This document summarizes information about preterm labor prevention and treatment. It defines preterm labor and discusses risk factors like prior preterm birth, infections, and cervical length. Interventions discussed include progesterone supplementation, treating asymptomatic bacteriuria, and cervical cerclage for short cervix. Fetal fibronectin testing and transvaginal ultrasound are presented as tools to assess preterm labor risk based on cervical length and funneling.
- The patient is a 27-year-old woman (G2P1L1) who is 40 weeks pregnant and has a previous cesarean section 2 years ago for breech presentation.
- She was admitted with oligohydramnios and underwent a prolonged latent phase of labor with delayed interventions.
- The baby was eventually delivered via emergency cesarean section with low Apgar scores and developed profound neurological disabilities.
Preterm labor is defined as labor beginning before 37 weeks of gestation. It occurs in 7-12% of pregnancies worldwide and is a major cause of neonatal mortality and morbidity. Risk factors include infections, uterine distention from multiples, short cervical length on ultrasound, prior preterm births, and short inter-pregnancy intervals. Diagnosis involves assessing cervical dilation and effacement on exam along with fetal fibronectin testing and ultrasound evaluation of the cervix. Management aims to delay delivery as long as possible to improve neonatal outcomes.
An ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, usually in the fallopian tubes. Risk factors include previous ectopic pregnancy, infections, scarring of the fallopian tubes, and fertility treatments. Ectopic pregnancies can cause life-threatening bleeding if not treated properly. Diagnosis involves beta-hCG levels and ultrasound imaging. Treatment options include medication with methotrexate, expectant management with close monitoring, or surgery depending on the stability of the patient and characteristics of the ectopic pregnancy.
Preterm labour is defined as onset of labour between the gestation of viability (24 weeks) and 37 completed weeks. The majority of preterm births occur between 32-37 weeks (late preterm). Risk factors include low socioeconomic status, maternal age, smoking, infection and previous preterm birth history. Screening methods include cervical length screening by ultrasound and fetal fibronectin testing. Management includes progesterone supplementation for women with a short cervix, cervical cerclage for those with a history of prior preterm birth, and corticosteroid administration to accelerate fetal lung maturity. While tocolytic drugs may temporarily stop contractions, there is no evidence they improve neonatal outcomes.
This document provides guidelines for managing pregnancies of unknown location (PUL). It states that women with a PUL could have an ectopic pregnancy until the location is determined. Serum hCG measurements should only be used to assess trophoblastic proliferation and help determine management, not to determine pregnancy location. Clinical symptoms are more important than hCG levels, and women should be monitored if symptoms change. The guidelines provide recommendations for next steps based on whether hCG levels increase or decrease more than 63% or 50% over 48 hours. Ultrasound or clinical review is recommended in certain scenarios to identify pregnancy location. Progesterone measurements should not be used to diagnose pregnancy type when using serial hCG tests to manage a PUL.
This document discusses various abnormal fetal heart rate patterns seen on a cardiotocography (CTG) tracing during labor and delivery. It describes fetal tachycardia as a heart rate over 160 bpm and potential causes like infection or drugs. Fetal bradycardia below 120 bpm is ominous and can be caused by hypoxia. Early decelerations occur with contractions and recover after, while late decelerations begin with contractions but recover slowly, indicating hypoxia. Variable decelerations can be caused by cord compression. Reduced variability may indicate fetal sleep, acidosis, or drugs. Management depends on whether the CTG is reassuring or pathological, with pathological cases requiring specialist evaluation and potential urgent delivery.
This document defines and describes multiple pregnancies, including twins, triplets, and higher order multiples. It discusses the types of twin pregnancies as either monozygotic (identical) or dizygotic (fraternal) twins. Diagnosis and determination of chorionicity and zygosity are important for management. Multiple pregnancies face higher risks and require increased prenatal care and surveillance due to concerns like preterm birth and discordant growth. Vaginal delivery of multiples follows certain guidelines, while C-section may be recommended depending on presentation.
Uterine inversion occurs when the uterus turns inside out, most commonly during the third stage of labor. It has an incidence of 1 in 2000 deliveries. The main causes are mismanagement of the third stage through excessive cord traction or fundal pressure. Uterine inversion can be first, second, or third degree depending on how far the inversion has progressed. Clinical presentation includes abdominal pain, postpartum hemorrhage, and shock. Management involves prompt recognition and replacement of the inverted uterus manually or through hydrostatic replacement, with tocolytics as needed. Prevention focuses on controlled cord traction and avoiding fundal pressure before signs of placental separation.
1) The use of tocolytic drugs is associated with prolonging pregnancy up to 7 days but does not significantly impact preterm birth rates or neonatal outcomes.
2) Tocolysis should only be considered if delaying birth will allow for completing a course of corticosteroids or in utero transfer to another hospital.
3) Nifedipine and atosiban are effective tocolytic options, with fewer maternal side effects than beta-agonists, though long-term neonatal outcomes remain unclear for all tocolytic drugs.
Preterm labor is defined as the onset of labor before 37 weeks of gestation. It can be spontaneous or medically indicated and accounts for a majority of neonatal deaths and disabilities. Risk factors include multiple pregnancies, infections, cervical insufficiency, and genetic factors. Management involves tocolytic drugs to delay labor, corticosteroids to improve neonatal outcomes, and careful fetal monitoring during labor. Prematurity and its complications remain a major challenge in obstetrics.
Keith Moore Said "It has been a great pleasure for me to help clarify statements in the Qur'an about human development. It is clear to me that these statements must have come to Muhammad from God, or Allah, because most of this knowledge was not discovered until many centuries later. This proves to me that Muhammad must have been a messenger of God, or Allah."
This document discusses preterm birth and preterm premature rupture of membranes (PPROM). It defines preterm birth as delivery before 37 weeks of gestation and notes that the rate of spontaneous preterm births is decreasing while induced preterm births are rising. PPROM is defined as rupture of membranes before 37 weeks, and risk factors, diagnosis, and management approaches are outlined. Expectant management is generally recommended for PPROM between 24-34 weeks to balance infection and prematurity risks.
This document discusses postterm pregnancy, defined as any pregnancy exceeding 42 weeks. The incidence is 3-10% and increases with a history of prolonged pregnancy. Dates may be unreliable if last menstrual period is uncertain or contraception was recently used. Causes include incorrect dates, hereditary factors, and maternal or fetal issues. Diagnosis involves menstrual history, weight changes, ultrasound, and biophysical profile testing. Risks to the baby include meconium aspiration, respiratory distress, and hypoglycemia. Management involves antenatal testing starting at 41-42 weeks and potential induction of labor to reduce complications.
Venous thromboembolism is a major cause of maternal mortality. Pregnancy increases the risk of deep vein thrombosis due to physiological changes that cause venous stasis and a hypercoagulable state. The risk is highest in the antenatal period and after cesarean delivery. Diagnosis involves Doppler ultrasound or CT scan and treatment involves low molecular weight heparin for at least 6 weeks. Prevention through thromboprophylaxis is recommended for women with prior VTE or thrombophilia.
