Premature delivery

2021-03-21 12:00 AM

All of these drugs can only prolong pregnancy for a limited period of 2 to 7 days, which is the length of time for steroid use.

Outline

Define

According to the World Health Organization, preterm labor is a labor that occurs from week 22 to before week 37 of pregnancy starting from the first day of the last menstrual period.

Ratio

Preterm birth has rate from 5% to 15% of the total number of births.

Race: white 8.5%, black: 18.3%. (According to the World Health Organization, 1997).

The preterm birth rate in France in 1972 was 8, 2% and 1981 was 5, 6%.

At Hue Central Hospital, preterm birth rate was 7.8% (1995).

The importance to the community

Preterm birth is dangerous for newborn babies, the higher the rate of perinatal mortality the longer the gestational age becomes. In particular, premature babies are at high risk of neurological sequelae. Before 32 weeks, the rate of sequelae was 1/3. From 32-35 weeks, the rate of neurological sequelae is 1/5. From 35 to 37 weeks the rate of sequelae is 1/10.

Taking care of a preterm birth is very expensive. In addition, when growing up, the child also has mental sequelae, which is a burden for the family as well as the society.

If the mother is born prematurely, she can easily complicate vegetables and postpartum infections.

Therefore, preterm birth is one of the important problems facing physicians and society.

Reason

There is about 50% of premature birth with no known reason.

Here are some favorable reasons and factors:

Social factors 

Low socio-economic life, inadequate antenatal care.

Maternal low weight and / or poor weight gain.

Struggling during pregnancy.

Mother's age under 20 or older child over 35 years old.

Mother is addicted to tobacco, alcohol or cocaine.

By mother

The cause is due to systemic pathology:

Infectious diseases: urinary tract infections, serious infections caused by bacteria, viruses.

Injuries in pregnancy: Direct injury to the abdomen or indirectly due to abdominal surgery.

Occupation: occupations exposed to toxic chemicals, hard labor, stress.

Maternal systemic disease: heart disease, liver disease, body disease, anemia.  

Disorders of high blood due to pregnancy: Pre-eclampsia - eclampsia (9%).

 Immunity: Anti-Phospholipid antibody syndrome.

Causes in place:

Uterine congenital malformation: accounts for 5% of premature birth. If this is the case, the risk of preterm labor is 40%. Common malformations: uterus, one horn, underdeveloped uterus, uterine septum.

Acquired abnormalities in the uterus: Adhesions of the uterus, fibroids of the uterus, uterus with scarring.

Uterine hypertrophy: 100% deliver premature if untreated.

Surgical interventions in the cervix such as amputation.

Inflammation of the vagina - cervix.

History of preterm birth:

The risk of recurrence is 25 - 50%. This risk increases with many previous preterm births.

Due to pregnancy and the appendage of the fetus

Premature rupture of membranes, premature rupture of amniotic fluid: 10% of full term and 30% of premature delivery, there is a risk of infection for the fetus.

Amniocentesis.

Multiple pregnancy: 10-20% premature birth.

Polyhydramnios: the uterus is too tight, causing premature labor.

Striker: 10% of cases of premature birth because of bleeding before giving birth or ruptured amniotic fluid.

Young vegetables.

In short, in order to find out the causes of preterm birth, we have to review the whole pathology of obstetrics and gynecology, there are causes on the part of the mother, the fetus side, and the appendages of the fetus, there are combined causes.

Diagnosis of preterm birth and preterm delivery 

Threatened premature birth

Mechanical symptoms:

Abdominal pain: Women feel abdominal pain in bursts or heaviness in lower abdomen.

Vaginal discharge: This can be vaginal mucus, bleeding or amniotic fluid.

Physical symptoms:

Uterine contractions: mild, with 1-2 contractions in 10 minutes and observation time over 30 minutes.

The cervix may be long, closed, but it may also be erased and opened up to <4cm.

Premature rupture of membranes: leads to short-term labor. It is a turning point in preterm labor because it expands the amniotic chamber, increasing the risk of infection.

