Management of preterm labour

1
Management of preterm labour

• Session 4 Chairman
• Professor Luis Cabero Roura
• Hospital Materno-Infantil Valle Hebron,
  Barcelona, Spain

1st International Preterm Labour Congress,
Montreux, Switzerland, June 2002
2
Issues in the management of preterm labour

• Dr Helen McNamara
• Womens Pavilion Royal Victoria Hospital,
  Montreal, Quebec, Canada

1st International Preterm Labour Congress,
Montreux, Switzerland, June 2002
3
Issues and challengesclinical issues (1)

• A. Definition issues
• - 3437 weeks?
• - 2224 weeks?
• B. Diagnosis issues
• - true vs false labour? continuum? -
  cervical length and fetal fibronectin?
• - use of term idiopathic?

Helen McNamara
4
Issues and challengesclinical issues (2)

• C. Aetiology issues
• - current research?
• - genetic and infection components?
• - roles of other components?
• - aetiology directed management?
• D. Treatment issues
• - specificity of treatment?
• - combination treatment?
• - record treatment outcomes?

Helen McNamara
5
Issues and challengesresearch Issues

• A. Definition of outcome variable
• ( preterm labour vs preterm birth)
• B. Definition of exposure variable
• ? cause, ? spontaneous preterm labour
• C. Definition of population
• D. Combined research basic and clinical (MOD)

Helen McNamara
6
Challenges in managementante-partum (selected)

• 1. Limit of viability
• 2. Emergency cervical cerclage
• 3. Maternal transport
• 4. Management 3237 weeks
• 5. Inpatient vs outpatient
• 6. Psychosocial therapy

Helen McNamara
7
Challenges in managementintra-partum

• 1. Mode of delivery
• 2. Neonatal care
• 3. Cord blood (CRF-BP, IL-6 etc)
• 4. Placental examination

Helen McNamara
8
Challenges in managementpost-partum

• 1. Special parental consultation
• 2. Full diagnostic workup (like still birth)
• - ? Cause
• - ? Modified plan for next pregnancy
• - ? Clinical research database
• (aetiology)
• 3. Post-partum psychosocial therapy

Helen McNamara
9
The way forward

• 1. Acknowledge futility of one size fits all
  approach to preterm labour
• 2. Radical change in addressing the problem of
  preterm labour e.g. cardiovascular disease
• 3. Prevention (primary care)
• 4. Tailored individualised management e.g. how?,
  when? and why?

Helen McNamara
10
Clinical approaches to preterm labour management

• Professor James McGregor
• Cedars-Sinai Medical Centre, Tucson, USA

1st International Preterm Labour Congress,
Montreux, Switzerland, June 2002
11
Issues for the fetus labour

• Time needed for antenatal steroids to have an
  effect
• Potential for asphyxia and trauma in labour,
  especially if poorly grown
• Cord prolapse?
• Entrapment of the fetal head?
• Need for expert resuscitation and transfer to be
  available
• more risk if breech-presentation or other
  malpresentation

James McGregor
12
Issues for the fetus elective CS

• May be carried out unnecessarily early
  spontaneous labour often remits
• Difficulty in delivering the fetus abdominally
  with marked bruising if descent has begun?
• Adverse effects of anaesthesia/surgery,
  especially if prolonged, on fetal oxygenation
• Labour may protect against respiratory distress
  syndrome
• ? more risk if breech-presentation or other
  malpresentation

James McGregor
13
Issues for the mother CS-1

• Anaesthesia
• Major abdominal surgery
• Lower segment of the uterus not formed, may
  necessitate either an extension to the incision
  or a classical incision, with increased risks in
  a subsequent pregnancy
• Increased risk of haemorrhage, blood transfusion

James McGregor
14
Issues for the mother CS-2

• Higher risks of morbidity
• Thrombosis and pulmonary embolus
• Postnatal infection
• Abdominal and wound pain, wound breakdown
• Post-discharge morbidity (Glazener, Brown)
• Longer term sequelae (?) infertility, placenta
  praevia
• Lower risks of pelvic floor sequelae

James McGregor
15
Issues for the mother labour

• May still require a caesarean delivery if
  complications develop e.g. cord prolapse
• Risk of needing an assisted breech delivery or
  breech extraction
• Faster postnatal recovery
• More risk of pelvic floor sequelae (but possibly
  less than at term?)

James McGregor
16
Conclusions of the review

• A policy of elective caesarean delivery is
  associated with increased maternal morbidity and
  may occasionally lead to unnecessary delivery
  of a small baby in a pregnancy in which preterm
  labour would otherwise have stopped. Such a
  policy may be associated with important benefits
  for some babies, but this is uncertain, the size
  of any beneficial effect is unclear and we cannot
  say whether it outweighs the increased maternal
  risks.

James McGregor
17
Mode of delivery for the preterm infant

• Professor Judith Lumley
• Centre for the Study of Mothers and Childrens
  Health, Carlton, Australia

1st International Preterm Labour Congress,
Montreux, Switzerland, June 2002
18
Primary causes of preterm birth/pPROM

• Pathogenic causes (f) time, geography, care
• Infection/inflammation Bleed/clot
• Cervical Stress, early
• Uterus BMI
• Substances Short conception cycle lt 1 year
• Multiples Age lt 17 gt 35 year
• Medical causes
• a) fetal b) maternal c) mixed, d) teratogenic

Overdistention
Bleed/clot
Inf/infl
Multiples
Substances
Bad stress
Nutrition
Work/standing
Judith Lumley
19
Five things to remember

• Syndrome at preterm birth/pPROM
• Complex, interactive, multi-step, non-linear
  disease infection/inflammation
• Biology of parturition fetus, placenta, mother
• Available clinical tools
• Comprehensive evidence-based approaches
• Opportunities
• Imperatives
• Obligation

Judith Lumley
20
Syndrome vs complex diseases

• Syndrome vs complex disease vs simpler disease
• Low birthweight Maternal TNF-308 Maternal G
  with infection protein beta 3 subunit
  polymorphism
• Preterm labour/pPROM Maternal/ deciduitis/
  trophoblast/ amniochorio
• fetal inflammation due to specific
• and infection infection, bacterial
• vaginosis, sexually transmitted
  infection

Judith Lumley
21

• A coherent gene-environment approach, with
  attention to genetically susceptible populations
  who are disproportionately exposed to
  environmental reproductive hazards may provide
  further insights into the etiology of IUGR and
  preterm birth and may help identify high risk
  sub-populations for clinical or public health
  interventions.
• Wang et al. JAMA 2002 (smoking and polymorphisms)

Judith Lumley
22
Short cervix
Bad stress
Smoking
PTB/pPROM
BV, CT, TV, MN
Nutrition omega 3 6 antioxidants micronutrients
Genetic predisposition polymorphism TNF, IL-6, 1
etc (mother/baby)
Judith Lumley