This document summarizes guidelines on the use of antenatal corticosteroids. It states that a single course of antenatal corticosteroids between 24-34 weeks of gestation significantly reduces neonatal death, respiratory distress syndrome, and intraventricular hemorrhage, with no known benefits or harms for the mother. It provides guidance on appropriate patients, timing, dosage, and considerations for particular clinical contexts. Repeating courses weekly is not recommended due to potential effects on growth, though a second course may be considered in limited circumstances.
MANAGEMENT OF ACUTE UTERINE INVERSION BY DR SHASHWAT JANIDR SHASHWAT JANI
1) Acute uterine inversion occurs within 24 hours of delivery when the uterus turns inside out, often due to fundal placenta insertion and uterine atony.
2) Immediate manual replacement of the inverted uterus without anesthesia has the highest chance of success and should be attempted promptly.
3) If manual replacement fails or the patient presents later, general anesthesia and tocolytic agents like nitroglycerin are administered to relax the uterus before again attempting manual replacement while controlling hemorrhage. Prompt treatment is critical to prevent complications like shock.
Cervical cerclage is a surgical procedure where stitches are placed around the cervix to help prevent preterm birth. There are different types of cerclage indicated for various high-risk situations like previous preterm births, cervical insufficiency, or short cervix found on ultrasound. Cerclage can be placed transvaginally or transabdominally depending on the situation. Risks include infection or early rupture of membranes, but cerclage has been shown to delay delivery by 5 weeks on average in rescue situations. The cerclage is usually removed between 36-37 weeks to allow for normal vaginal delivery. Cervical pessaries are a non-surgical alternative that can also help support the
1) Placenta accreta spectrum disorders occur when the placenta invades and is inseparable from the uterine wall, posing risks of heavy bleeding. The incidence has increased 10-fold in recent decades due to rising c-sections.
2) Risk factors include placenta previa, prior c-sections, and other uterine surgeries. Early diagnosis using ultrasound and MRI is important for management planning.
3) Management involves a multidisciplinary approach, with the goal of minimizing blood loss through techniques like arterial embolization and hysterectomy if needed. Conservative management is sometimes attempted but carries risks if failed.
This document summarizes evidence on the use of antenatal corticosteroids (ACS) to improve outcomes for preterm infants. It finds that a single course of betamethasone or dexamethasone between 23-34 weeks reduces rates of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and mortality. Multiple courses increase risks of fetal growth restriction. Benefits are seen 1-7 days after treatment. ACS is now recommended for women at risk of preterm birth from 24-34 weeks to improve neonatal outcomes.
This document discusses the history and risks/benefits of vaginal birth after cesarean (VBAC) versus elective repeat cesarean section. It notes that while VBAC was originally encouraged due to risks of multiple c-sections, safety concerns led to declining VBAC rates. VBAC carries risks of uterine rupture but reduces risks of respiratory issues compared to repeat c-section. Proper patient selection and access to emergency c-section are important to support a planned VBAC attempt. The risks and benefits should be discussed thoroughly to help each woman make an informed decision.
This document provides information from a lecture on preterm birth and its modern management. It begins with polling questions on topics like the percentage of preterm births in the US and trends over time. It then defines preterm birth and its subdivisions. It discusses risks of prematurity like infant death and long-term complications. It notes that since 2006, the US preterm birth rate has dropped for the sixth consecutive year. However, the US rate remains the highest among industrialized nations. The document explores factors that may be contributing to the decline in preterm births and reviews evidence on the effects of prenatal care. It also examines current understanding of the pathology underlying preterm labor and discusses progesterone and 17-alpha hydroxyprogesterone cap
This document discusses preterm labor, including a case study. It defines preterm labor as occurring between 24-37 weeks gestation. Epidemiology shows that 12% of deliveries are preterm. Risk factors include previous preterm birth, infections, and smoking. Diagnosis involves assessing contractions and cervical changes. Complications of prematurity include respiratory distress and intraventricular hemorrhage. Management goals are to delay delivery for steroid administration and transport to facilities with NICU capabilities using tocolysis like nifedipine. Prevention strategies have not proven consistently effective.
1. Cervical length measured by transvaginal ultrasound can predict preterm birth, with a length under 25mm indicating higher risk.
2. For women at high risk of preterm birth due to prior preterm births or cervical procedures, regular cervical length screenings from 16-24 weeks and interventions for those under 25mm can help prevent preterm birth.
3. Cervical length is also a useful predictor for twin and triplet pregnancies, though the accuracy varies more than for single pregnancies. Interventions like cerclage or progesterone may help for women with short cervical lengths.
Screening for and treatment of asymptomatic bacteriuria in high-risk pregnant women reduces the risk of preterm birth. However, routine screening of all pregnant women in the first trimester with urine culture is not currently recommended due to the low prevalence of asymptomatic bacteriuria in the general pregnant population and the costs of universal screening.
The document discusses preterm birth rates in the United States, risks of preterm birth for infants, and potential causes and predictors of preterm birth. It also reviews various interventions for preventing preterm birth, including cervical cerclage, tocolytic medications, progesterone supplementation, and cervical length screening.
1) Recent research has found that fetal fibronectin testing and ultrasound assessment of cervical length can help predict preterm birth in symptomatic women, though fetal fibronectin may have limited accuracy within 7 days.
2) Nifedipine and atosiban appear to be effective tocolytic options with fewer side effects than alternatives like ritodrine and indomethacin. Tocolysis is generally not continued past 48 hours except in special cases.
3) Antenatal corticosteroids between 24-34 weeks can help reduce fetal morbidity from preterm birth. Routine antibiotics without ruptured membranes do not prolong pregnancy or improve neonatal outcomes. Bed rest does not lower preterm
Dr. Kirtan Vyas is an assistant professor who has numerous qualifications and accomplishments. He has published in international journals, presented at conferences, and held various organizational roles. The document discusses preterm labor (PTL), defining it as labor before 37 weeks of pregnancy. It outlines the significance and risk factors of PTL and describes the initial evaluation, management, and potential neonatal complications of PTL. Evaluation includes examination, ultrasound, and biochemical markers to assess the status of the cervix and predict the likelihood of preterm delivery."
This document discusses preterm labour, including definitions, incidence, risk factors, causes, prevention, diagnosis, and treatment. It causes can include activation of the HPA axis, inflammation, decidual hemorrhage, and uterine overdistention. Treatments include tocolytics like beta-mimetics and calcium channel blockers, antibiotics, cervical cerclage, progesterone, and antenatal steroids.
This document discusses preterm labour, including definitions, incidence, risk factors, causes, diagnosis, prevention, treatment, and management. Some key points:
- Preterm labour is defined as labour beginning before 37 weeks of gestation and is a leading cause of infant mortality.
- Risk factors include stress, smoking, infections, cervical factors, multiple gestation, and decidual hemorrhage. Causes include activation of the HPA axis, inflammation, uterine overdistention, and cervical insufficiency.
- Prevention strategies with some evidence include progesterone supplementation, smoking cessation, cervical cerclage, and early treatment of infections.
