Please enable JavaScript.

Coggle requires JavaScript to display documents.

Preterm birth (Background (Preterm birth: delivery between Fetal viability…

- - - - :arrow_up: uterine contractility (UC)
      - Cervical ripening/Cervical dilatation
      - Membrane rupture/activation
    - - :heavy_plus_sign: Ca2+ → :heavy_plus_sign: Myometrium contractions
  - - - :star: Spontaneous preterm
        
        Preterm labour
        
        PPROM
        
        Multi-fetal gestations
      - Indicated preterm
        
        Pre-eclampsia
        
        IUGR
    - - :<3: Maternal
        
        Infection
        
        Extrauterine
        
        Systemic or Localized
        
        Bacteremia
        
        Periodontitis
        
        Asymptomatic bacteriuria
        
        Uncertained pathoPSO
        
        Chorioamnionitis
        
        etio of pathogen
        
        Polymicrobial
        
        M/C pathogen
        
        Ureaplasma urealyticum
        
        Gardenerella vaginalis
        
        Bacteroides species
        
        Mycoplasma hominis
        
        Streptococcus group B
        
        Escherchia coli
        
        Mostly subclinical infection
        
        20% Clinical chorioamnionitis
        
        Cervical disorders
        
        Congenital
        
        Hypoplastic cervix
        
        DES exposure in utero
        
        Surgical
        
        Conization
        
        Cold knife conization & LEEP
      - :blue_heart: Fetal
        
        Fetal demise, IUGR
        
        Uteroplacental insufficiency (UPI)
        
        Maternal medical conditions
        
        Lupus, HT, Thyroid ds
        
        Fetal infection
        
        Polyhydramnios, Multifetal pregnancy
        
        Uterine distention (will stimulate ก.แข็งตัว)
      - :yellow_heart: Placenta
        
        Placenta abruption
        
        Types
        
        Revealed abruption
        
        Concealed abruption
        
        Placenta previa
- - - - Antenatal corticosteroids
        
        :cookie: Most beneficial intervention for neonatal outcomes improvement
        
        I/C :check:
        
        Single course: GA 23 - 34 wks
        
        Repeated course (Rescue)
        
        7 days after 1st course
        
        Pt remain at risk of preterm birth before 34 wks
        
        Caution :warning:
        
        Women with systemic infections (TB, sepsis)
        
        Possible chorioamnionitis
        
        Multiple courses of steroids
        
        Growth delay
        
        Brain developmental delay
        
        :ballot_box_with_check: Drugs of choice
        
        Dexamethasone 6 mg IM q 12 hrs x 4 doses
        
        Betamethasone 12 mg IM q 24 hrs x 2 doses
        
        Administrations
        
        1st dose should be given even if ability to give 2nd dose is unlikely
        
        No additional benefit for shorter interval steroids
    - - I/C :check:
        
        Delay delivery provided benefit to newborn
        
        Viable preterm labor < 34 wks
        
        Before viable GA
      - :star2: C/I :red_cross:
        
        Intrauterine fetal demise
        
        Lethal fetal anomaly
        
        Non-reassuring fetal status
        
        Severe preeclampsia or eclampsia
        
        Maternal bleeding c hemodynamic instability
        
        Chorioamnionitis
        
        PPROM
        
        Maternal C/I to tocolysis (agent specific)
      - :ballot_box_with_check: Drugs of choice
        
        1st line Rx
        
        :tada:CCBs
        
        Mech
        
        :heavy_minus_sign: voltage dependent channels of Ca
        
        :arrow_down: intracellular Ca
        
        C/I :red_cross:
        
        Hypotension
        
        Pre-load dependent cardiac lesions (aortic insufficiency)
        
        SEs
        
        Maternal
        
        Dizziness
        
        Flushing
        
        Suppression of HR, cardiac contractility
        
        Fetal (no known SEs)
        
        Drug names
        
        Nifedipine (Adalat)
        
        1st dose: 20 mg po q 30 mins x II doses
        
        Maintenance: 20 - 40 mg q 6 hrs
        
        Max dose = 160 mg/day
        
        :tada: NSAIDs
        
        Mech
        
        COX inhibitors
        
        :arrow_down: PG level
        
        C/I :red_cross:
        
        Plt dysfunc
        
        Bleeding disorder
        
        GI ulcerative ds
        
        Asthma
        
        SEs
        
        Maternal
        
        N/V
        
        Gastritis, GERD
        
        Fetal
        
        DA constriction
        
        Oligohydramnios
        
        Patent DA/NEC in preterm
        
        Drug names
        
        Indomethacin (Indocid)
        
        1st dose: 50 - 100 mg po
        
        Maintenance: 25 - 50 mg q 6 hrs
        
        Max dose = 200 mg/day
        
        *ห้ามใช้เกิน 48 hrs
        
        :tada: Beta-adrenergic receptor agonist
        
        Mech
        
        rela sm ms of myometrium
        
        C/I :red_cross:
        
        Tachycardia sensitive cardiac ds
        
        Poor controlled DM
        
        Hyperthyroidism
        
        SEs
        
        Maternal
        
        Tachycardia
        
        HypoK, Hyperglycemia
        
        Pulmonary edema
        
        Fetal
        
        Fetal tachycardia
        
        Drug names
        
        :star: Terbutaline (Bricanyl)
        
        Oral drug should not be used in preterm labor
        
        :warning: US FDA warning
        
        Monitor
        
        3 more items...
        
        Routes
        
        2 more items...
        
        Ritrodine
        
        Others
        
        :tada: MgSO4
        
        I/C :check:
        
        Inhibit labor (up to 48 hr)
        
        :blue_book: Neuroprotection
        
        Indicated in GA < 32 wks
        
        :arrow_down: severity and risk of cerebral palsy
        
        not well understood mechanism
        
        Seizures prevention in preeclampsia/eclampsia
        
        *ห้ามใช้เกิน 48 hrs
        
        Oxytocin receptor antagonist
        
        NO NEED to prophylatic tocolysis in premature UC and NO NEED to maintenance therapy after acute therapy
    - - Role of ATBs in preterm
        
        GBS prophylaxis
        
        GBS carrier
        
        Intrapartum prophylaxis in preterm labor
        
        ATBs for prolonged latency
        
        PPROM
- - - - Smoking
      - Illicit drug use
      - Poor weight gain
    - - interval < 18 or > 59 months
    - - UTI
      - genital tract infection
      - periodontal ds
    - - Major risk factor for preterm labor
  - - - TVUS (transvaginal ultrasonography) for Cervical length measurements
  - - - I/C:
        
        Short cervix < 2.5 cm
        
        Hx of preterm birth < 34 wks
      - Types of Cerclage: McDonald, Shirodka
    - - Purpose: to maintain uterine quiescence regardless of cervical lenght
      - When to start? @ 16 - 24 weeks
      - :star::star:Compounds
        
        17α-hydroxyprogesterone caproate 250 mg IM weekly (Protulon®)
        
        Micronized progesterone vg (สอด) daily : Tablet/Gel (Utrogestan®)
    - - Open-label randomization in 385 woman with short cervix < 2.5 cm found that rate of spontaneous delivery at < 34 wks of gestation was significantly lower in pessary group
- - - - Regular UC
        
        4 UC in 20 mins or
        
        8 UC in 60 mins
      - Cx dilatation ≥ 1 cm
      - Cx effacement ≥ 80% effacement
  - - - if < 2 mm: มีโอกาสจะเกิด preterm ในอนาคตได้