Subclinical:

Ultrasound: survey the length of the cervix, if less than 2.5cm, the risk of preterm birth is high.

Evaluate the pregnancy and monitor the go-bust attack by Monitoring, if there are 1-2 regular contractions in 10 minutes.

Index of threat of preterm labor is less than 6.

Also need to do tests to find the cause:

Urine germ cells.

Test for bacteria in the cervix.

If fever must pull blood to find malaria parasites, CRP, and blood transplants, depending on the case.

Consider amniocentesis to eliminate the possibility of amniocentesis.

Premature birth

Mechanical symptoms:

Abdominal pain: abdominal pain in pregnant women, the pain gradually increases.

Vaginal discharge: This can be vaginal mucus, bleeding or amniotic fluid.

Physical symptoms:

Uterine contractions: 2 - 3 uterine contractions in 10 minutes, gradually increasing.

The cervix erases more than 80%, or opens more than 2 cm, the amniotic fluid begins to form or the amniotic fluid begins to rupture prematurely.

Monitor go go by Monitoring, if there are 2-3 regular go attacks in 10 minutes.

Index of threat of preterm labor is greater than 6.

Prognosis

Based on 4 factors: contractions, changes in the cervix, ruptured amniotic fluid, vaginal bleeding and an index of risk of preterm labor has been built up.

Board. Index of the threat of preterm labor.

 

1 point

2 points

3 points

4 points

Go uterus

Erratic

All

 

 

Broken weather

 

May

 

Clearly

Bleeding

Fit

> 100ml

 

 

Open the cervix

1cm

2cm

3cm

> 4cm

Table: Probability of successful termination of labor (according to the risk of preterm labor index).

Index

1

2

3

4

6

> 7

Labor stopped (%)

100

90

84

38

7

0

Treatment 

Threatened premature birth

Commune level:

Should not treat the threat of preterm birth, switch to higher level as soon as possible.

District and specialized hospitals:

Use drugs to inhibit labor.

Studies that compare the efficacy of drugs show that no drug has a dominant advantage. All of these drugs can only prolong pregnancy for a limited period of 2-7 days, which is the length of time to use steroids and transport the mother to the health facility with the recovery room. new-born. Therefore, which drug is chosen depends on the availability of the drug and its adverse effects on the mother and fetus.

Types of beta-mimetic:

Are beta-sympathomimetic drugs.

Ritodrine. A drug that directly reduces the smooth muscles of the uterus and lungs. Mix 150mg in 500ml of isotonic saline solution.

Attack dose: Start infusion at a rate of 20ml / hour and increase to 10ml / hour every 15 minutes and increase to a maximum of 70ml / hour.

Maintenance dose: When the attack is stopped, continue to maintain for another 12 hours. 30 minutes before withdrawing the infusion line for Ritodrine every 2 hours 10 mg for 24 hours and then maintained at a dose of 20 mg / 4-6 hours until the pregnancy is 36 weeks. Stop the drug when the mother's heart rate is over 150 times / minute and the fetal heart rate is over 200 times / minute. The systolic blood pressure is over 180mmHg and the diastolic pressure is less than 40mmHg.

Maternal side effects include: increased heart rate, hyperglycemia, hyper insulinemia, hypokalemia, tremor, palpitations, restlessness, nausea, vomiting, hallucinations.

Effects on the fetus: tachycardia, hypocalcemia, hypoglycemia, hypotension, hyperbilirubinemia, ventricular hemorrhage.

Contraindicated in heart disease, hyperthyroidism, uncontrolled hypertension, severe diabetes, liver cirrhosis and chronic kidney disease. Patients over 35 years of age also have contraindications.

Terbutaline. Indications and contraindications similar to Ritodrine.

Attack dose: Initial dose 250mcg, IV infusion at a rate of 10-80 µg / min until labor stops. Then subcutaneously 0.25-0.5mg / 2-4 hours for the next 12 hours.

Maintenance dose: 5mg dose every 4-6 hours until 36 weeks pregnant. Maternal side effects: arrhythmia, pulmonary edema, myocardial anemia, hypotension, tachycardia. Effects on the fetus: tachycardia, hyperglycemia, increased blood insulin, myocardial hypertrophy, myocardial anemia.