- Tocolytics like beta-agonists and calcium channel blockers
This document summarizes evidence on the use of progesterone to prevent preterm birth. It finds that progesterone reduces the risk of preterm birth before 37 weeks in women with a prior preterm delivery or short cervix. Progesterone may also reduce complications for infants born preterm to mothers receiving it. However, progesterone does not prevent early preterm birth in twin or triplet pregnancies. No long-term harms were seen in children exposed to progesterone prenatally.
This document summarizes research on the role of progesterone in various obstetric contexts. It finds that progesterone supplementation reduces the risk of miscarriage in women with recurrent miscarriages. It also reduces the risk of preterm birth in women with a prior spontaneous preterm birth or a short cervix found on ultrasound. Progesterone treatment is associated with decreased rates of preterm birth before 37 weeks when administered to women with threatened miscarriage or preterm labor. However, it does not significantly reduce preterm birth risks for twin pregnancies or women with other risk factors.
This document discusses preterm labour, including definitions, incidence, risk factors, causes, prevention, diagnosis, treatment, and management. Some key points:
- Preterm labour is the leading cause of neonatal mortality and morbidity. Risk factors include infections, cervical issues, multiple gestations, and stress.
- Causes include activation of the HPA axis, inflammation, decidual hemorrhage, and uterine overdistention. Progesterone supplements and smoking cessation may help prevent preterm labour.
- Diagnosis relies on regular contractions and cervical changes before 37 weeks. Tocolytics like terbutaline and nifedipine can delay delivery to allow antenatal steroids to improve neonatal outcomes.
This document discusses recurrent miscarriage, providing definitions and epidemiology. It defines recurrent miscarriage as 3 or more consecutive miscarriages. Causes discussed include polycystic ovary syndrome, antiphospholipid syndrome, chromosomal abnormalities, endocrine disorders, and uterine abnormalities. Investigation and management strategies are presented for different potential causes. For unexplained recurrent miscarriage, progesterone and aspirin are discussed but evidence for their effectiveness is limited. Counseling and lifestyle modifications are recommended.
Preterm birth refers to birth between 20-36 weeks gestation. It can result from preterm labor, preterm prelabor rupture of membranes, or provider-initiated early delivery for maternal or fetal indications. Risk factors include prior preterm birth, short cervical length, infection, uterine bleeding, multiple gestation, and maternal medical conditions. Complications of prematurity include respiratory distress, brain hemorrhage, and long term issues like cerebral palsy and developmental delays. Progesterone supplementation and cervical cerclage may help prevent recurrence in high risk groups.
The document discusses preterm labor and birth. It defines preterm birth as babies born alive before 37 weeks of pregnancy. It notes the main complications of preterm birth include neonatal death, respiratory distress syndrome, and other issues. Risk factors for preterm birth include multiple pregnancies, smoking, cervical insufficiency, and infection. The prevention and treatment of preterm labor focuses on identifying women at risk and using interventions like progesterone supplementation, cervical cerclage, and tocolytic drugs to delay birth.
This document provides information on preterm and post-term labor. It defines preterm labor as onset of labor before 37 weeks of gestation and discusses the main risk factors, diagnosis, and management. Diagnosis requires documentation of regular contractions and cervical changes. Tocolytics and steroids are used to delay delivery. For post-term labor, it defines this as pregnancy exceeding 42 weeks and notes the risks include macrosomia, dystocia, and complications of prolonged labor. Conservative management or induction is recommended depending on cervical status and fetal well-being.
This document discusses cervical ripening and labor induction. It provides indications and contraindications for labor induction, as well as factors that predict success. Methods for cervical ripening include prostaglandins and mechanical/alternative methods. Oxytocin and prostaglandins like misoprostol are common agents for labor induction, but they carry risks like uterine hyperstimulation and abnormal fetal heart rate patterns. Careful dosing and monitoring are important when inducing labor.
Preterm labor is defined as labor beginning before 37 weeks of gestation and can result in neonatal morbidity and mortality. The causes are often multifactorial but include infection, cervical insufficiency, multiple gestation, and prior preterm birth. Diagnosis requires regular contractions and cervical changes. Management focuses on delaying delivery through tocolysis if possible, administering steroids to enhance lung maturity, and preventing infections. Close monitoring of labor and resuscitation of premature newborns is important.
Dr Sujoy Dasgupta was invited to deliver a lecture at BOGSCON (The Annual Conference of Bengal Obstetric and Gynaecological Society) held at Kolkata in December 2019
Management of postterm pregnancy involves balancing risks to the fetus and mother. Postterm is defined as past 42 weeks gestation. Accurately dating the pregnancy is important to avoid false diagnosis. Risks to the fetus include stillbirth, meconium aspiration, and macrosomia. Risks to the mother include dystocia and infection. Studies show inducing labor at 41 weeks reduces stillbirths without increasing C-sections. Methods of antenatal testing after 41 weeks are debated, though monitoring is recommended. While an unfavorable cervix was viewed as a risk factor for C-section, recent evidence suggests underlying issues may be more important. Further research is needed to determine the optimal time for induction to minimize risks
This document provides an overview of preterm labour, including risk factors, causes, pathophysiology, diagnosis, management, and outcomes. Some key points:
- Preterm labour is defined as labour beginning between 24-37 weeks of gestation. It is a leading cause of perinatal morbidity and mortality.
- Risk factors include ART, multifetal pregnancies, smoking, infections, poor nutrition, and socioeconomic factors. The causes are often multifactorial and not fully understood.
- Diagnosis involves assessing for regular contractions and cervical changes via digital exam or ultrasound. Biomarkers like fetal fibronectin can help predict risk of imminent delivery.
- Management includes corticost
This document summarizes information on preterm birth (PTB) and the use of progesterone supplementation to prevent PTB. It begins by defining PTB as birth before 37 weeks gestation. It then discusses risk factors for PTB like previous preterm births, infections, cervical factors. It describes evaluating cervical length via transvaginal ultrasound to predict risk. Progesterone supplementation options are discussed including various formulations and 17-alpha hydroxyprogesterone caproate injections. The document summarizes evidence that progesterone reduces rates of preterm birth and improves neonatal outcomes.
This document discusses preventing preterm labour. It begins by providing statistics on the incidence of preterm birth in various locations. It then discusses the magnitude of the problem, highlighting the high costs of preterm birth. Several studies on outcomes of extremely preterm infants are summarized. The document is then organized into sections on primary, secondary, and tertiary prevention of preterm labour. Key points are made about various risk factors and diagnostic tools, as well as treatments such as progesterone, cerclage and antibiotics.
The document discusses antenatal assessment, which involves the systematic supervision of a pregnant woman. It involves determining risk factors through a comprehensive history and physical exam. Regular checkups are recommended, starting with monthly visits until week 28, then twice monthly until week 36, and weekly during the last 4 weeks. The assessments monitor maternal and fetal health and wellbeing through tests, exams, ultrasounds and more. The goal is to promote a healthy pregnancy and delivery.
