heart attack, Hyperglicemia
stimulation of fetal lung maturation
treatment of infections(antibiotic therapy)
neuroprotection
Early treatment increases chances for pregnancy prolongation.
Corticosteroids
Indications
threatening preterm delivery
preterm premature rupturę of membranes
vaginal bleeding before delivery
Other siturations requiring preterm delivery
Administered between 24-34 weeks after excluding intrauterine infection
stimulation of lung maturation
neuroprotection
The most frequently used are Betamethasone and Dexamethasone
decrease Neonatal mortality, NEC, PDA, Intracranial hemorrhage
Magnesium sulfate
Neuroprotection
Slight tocolytic effect
PROM / PPROM
PREMATURE RUPTURE OF MEMBRANES: rupture of all 3 layers of membranes before the onset of uterine contractions (Before 37 weeks)
Diagnosis
Gynecological examination in specula
Vaginal pH
The amniotic fluid crystallization test
Microscopic examination of amniotic fluid sediment
Immunochromatographic tests (AMNIOQUICK test)
Obstetrical risk factors
MATERNAL
multiparity
maternal age >35
cervical insufficiency
uterine defects
history of PROM
placenta previa
more than one episode of uterine dilation and curettage
FETAL
malformations
structural abnormalities of membranes
polyhydramnios
Environmental risk factors
Low socioeconomic status
Smoking
Nutritional deficiencies: vitamin C, copper, zinc
Inappropriate working conditions
Infections
Streptococcus agalactiae, viridans, pneumoniae, Escherichia coli
Mycoplasma hominis, Ureaplasma urealiticum, Candida albicans, bacterial vaginosis
MANAGEMENT
Expectant
ACTIVE
tocolysis
corticosteroids
antibiotics
spasmolytics
PASSIVE
antibiotics
Active
IMMEDIATE LABOR INDUCTION
Factors determining the way of clinical management
Attitude of a pregnant woman
Fetal status, Fetal maturity
Gestational age, Obstetrical status
Indicators of infection
General medical history
Obstetrical history
Family history
Neonatal ward
Possibility of in utero transfer
Term pregnancy
expectant management
monitoring of the fetus
exclusion of infection with group B streptococci
antibiotic prophylaxis
assessment of the cervix
induction of labor in the cases of: fetal asphyxia, infection risk, ripe uterine cervix
active management
induction of labor – after 6-12 hours of expectant treatment (PTG)
antibiotic prophylaxis – after 6 hours
34 - 36 weeks
assessment of fetal risk
assessment of infection risk
AFI
fetal lung maturity
antibiotic prophylaxis
corticosteroids – not recommended
24 - 34 weeks
assessment of fetal risk
assessment of infection risk
AFI
fetal lungs maturity
antibiotic prophylaxis
corticosteroid therapy
tocolysis
MgSO4 before 32 weeks of pregnancy
LONG-TERM COMPLICATIONS OF PPROM < 37 WEEKS
developmental delay : motor, mental
cerebral palsy chronic
pulmonary diseases
vision disorders
hearing disorders
permanent deformations
Cervical incompetence
inability of the uterine cervix to retain pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester
aetiology
congenital, iatrogenic (cervical injury), hormonal , biochemical
Diagnosis
vaginal examination – evaluation of consistency of the uterine cervix
ultrasound examination (funnel symptom)
elastographical examination
treatment
cervical cerclage – reinforces the cervical tissue by placing sutures above the opening of the cervix to close the cervical canal
cervical pessary – silicon ring, an alternative to cervical cerclage