Calcium antagonists.

Magnesium Sulfate: An alternative to sympathomimetic beta drugs in the presence of contraindications to these drugs or when drug poisoning is present.

Attack dose: 4-6g in 100ml of 5% Dextrose intravenously for 15-20 minutes.

Maintenance dose: 2g / hour IV infusion, within 12 hours, then 1g / 1 hour for 24 -48 hours. Monitor serum Mg ++ concentration maintained from 5-7mg / dL.

Maternal side effects: hot flashes, lethargy, headache, fatigue, dry mouth, respiratory depression, decreased tendon reflexes. Try a tendon reflex test to detect an overdose of the drug. Cardiac and respiratory arrest may occur if overdose. The antagonist is calcium (Calcium gluconate or calcium chloride dose 1g IV slowly).

Effects on the fetus: lethargy, decreased muscle tone, respiratory failure.

Nifedipine.

Attack dose: 20mg sublingual every 20 minutes, maximum 3 doses.

After that, when the attack has stopped, the dose of 10-20mg orally every 4-6 hours is maintained.

Contraindicated in cases of heart disease, low blood pressure (below 90 / 50mmHg). Do not use together with Magnesium sulphate. Be careful when using for people with kidney disease.

Maternal side effects: hot flashes, headache, nausea, transient hypotension. Effects on the fetus: currently no special records have been made.           

Prostaglandin synthesis inhibitor.  Indomethacin dose 25mg / 6 hours for 5 days or insert anus 100mg then take 25mg / 6 hours until 24 hours after the attack is gone. This drug has adverse effects on the fetus: ductus spasm, pulmonary hypertension, amniotic fluid, ventricular hemorrhage, necrotizing enterocolitis, and hyperbilirubinemia.

Corticosteroid use.

Helping the adult fetal lungs avoid endothelial disease, only for use in cases of less than 35 weeks of pregnancy.

Maternal corticosteroids reduce the risk of endothelial disease by 40-60% in neonates.

Betamethasone (Celestene) 2 ampoules / day or 1 ampoule / day for 2 days, or Dexamethasone (Dexaron): 12mg / day (3 ampoules) intramuscularly x 2 consecutive days. The maximum effect of corticosteroids is achieved within 24-48 hours, so try to delay labor for at least 24 hours after using this drug.

Premature birth

Commune level:

Advice and referral as soon as possible.

In case of giving birth in commune:

Newborn care according to the regimen of preterm and low birth weight newborn care.

Maternal care: monitor bleeding, control the uterus if the placenta lacks counseling, and refer higher referrals if needed.

District and specialized hospitals:

Management attitude for preterm labour is different, depending on whether the amniotic fluid remains or has ruptured, gestational age is a very important factor.

Make sure your baby is least traumatized in childbirth because preterm babies are very weak. It is easy to appoint a cesarean section for the benefit of the child if it is a buttock, fetal failure.

Bottom lane piling is acceptable as a cusp and qualifies.

After giving birth, you must control the uterus to avoid vegetables, look for uterine deformities, test bacteria (vegetables, urine and babies).

Special monitoring is required during labor and in active care room for preterm infants.

Pregnancy resuscitation and asphyxiation: Give mothers oxygen intermittently, each time 10 minutes, 3-4 times / hour, flow 6-8l / minute.

Avoid trauma to the fetus: Protect the amniotic sac until it is almost fully open or fully open. Limit your use of oxytocin. Make it easy to get pregnant by cutting the episiotomy during pregnancy.

Avoid losing heat to newborn babies, ensuring warmth for babies.

Preventive

Once risk factors have been identified, a preventive role is to attempt to eliminate the risk factors:

Do not travel far, motivate maximum rest.

Respect the 6-week prenatal leave (8 weeks if more than 3 children).

Treat any infections if present.

Stabilize maternal diseases such as fetal toxicity, diabetes, especially high-risk pregnancies.

Stitch the cervix from 12-14 weeks if there is an open waist.