This document summarizes the role of progesterone in preventing preterm labor. It discusses international guidelines that recommend daily progesterone supplementation for women with a prior preterm birth or short cervix. Studies show progesterone is effective at maintaining uterine quiescence and preventing preterm birth by regulating stress hormones and limiting prostaglandin production. Progesterone reduces the risk of preterm birth in women with a short cervix, prior preterm birth, or twin gestation with short cervix. It may also be beneficial for maintenance tocolysis after arrested preterm labor when compared to placebo or no treatment.
Fibromyalgia is a chronic pain condition characterized by widespread muscle aches, pain and fatigue. While the exact cause is unknown, it involves dysregulation of the autonomic nervous system and neuroendocrine changes. The American College of Rheumatology diagnostic criteria includes widespread pain for over 3 months and tender points found in 11 of 18 sites. Treatment options with mild to moderate effectiveness include low-dose antidepressants, aerobic exercise and cognitive behavioral therapy, though more research is still needed on alternative therapies.
The document discusses dementia, including its various types, symptoms, diagnostic criteria, assessment methods, and treatment options. It defines dementia as the loss of cognitive and intellectual function without impairment of perception or consciousness. The five major types of dementia are Alzheimer's disease, cerebrovascular disease, Lewy body disease, frontotemporal dementia, and Parkinson's disease with dementia. Assessment involves interviews, examinations, and tests to evaluate cognition, function, and rule out other conditions. Treatment focuses on enhancing quality of life and includes both non-pharmacological and pharmacological approaches.
This document outlines desirable components and characteristics for developing medical school cases for small group learning. It recommends that cases have clear, measurable learning objectives; content matched to the objectives; effective inserted questions to stimulate discussion; appropriate context and level; authentic problem scenarios; clear organization; appropriate length; high quality exhibits; up-to-date medical information; opportunities to use medical informatics; connections to other course content; and facilitator guides with discussion points. It also stresses obtaining feedback to improve cases.
The Role of Human Papillomavirus (HPV) Infection in Abnormalities of the CervixMedicineAndDermatology
The document discusses the financial burden that prescription drugs place on elderly patients. Only 75% of community dwelling Medicare beneficiaries have prescription drug coverage, and of those only half have continuous coverage over a year. The costs of prescription drugs are expected to reach $1.8 trillion from 2004-2013, far exceeding the allocated federal budget of $400 billion. The financial burden disproportionately impacts low-income elderly patients and can prevent them from affording necessary medications. The document outlines ways physicians can help elderly patients access affordable prescription drugs, such as utilizing patient assistance programs, state and local programs, and Medicare drug discount cards.
This document discusses medical considerations and recommendations for managing diabetes during Ramadan. It notes that fasting is prohibited if it poses health risks. For those with diabetes who choose to fast, risks include hypoglycemia, hyperglycemia, dehydration, and electrolyte abnormalities. It provides guidelines on fasting for those with type 1, type 2, or using insulin based on their risk level and treatment plan. Doctors should discuss concerns with patients and encourage frequent monitoring if fasting.
This document discusses HPV (human papillomavirus), its relationship to cervical cancer, and cervical cancer screening guidelines. It describes the different types of HPV and their risks, how HPV is transmitted, how infections typically progress, and methods of detection. The document also outlines cervical cancer screening guidelines and provides an introduction to colposcopy, using images to illustrate cervical abnormalities.
This document outlines four teaching formats to educate learners about developmental delay, mental retardation, pervasive developmental disorder, and autism:
1. Point of Care provides resources for immediate patient care and self-directed learning.
2. Morning Report discusses case studies highlighting key issues.
3. Noon Conference is a formal lecture presenting evaluation approaches and genetic testing options.
4. Self-Directed Learning is a web-based module teaching the basics through case-based examples. Each format identifies educational materials, pre-reading, teaching approaches, and evaluation methods.
This document discusses incorporating portable ultrasound technology into family medicine clerkship teaching. It describes how a 90-minute hands-on workshop is used to teach students basic ultrasound skills like identifying fetal anatomy and assessing the abdomen. Students practice scanning each other and sometimes make unexpected findings. Portable ultrasound can also be used in community outreach settings. The document provides resources for learning and teaching ultrasound skills pertinent to family medicine.
The USPSTF strongly recommends screening for colorectal cancer in adults aged 50-75 with fecal occult blood testing, sigmoidoscopy, or colonoscopy. It recommends against screening for ovarian and testicular cancer due to lack of evidence that screening improves outcomes and potential for harms from unnecessary procedures. For breast, lung, and prostate cancer, the USPSTF found insufficient evidence to recommend for or against routine screening due to uncertainty around benefits and harms of screening for certain age groups and cancer stages.
This study analyzed blood cultures from neonatal intensive care unit patients from 1997 to 2001 in Tripoli Medical Center, Libya. A total of 1431 blood culture sets from 1092 patients were positive for bacterial growth in 801 sets, representing 648 cases of neonatal bacteraemia. The most common causative agents were members of the Enterobacteriaceae family including Serratia, Klebsiella, and Enterobacter species as well as coagulase-negative and positive Staphylococci. Antibiotic susceptibility testing found high levels of resistance among the most frequent pathogens, though resistance to newer antibiotics like aztreonam and imipenem was less common. Resistance in Staphylococcus to anti-stap
This document outlines four formats for teaching approaches about Alzheimer disease: point of care, morning report, noon conference, and self-directed learning. For point of care, it suggests having web-based resources directly accessible in clinical settings to address common questions. The morning report format suggests discussing case-based materials covering major Alzheimer disease points, potentially using online teaching cases. For self-directed learning, it recommends online videos, comprehensive summaries of Alzheimer disease genetics from GeneReviews, and other resources.
This document provides guidance on screening, diagnosing, and managing hypertension through patient-centered care and therapeutic lifestyle changes. It presents a case study of a 45-year-old man with new onset high blood pressure and discusses further evaluation, initial recommendations, and follow-up based on guideline-recommended treatment goals. The document also addresses how care may differ based on patient characteristics and explores assessing psychosocial factors that could impact treatment.
This document discusses common causes of anemia by presenting several case studies and providing conceptual frameworks for evaluating patients. It covers increased red blood cell loss or destruction, decreased red blood cell production, plasma volume expansion, and maldistribution as primary causes. Specific conditions discussed include iron deficiency, hemolytic anemias, myelopathies, chronic kidney disease, and anemia of chronic disease. The importance of considering epidemiology and performing a full blood count with differential to form a differential diagnosis is emphasized.
This document discusses barriers to teaching addiction medicine in residency programs and strategies for overcoming them. It describes how a private foundation called MERF partners with family practice residencies to provide faculty development support through educational conferences and scholarships. This helps improve faculty expertise and attitudes, and allows for better integration of addiction curriculum that increases screening and treatment of substance use disorders. Evaluation found the program successfully increased faculty and resident knowledge and comfort with addiction medicine.
