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FOGSI FOCUS PTL-Final Editors : President: Jaideep Malhotra Dr. Rishma Dhillon Pai Narendra Malhotra Contributors Preface Dr. Asha Reddy Dr. Ruchika Garg, Assistant Professor obs. & gynae, Dr. Apoorva Pallam Reddy, SN Medical College, Agra Consultant Preterm Labour is one of the 5 ‘P’ problem of pregnancy. Dr. Rajalaxmi Walavalkar, Dr. Anuradha Khar, Senior consultant, Cocoon fertility centre, Despite of understanding the problem, the prevalence is static Director, nurture IVF, Bangalore Thane even in developed countries. Dr. Arshi Iqbal, Dr. Raju Sahetya, Director Arshi fertility, Kota, Consultant obs. and gynae, Hinduja The problem of being born to soon is more in babies born Rajasthan Hospital, Mumbai before 33 weeks gestation and babies born in developing countries with low resource settings. Dr. Chaitanya Ganapule, Dr. Rakhi Singh, Pearl IVF, Pune Director Abalone clinic and IVF centre, Noida This multiauthored FOGSI focus is a comprehensive Dr. Kavita N Singh, collection of all aspects of Preterm Labour. The authors have Associate Professor, NSCB Medical Dr. Shalini Chauhan, done a great job in rehearsing each topic and compiling College, Jabalpur Assistant Professor, PGI Tanda relevant information which will be useful to the practising Dr. Kavitha Gautam, Dr. Seema Pandey, obstetrician. Director Bloom fertility, Chennai Director Seema Hospital and Eva fertility centre, Azamgarh Dr. Neema Acharya, We hope all FOGSIANS will benefit from this manuscript. Professor, DMIMS DU, Wardha Dr. Swati Upadhyay, SR KIMS, Trivendrum Dr. Niharika Malhotra Happy Reading Dr. Uma Pandey, Dr. Parul Mittal, specialist obs. & gynae, Professor obs. & gynae, IMS BHU, Aster D.M. Healthcare, Dubai, UAE Varanasi Jaideep Malhotra, Narendra Malhotra Dr. Paresh K Solanki Dr. Vimee Bindra, Consultant Apollo Hospital, Hyderabad Editors : Prof Jaideep Malhotra Prof Narendra Malhotra MD, FICMH, FICOG, FICS, FMAS, FRCOG, FRCPI MD, FICMCH, FICOG, FICS, FMAS, FRCOG, AFIAPM President Elect FOGSI -2018 Vice President World Association Perinatal Region Director Ian Donald School Medicine President I.S.P.A.T 5 Index Epidemiology of preterm labour- Where do we stand? 1 1 Dr.Seema Pandey 2 Causative factors- how much do we know 3 2.1 Etiopathogenesis of preterm labour. Dr. Asha Reddy 3 2.2 Infection and preterm labour. Dr. Arshi Iqbal 5 2.3 Anatomical factors in preterm labour. Dr.Vimee Bindra Basu 7 2.4 Medical and systemic disorders in preterm labour. Dr. Chaitanya Ganapule 8 2.5 Multiple pregnancies and preterm labour. Dr. Kavitha Gautam 9 2.6 ART and preterm labour. Dr. Seema Pandey 13 2.7 Iatrogenic causes of preterm labour. Dr. Raja laxmi walavalkar 15 3 How sharp are our diagnostic tools? 18 3.1 Predictors of preterm birth. Dr. Raju Sahetya 18 3.2 Biophysical markers and USG in predicting preterm labour. Dr. Selvapriya 21 3.3 Role of biochemical markers as diagnostic tools. Dr. Ruchika Garg 24 4 Management- where are we today? 27 4.1 Can we prevent preterm labour? Dr. Anuradha Khar 27 4.2 Tocolysis and preterm labour. Dr. Neema Acharya 30 4.3 Atosiban and preterm labour. Dr. Niharika Malhotra 33 4.4 Role of antibiotics in preterm labour. Dr. Paresh kr. Solanki 36 4.5 Progesterone in preterm labour. Dr. Seema Pandey 38 4.6 Steroids in preterm labour. Dr. Apoorva Pallam 41 4.7 Surgical management of preterm labour. Dr. Vimmi Bindra 48 4.8 LSCS in preterm labour. Dr. Uma Pandey 51 4.9 Intrapartum management of preterm labour. Dr. Kavita N Aggarwal 54 4.10 Twin gestation & preterm birth. 57 5 Miscellanious 61 5.1 Premature rupture of membrane and preterm labour. Dr. Rakhi Singh 61 5.2 Precipitous labour. Dr. Shalini Chauhan 64 5.3 Various guidelines in preterm labour. Dr. Parul Aggarwal 65 5.4 Managing a preterm neonate. Dr. Swati Upadhyay 68 6 Acknowledgment 73 FOGSI FOCUS Prevention of Pre-Term Labour • There are ethnic variations in preterm birth rates and it is higher in black population. This could be associated Epidemiology of preterm labour with an accelerated rate of maturity in black fetus and 1 neonate. Surprisingly the gestation specific mortality Dr. Seema Pandey, MD, FICOG rate is lower in these neonates who are born before 38 completed weeks. • 45-50% preterm deliveries are idiopathic, followed by PROM in 30% and 15-20% are medically indicated planned preterm deliveries, • Iatrogenic preterm delivery is the main cause in 40-50% ldiopathic 30% PROM developed countries. These births take place between 28 to 35 weeks mostly due to hypertension and pre- 15-20% Medically Indicated Out of all the anthropoid species the human neonate is countries. The prevalence has been static in developed eclampsia. born much more immature, perhaps its nature's countries for decades and is in the range of 5-10%. mechanism to avoid the large head of the human fetus • The commonest etiological factor worldwide is • 28% of total early neonatal deaths (death within 7 days) Figure 2- Major causes of PTL from becoming impacted in small pelvis of the mother infection, mainly due to Malaria and HIV. are due to preterm birth. who has adopted to a bipedal gate. Spontaneous Iatrogenic • Other responsible factors are, multiple pregnancies, • The children who survive, there are major financial intra-uterine growth retardation (IUGR), maternal burdens due to the morbidity associated with physical Infection Hypertension stress and intense physical labor. and psychological issues. Definition: PROM Diabetes • The main challenge is finding ways to distinguish and • Though the incidence of preterm birth is on the rise but quantify very early, early and late pre-term births, which as per world health organization (WHO) and federation of events leading to this are not clear and well understood. Intra uterine growth will decide the terms of survival, short and long term international gynecologist and obstetricians (FIGO) Idiopathic contractions Etiology is thought to be multifactorial, whether these retardation (IUGR) Spontaneous preterm labor is “labor resulting in birth morbidity and health resources investments. factors play independently or work in unison is still not before 37 completed weeks (259 days) of gestational age, clear. Multiple pregnancies • Categorization of pre-term birth (spontaneous vs based on the first day of last menstrual period.” iatrogenic) is important as this will show the true global Cervical dysfunction • This definition has no functional basis and must not be trend of PTL and at the same time it will help in confused with prematurity, which is the lack of Factors leading to increased PTL making policies and interventions to reduce the risk of Antepartum hemorrhage development of various organ systems (especially lungs preterm labor and deliveries. leading to respiratory distress syndrome) at the time of Stress birth. • The concept of completed weeks should not be Malnutrition References: misunderstood while truncating it to a round of form of weeks. For example a woman with 36 weeks plus 6 days 1. Stacy Beck, Daniel Wojdyla, Lale Say, Ana Piler Betran, Mario Marialdi, Jennifer Harrisrequejo, Craig Rubens, Ram Kumar Menon, Paul Fu Vonlook, would be considered as 36 completed weeks and not 37. The worldwide incidence of preterm birth: A systemic review of maternal Due to this error up to 10% of preterm babies are mis- mortality and morbidity. Bull World Health Organ;88(1) Genebra Jan 2010. classified. 2. P. Steer, faculty of medicine, Imperial college London • The main concern and burden comes from those who are born before 33 weeks (90%) Medical condition of mother and fetus genetic influences environmental exposure infertility treatment behavioral and socioeconomic factors iatrogenic Epidemiology: Figure 1- Major categories of Preterm labor • The burden of pre-term labor is much more in developing countries like India. • There are no accurate recent world wide data regarding the prevalence of preterm labor, but estimate ranges from 5% in developed countries to 25% in third world 1 2 FOGSI FOCUS Prevention of Pre-Term Labour Etiology and Mechanisms of Preterm Labor 1) Maternal-fetal HPA activation Stress Maternal-fetal HPA activation 2 Causative factors - how much do we know 2) Infection and inflammation Intrauterine Lower genital tract Proinflammatory cytokine and prostaglandin cascade Systemic Matrix metalloproteinases 2.1 Etio-pathogenesis of preterm labor 3) Decidual hemorrhage Thrombophilias, Abruptio placentae Thrombin Autoantibody syndromes Matrix metalloproteinases Dr Asha Reddy 4) Pathologic uterine Multifetal gestation Expression of gap junctions proteins overdistension Polyhydramnios Prostaglandins Oxytocin receptors Causes of preterm labor are multifactorial and vary HPA activation plays a role. Similarly, whether they are according to gestational age. Each pathway to preterm related to infection, uterine overdistension, or PPROM, labor has its specific initiators. Most of these pathways MMPs play a role. As a final point, myometrial The pathophysiology of preterm birth is multifactorial, 4) Maternal smoking during pregnancy, eventually share uniform effectors of preterm labor. For contractility is initiated by prostaglandins; regardless of the very complex and not clearly understood. Several genetic, 5) Advanced maternal age, example, whether it is related to stress or infection, fetal initiating cause. physiological and environmental factors are associated with preterm birth and contribute to uterine activation, 6) Sub-optimal weight gain during pregnancy, labor and birth. In the recent years increasing assisted 7) Maternal stress reproduction techniques, increasing
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