The document discusses community-acquired pneumonia (CAP), including common pathogens, signs and symptoms, diagnosis, and treatment options. The most common pathogens for typical CAP are Streptococcus pneumoniae, while atypical CAP is commonly caused by organisms such as influenza virus, Mycoplasma, and Chlamydia. Signs and symptoms include cough, fever, chills, dyspnea, and fatigue. Diagnosis involves a chest x-ray and labs such as a complete blood count and sputum/blood cultures. Treatment depends on severity and location (outpatient vs inpatient), but generally includes macrolides, fluoroquinolones, or doxycycline.
The document discusses community-acquired pneumonia (CAP), including common pathogens, signs and symptoms, diagnosis, and treatment options. The most common pathogens for typical CAP are Streptococcus pneumoniae, while atypical CAP is commonly caused by organisms such as influenza virus, Mycoplasma, and Chlamydia. Signs and symptoms include cough, fever, chills, dyspnea, and fatigue. Diagnosis involves a chest x-ray and labs such as a complete blood count and sputum/blood cultures. Treatment depends on severity and location (outpatient vs inpatient), but generally includes macrolides, fluoroquinolones, or doxycycline.
1. Multiple Sclerosis (MS) is a disease of the central nervous system that results in demyelination and damage to the protective covering of nerve fibers. It commonly causes visual issues, weakness, sensory problems, and other neurological symptoms.
2. The diagnosis of MS involves demonstrating dissemination of lesions in both time and space, either clinically or radiologically. The McDonald criteria from 2001 provides guidelines for diagnosing MS based on clinical attacks, MRI findings, and cerebrospinal fluid analysis.
3. Common symptoms of MS include visual problems, motor weakness, sensory issues like numbness and tingling, and bladder/bowel dysfunction. Symptoms vary depending on location of lesions in the brain and spinal
1. Multiple Sclerosis (MS) is a disease of the central nervous system that results in demyelination and damage to the protective myelin sheaths surrounding nerve fibers. Common symptoms include visual problems, muscle weakness, sensory issues, and coordination and balance issues.
2. The diagnosis of MS is based on clinical evidence of lesions in the brain and spinal cord disseminated in time and space. MRI and lumbar puncture are important tests to support the diagnosis.
3. There are different clinical courses of MS including relapsing-remitting, secondary-progressive, primary-progressive and progressive-relapsing. The McDonald criteria from 2001 is now commonly used to diagnose MS based on clinical and
This document provides information on smoking cessation and motivational interviewing techniques to help patients quit smoking. It discusses:
- The 5 A's approach to smoking cessation in primary care (Ask, Advise, Assess, Assist, Arrange).
- Stages of change model for behavior change, including precontemplation, contemplation and preparation stages.
- Motivational interviewing techniques like expressing empathy, developing discrepancy, avoiding arguments and rolling with resistance to help move patients through the stages of change.
- Using the 5 R's of relevance, risks, rewards, roadblocks and repetition when motivational interviewing with precontemplative and contemplative patients.
The document discusses sleep, insomnia, and their treatment. It defines insomnia as difficulty initiating or maintaining sleep. Insomnia can be transient, acute, or chronic. Common causes include medical, psychiatric, substance-related, and circadian issues. Treatment involves addressing underlying causes, improving sleep hygiene, cognitive-behavioral therapy including stimulus control and sleep restriction, and may include pharmacotherapy with hypnotics as a short-term option. Multicomponent cognitive behavioral therapy is most effective for insomnia.
Surgical Infection Powerpoint based on Scwartz Principlse of SurgeryMedicNerd
A presentation on surgical infections would encompass an in-depth examination of infections that occur post-surgery, highlighting their significance in clinical settings. It would cover the various types of surgical infections, such as superficial incisional infections, deep incisional infections, and organ/space infections, delving into their causes, including microbial contamination during surgery, patient-related factors, and procedural factors. The presentation would discuss diagnostic techniques, such as clinical evaluation, laboratory tests, and imaging studies, alongside treatment strategies that include antibiotic therapy, surgical intervention, and supportive care. Additionally, it would emphasize preventive measures, such as stringent aseptic techniques, preoperative skin antisepsis, and postoperative care protocols, to mitigate the incidence of these infections.
The Revolutionary Nature of Needleless Double Transfer Spikes in HealthcareNanchang Kindly Meditech
It's likely that you have witnessed medical personnel using needles to transmit fluids or medicines if you have ever visited a hospital or other healthcare facility. But as technology advances, needleless double transfer spikes are becoming more and more common and revolutionizing the delivery of healthcare.
Human blood has a hydrogen ion concentration [H+ ] of 35 to 45 nmol/L and it is essential that its concentration is maintained within this narrow range.
Hydrogen ions are nothing but protons which can bind to proteins and alter their characteristics.
All the enzymes present in the body are proteins and an alteration in these enzyme systems can change the homeostatic mechanisms of the body.
Hence, a disturbance in acid-base balance can result in malfunction of the various organ systems.
The normal pH of blood is 7.35-7.45.
Acidosis is defined as a pH Less than 7.35.
Conversely, when the pH is more than 7.45, alkalosis is said to exist.
Acidosis and alkalosis are of two types each: respiratory and metabolic.
An increase in carbon dioxide (CO2 ) levels increases the plasma [H+ ] and decreases the pH (respiratory acidosis).
Similarly, a decrease in plasma carbon dioxide levels reduces the [H+ ] and increases the pH (respiratory alkalosis).
A decrease in [HC03 -] reduces the pH and is called metabolic acidosis.
Similarly, an increase in [HC03 -] increases the pH and produces metabolic alkalosis.
The pH is regulated in the human body mainly by two organs: the respiratory system and the renal system.
The arterial carbon dioxide levels are regulated by the respiratory system.
Any increase in carbon dioxide levels stimulates the respiratory centre in the medulla thus augmenting respiration, alveolar ventilation and elimination of extra CO2 levels.
A decrease in CO2 levels may reduce the stimulus to breathe and cause hypoventilation.
This response is limited by hypoxia as the hypoxic drive stimulates the patient to maintain respiration.
Respiratory response to changes in CO2 level occurs very fast.
The plasma bicarbonate levels are regulated by the kidneys.
Any decrease in [HC03 -] stimulates the kidney to retain and synthesise bicarbonate.
High [HC03 -] results in elimination of more bicarbonate in urine.
In general, the pulmonary response to a change in acid-base status is faster and occurs immediately.
However, renal regulation takes time, a few hours to days.
Kidneys filter and reabsorb all the bicarbonate in the urine.
When necessary, kidneys can also produce extra bicarbonate through the glutamine pathway.
When an acid-base disorder occurs, the initial disturbance that occurs is termed the primary disorder.
The body attempts to normaliZe the pH by certain compensatory mechanisms resulting in a secondary disorder, e.g. primary metabolic acidosis results in an increase in hydrogen ions and a consequent decrease in bicarbonate ions.
To compensate for this, the patient hyperventilates and reduces the arterial carbon dioxide levels, thus moving the pH back to normal ( compensatory respiratory alkalosis )
an huge problem we are facing about the anaemia , we slight our contribution to aware with one of its class , with detailed description. it is usefull for health , medicine , pharmacy , nursing.
Co-Chairs, Hussein Tawbi, MD, PhD, and Prof. Christian Blank, MD, PhD, discuss melanoma in this CME activity titled “Deploying the Immune GAMBIT Against Melanoma: Guidance on Advances and Medical Breakthroughs With ImmunoTherapy.” For the full presentation, downloadable Practice Aids, and complete CME information, and to apply for credit, please visit us at https://bit.ly/4edfNpE. CME credit will be available until July 5, 2025.
TEST BANK Physical Examination and Health Assessment 9th Edition by Carolyn J...rightmanforbloodline
TEST BANK Physical Examination and Health Assessment 9th Edition by Carolyn Jarvis, All Chapters 1 - 32 Full Complete.pdf
TEST BANK Physical Examination and Health Assessment 9th Edition by Carolyn Jarvis, All Chapters 1 - 32 Full Complete.pdf
As a leading rheumatologist in Chandigarh, Dr. Aseem specializes in the diagnosis and management of a wide range of rheumatic conditions, including but not limited to:
Rheumatoid Arthritis: An autoimmune disorder that causes chronic inflammation of the joints.
Osteoarthritis: A degenerative joint disease characterized by the breakdown of cartilage.
Lupus: A systemic autoimmune disease that can affect the skin, joints, kidneys, and other organs.
Ankylosing Spondylitis: A type of arthritis that primarily affects the spine, causing pain and stiffness.
Gout: A form of arthritis characterized by sudden, severe attacks of pain, redness, and tenderness in the joints.
Psoriatic Arthritis: A type of arthritis that affects some people with psoriasis.
Vasculitis: An inflammation of the blood vessels that can cause a variety of symptoms.
Sjogren’s Syndrome: An autoimmune disorder characterized by dry eyes and mouth.
Accurate diagnosis is crucial for effective treatment. Dr. Aseem Goyal utilizes advanced diagnostic techniques to identify the underlying causes of rheumatic conditions. Our state-of-the-art facility is equipped with the latest technology to provide comprehensive diagnostic services, including:
Blood Tests: To check for markers of inflammation and autoimmune activity.
Imaging Studies: Such as X-rays, MRI, and ultrasound to assess joint and soft tissue damage.
Joint Fluid Analysis: To examine the fluid in the joints for signs of inflammation or infection.
Biopsy: In certain cases, a small tissue sample may be taken for further examination.
Treatment Approaches
Dr. Aseem Goyal adopts a holistic and patient-centered approach to treatment. Depending on the specific condition and its severity, treatment options may include:
Medications
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): To reduce inflammation and relieve pain.
Disease-Modifying Antirheumatic Drugs (DMARDs): To slow the progression of rheumatic diseases.
Biologic Agents: Targeted therapies that block specific pathways in the immune system.
Corticosteroids: To control severe inflammation quickly.
All the information you need to know about Hypothyroidism - Introduction,
Etiology, clinical manifestations, complications, pathophysiology,
diagnosis, treatment, precautions.
THE MANAGEMENT OF PENILE CANCER. PowerPointBright Chipili
This PowerPoint includes all the relevant information and science about penile cancer and its management. Information is based on Campbell 12th edition and EAU 2024 updated guidelines.
Regenerative Medicine in Chronic Pain ManagementReza Aminnejad
Regenerative technologies are the future of medicine. The current clinical strategy focuses primarily on treating the symptoms but regenerative medicine seeks to replace tissue or organs that have been damaged by age, disease, trauma, or congenital issues.
Factors influencing growth & development:
Growth & development depend upon multiple factors or determinants. They influence directly or indirectly by promoting or hindering the process.
The determinants can be grouped as Heredity & environment..
Heredity or genetic factors are also related to sex, race, & nationality. Environment includes both pre natal & post natal factors.
Introduction to Dental Implant for undergraduate studentShamsuddin Mahmud
Introduction to Dental Implant
Dr Shamsuddin Mahmud
Assistant Professor, Department of Prosthodontics
Nortth East Medical College (Dental Unit)
Definition of Dental Implant
A prosthetic device
made of alloplastic material(s)
implanted into the oral tissues beneath the mucosal and/or periosteal layer and
on or within the bone
to provide retention and support for a fixed or removable dental prosthesis.
Classification of Dental Implant
According to placement within the tissue
Blade/Plate form implant
According to Material Used
A) METALLIC IMPLANTS
Commercially pure Titanium
Cobalt chromium molybdenum
Titanium aluminum vanadium
Stainless steel
B) NON-METALLIC IMPLANT
Zirconium
Ceramic
Carbon
According to the ability of implant to stimulate bone formation
A) Bio active
Hydroxyapatite
Tri Calcium Phosphate
B) Bio inert
Metals
Parts of Dental Implant
Implant fixture
Implant mount
Cover screw
Gingival former/healing screw/healing abutment/permucosal extension
Impression post/impression transfer abutment
Implant analogue
Abutment
Fixation screw
Implant Fixture
Implant Mount
Connected to the fixture
Function: used to carry implant from its vital to the prepared osteotomy site either by hand or with a ratchet/ handpiece adaption
Cover Screw
component that is used to cover the implant connection during the submerged healing of the implant
Function: preserves the patency of the connection by preventing any soft tissue ingrowth in the connection
Gingival former/ Healing Abutment/ Healing screw
Screw/ abutment used to create the soft tissue emergence profile around the implant.
Time of placement:
During 1st surgery – One step surgery
After Osseointegration – Two step/stage surgery
Gingival former/ Healing Abutment/ Healing screw
Placed in the site 2-3 weeks for soft tissue healing
Function:
Create gingival emergence profile
Formation of biological width
Impression post/impression transfer abutment
component that is used to trans- fer the implant Hex position and orientation from the mouth to the working cast.
Types
Closed tray
Open tray
Implant analogue/
component which has a different body but its platform and connection are exactly similar to the implant. The analogue is used to replicate the implant platform and connection in the laboratory mode.
Abutment
Abutments
Advantages of Dental Implant Retained Prosthesis
Maintain bone height and width by preventing bone resorption
Maintain facial esthetics
Improve masticatory performance
Improve stability and retention of prosthesis
More esthetics
Increase survival times of prostheses
There is no need to alter adjacent teeth
Improve psychological health
Disadvantages of Dental Implant Retained Prosthesis
Very expensive.
Cannot be used in medically compromised patients who cannot undergo surgery.
Longer duration of treatment
Requires a lot of patient co-operation because of repeated recall visits are essential
INDICATION OF DENTAL IMPLANT
Dental implants can successfully restore all
2. Objectives: Define preterm labor and its impact Describe Risk Factors for preterm birth Name several ways to prevent preterm birth Identify and diagnose preterm labor Outline an appropriate evaluation and management algorithm for patients who present with preterm labor and PPROM Understand risks and limitations of management strategies for treating patients with preterm labor and PROM
3. Definitions/ Epidemiology Definitions Preterm Labor : regular contractions with cervical change at <37 weeks gestation Preterm Birth : < 37 & 0/7 days Near term or Late term : 34 & 0/7 to 36 & 6/7 weeks Very preterm : < 32 & 0/7 weeks Extremely Preterm : < 28 & 0/7 weeks Rising Rates of Preterm Birth 1981-2003 PTB < 37 weeks: increase from 9.4 to 12.3% PTB “near term”, : increased from 6.3-8.8%
4. Race/Ethnicity and Prematurity 2000to 2002 1.5% 10.7% White 1.4% 10.2% Asian 1.7% 11.4% Hispanic 2.0% 12.9% Native American 4.1% 17.6% Black 1.9% 11.9% All US < 32wk US < 37wk Race/Ethnicity
6. Case #1 24 year old NA G2P1 presents at 16 weeks history of spontaneous preterm birth at 26 weeks, (no bleed, PPROM, or maternal illness) Is this patient high risk or average risk for Preterm Birth? What can I do different this pregnancy to prevent preterm birth?
7. Case #1 Preterm Labor Precautions Lifestyle BMI 18, wt 100 lbs, ¼ PPD tobacco, some marijuana New significant other last 1 month, not father of the baby Screening Labs: Wet Mount/Gram Stain: Bacterial Vaginosis Informed Consent Utox: negative Urine culture: no growth in 2 days Ligase Chain Reaction GC/Chlamydia: negative
8. Prematurity Risk Factors High Risk/Low incidence PTL after tocolysis 70% Bleeding > 20 wk OR 5.3 Twins 40% Unicornate uterus 30% Gravida 9+ 32% Incompetent cervix 25% Prior preterm birth 25%, with 25-70% Prior PPROM 29% Preterm contracts 25% High Incidence/mild risk Threaten Ab (30%) OR 4.1 Smoking (25%) OR 1.3 Black Race (9%) OR 1.5 Drug use (8%) OR 2.0 UTI/Bacteruria (5%) 2.0 Anemia (5%) OR 2.2 Chronic HTN (5%) OR 1.8 Mild PIH (5%) OR 1.7 3+ Abortions OR 2.9 Late to Care OR 2.0 Scoring systems have low predictive value
9. Cervical Incompetence Risks Past OB History Prior Midtrimester loss Prior Preterm delivery @ 24-30 weeks Previous cerclage History of multiple 1st Trimester TOP ( 2) History of one 2 nd trimester TOP Structural Uterine DES exposure Uterine malformation Hx of Cone Biopsy Current Pregnancy multiple pregnancy
10. Prematurity Interventions: Lifestyle Some Effect : Nutrition, zinc, folate and caloric supplementation, Smoking cessation Drug abstinence Income support, France and Germany Unknown/Maybe : Domestic Violence screen Light duty for fatigue work Ineffective: Nutrition counseling, vitamins and minerals Hydration Patient Education to detect contractions Psychological support Harmful Nutrition, Protein supplementation Bedrest
11. Expected pregnancy weight gain 15+ lbs > 29 Obese 15-25 lbs 26-29 High 25-35 lbs 19.8-26 Normal 28-40 lbs <19.8 Low Recommended wt gain BMI Kg/m2 Wt/ht category
12. Prematurity Interventions: Medical Effective : Rx Asymptomatic Bacteriuria (1970s tetracycline) Progesterone Supplementation Cerclage if prior incompetent cervix Unknown/Maybe : STD treatment BV Rx in high risk Anticoagulant in Thrombophilias Nurse phone calls to home Ineffective : More or enhanced prenatal care Risk Scoring systems Home Uterine Monitoring Treatment of BV in low risk women Cerclage in only short cervix Peridontal Disease treatment Harmful : Antibiotics with intact membranes Tocolysis > 48 hours
13. Asymptomatic Bacteriuria Defined as > 100K/ml single uropathogen Urine culture is gold standard Dipstick 86% sensitive, 86% specific, 54% PPV, 97% NPV 5-10% of all pregnancies Outcomes if treated (Cochrane database) Pyelonephritis OR 0.24 (0.19-0.32) Pre-term birth OR 0.60 (0.45-0.80)
15. Bacterial Vaginosis Common occurs in 20%, asymptomatic in 50% Diagnosis by wet mount (3 of 4 criteria: clue cells, pH > 4.5, positive whiff test with KOH for amine odor, thin homogenous discharge) gram stain, criteria on type and amount of bacteria Increased risk of OB complications, RR or 2.3 for preterm delivery, 2.4 for PROM, 3.2 for chorioamnionitis
16. Bacterial Vaginosis 1995 small (n=426) high risk (prior PTB) RTC showed a 30% decrease in preterm birth with Rx using Erythromycin (14d) and Metronidazole (7d) 2000 Large trial (n= 1953) low risk for PTB diagnosis by gram stain and treatment with metronidazole 2gm stat alone, with no effect AHRQ 2001 Review I rating for “high risk women” D rating for “low risk asymptomatic women”
17. Bacterial Vaginitis Metronidazole potential harm Metronidazole 2006 PREMET study, 900 screened 24 and 27 weeks for fetal fibronectin, 116 positive, 100 randomized, 400mg TID Metonidazole, 11/53 treated delivered < 37 weeks vs. 18/46 control, RR 1.6 (CI 1.05-2.4) 2001 Trichomonas study, 16-23 weeks, asymptomatic, treated with 2 grams for 2 doses, PTB 60/320 treated, 31/297 placebo, RR 1.8 (CI 1.2-2.7) 2004 Meta-analysis of 4 studies, 182/1,375 treated vs. 180/1,373 control, RR 0.92 (CI 0.52-1.62) for preterm birth, no difference
18. Bacterial Vaginitis Clindamycin Clindamycin 2003 RTC, Clindamycin low Risk, n= 494, Showed less Preterm Birth 11/244 vs. 28/241, NNT is 17, and less late miscarriage 13-24 weeks, 2 vs. 10, NNT of 10
19. Prevention with Progesterone High Risk Population of 463 women with prior preterm delivery (NIH study) >50% Black, Average prior birth at 30-31 weeks, one third with more than one prior preterm delivery Exclusions: multifetal pregnancy, planned cerclage, use of heparin or progesterone, chronic HTN on meds, seizure disorder Randomized 2/1 (310/153) double blind placebo weekly IM injections of 250mg 17 hydroxyprogesterone caproate starting 16-20 weeks Groups equal except average of 1.4 vs 1.6 prior preterm births in progesterone vs placebo
21. Progesterone Outcomes With Progesterone less NEC, need for O2, Trend but not significant less RDS, and ventilatory support, birth wt < 1,500 gms No difference in fetal or neonatal death, IVH grade 3 and 4, sepsis, anomalies One infant in progesterone group with torsion of testicles and subsequent infarction
22. Progesterone Meta-analysis Cochrane: Jan 2006, 6 RTCs, 988 patients PTB <37 weeks, RR 0.65 (CI 0.54-0.79), PTB < 34 weeks (one study) RR 0.15 (CI .04-.64), Less LBW RR 0.63 (.49-.81), IVH RR 0.25 (.08-.82) “ Not enough evidence”, desired further information on harms and other maternal and neonatal outcomes European: May 2006, 9 studies, n > 5,800, “ women at high risk of preterm birth should be recommended progestational agent therapy” PTB < 37 weeks, RR 0.42 (CI 0.31-0.57) NNT 9, PTB < 34 weeks, RR 0.51 (CI 0.34-0.77) NNT 42, RDS RR 0.55 (CI 0.31-0.96) Harms not significant
23. ACOG and Progesterone “ The hormone progesterone may be used as treatment to help prevent preterm birth but should be restricted to pregnant women with a documented history of preterm birth before 37 weeks gestation”
24. Preterm Birth Risk Stratification Contractions: 50% of those with threatened preterm labor deliver term pregnancies, can we further define risk Biochemical Markers Fetal Fibronectin Biophysical Markers Cervical Length
25. Markers for Prematurity Preterm Prediction Study: Case control 28 biologic markers studied in 2,929 women at 23 weeks 50 (1.7%) delivered < 32 weeks 127 (4.3%) delivered < 35 weeks
26. Most Potent Predictive Markers For Preterm Birth < 32 weeks 2 positive below OR 56.5 59% of cases and 2.4% of controls Fetal Fibronectin OR 32.7 > 90 th % AFP OR 8.3 > 90 th % Alk Phos OR 6.8 < 10% Cvx (25 mm) OR 5.8 > 75% GCSF OR 5.5 Any three tests positive 20% of cases and none of controls
27. Other Markers of Preterm Birth < 32 weeks > 90 th % Ferritin OR 8.0 Past Hx PTB OR 4.5* Vaginal pH 5.0 OR 3.3* Chlamydia Positive OR 2.6 Low Wt, BMI <19.8 OR 2.4 History of bleeding OR 1.8 * P <.05
28. Fetal Fibronectin Occurs in the choriodecidual junction Decreases 16-20 wks, absent 24-34 wks Taken from the vaginal fornix for 10 seconds, not in cervix No prior coitus or vaginal exam for 24 hrs ROM or bleeding make inaccurate
29. Fetal Fibronectin Asymptomatic Positive (n=1,530) 18.4% delivery <34 weeks LR 4.01 (2.93 to 5.49) Negative (n=23,150) 96.8% deliver >34 weeks LR 0.78 (0.72-0.84) Symptomatic Birth in 7-10 days Positive (n=1,270) 21% deliver in 7-10d LR 5.42 (4.36-6.74) Negative (n= 5865) 1% deliver in 7-10d LR 0.25 (0.2-0.31) Delivery < 34weeks Positive (n=189) 46.6%, LR 3.64 Negative (n= 498) 93.4%, LR 0.32
30. Fetal Fibronectin If positive One in 5 symptomatic deliver in 7-10 days One in 5 asymptomatic will deliver by 34 wks Nearly half symptomatic deliver by 34 weeks If negative One in 100 symptomatic deliver in 7-10 days Three in 100 asymptomatic deliver < 34 weeks 6-7 in 100 symptomatic deliver < 34 weeks
31. Case #2 Low Risk no prior PTB at 25 weeks Size < Dates, 21cm fundal height at 25 weeks Transabdominal Ultrasound shows normal growth cervix is with 1.2 cm length and 1.2 cm wide fluid filled beaking in upper canal Transvaginal Ultrasound repeat shows 2.3 cm long cervix, with again beaking down 1.3-1.5 cm of the length, 1.0 cm from beak tip to external os One hour of tocodynometer shows no contractions Vaginal exam is 2-3 cm long, closed, firm Outpatient vaginal Fetal Fibronectin is negative What precautions for this incidental US finding?
32. Transvaginal Cervical Length 1996 NEJM study of 2,915 women with US at 24 weeks, repeat on 2,531 at 28 weeks 126 with preterm birth < 35 weeks, 4.3% Was a general population, 42% were nulliparous 16% had history of prior preterm birth There was only 2mm difference between parous and nulliparous women, not clinically important Mean length was 35.2mm at 24 weeks and 33.7 mm at 28 weeks
33. Rate of Preterm Birth <35 weeks by Cervical Length at 24 weeks 34 % < 13 mm 20 % <20 mm 8 % 25 mm Rate Delivery Length
35. Cervical Length Caveats Distinguish Average Risk versus High Risk Population studies Cervixes change from the inside out, but digital vaginal exam of Bishops ≥ 4 is significant Ultrasound Higher risk of Preterm Birth with Funneling > 25% Earlier shortening 16 versus 24 weeks More rapid rate, <3mm/week reassuring, 5mm per week concerning at 20-24 weeks
36. Cerclage and Short Cervix 47,123 screened at 22-25 weeks 430 with cervical length < 15mm 253 in RTC No difference in delivery before 33 weeks with placement of Shirodkar suture 22% (28 /127 cerclage), 26% (33/126 control) RR 0.84 (CI 0.54-1.31) No difference in perinatal or maternal morbidity and mortality
37. Role of US and Cerclage High risk with 3 prior midterm losses Serial Cervical Length Ultrasound: May have a role in management Assessments should begin no earlier than 16-20 weeks No role for history of 1 st trimester losses Cerclage Only benefit in subgroup 3 prior midtrimester losses or preterm deliveries, 33% watched, 15% cerclage with delivery before 33 weeks, n=107, total groups n=1,292 No benefit in subgroups of one prior MTL/PTD, two prior MTL/PTD, history cone biopsy or cervical amputation, twins, prior TOP/uterine anomalie ACOG Practice Bulletin #48, Nov 2003
38. Short Cervix and Vaginal Progesterone 2003-2006, 24,620 screened by US at 20-25 weeks for short cervix during prenatal care, 413 with cervix ≤ 15mm, 250 accepted randomization, groups equal, 200mg micronized progesterone vaginally each night, 24 to 33 and 6/7 weeks, avoid intercourse PT Birth < 34 weeks, 26/125 progesterone vs. 43/125 placebo RR 0.60 (CI 0.38-0.86), NNT = 7 Not large enough to see neonatal outcomes
39. Contractions and Bishops Score And birth before 35 weeks 306 high risk women, singleton pregnancy with prior PTB or 2 nd trimester bleeding Contractions 4 per hour RR was with 3.0 but not significant, At 24 weeks CI (0.6-14.6) At 28 weeks CI (1.0- 8.7) Sens 6.7%, Specificity 92.3%, PPV 25%, NPV 84.7% 75% deliver at term Bishops Score 4 Significant only at 22-24 weeks OR 2.4 (CI 1.7-10.6) Sens 32 %, Specificity 91.4%, PPV 42.1%, NPV 87.4%
40. Threatened Preterm Labor Preterm Labor due to what? Treat reversible causes, such as UTI, Consider occult trauma of domestic violence, contractions of substance abuse Watch for PPROM, about 1/3 of preterm birth For Idiopathic Preterm Labor Four Categories Inflammation/ Infection Uterine Over-distension/ Structural Decidual Hemorrhage/ Bleeding Premature activation of normal initiators of labor
41. Idiopathic Preterm Contractions in Triage 179 randomized, singletons, 20-34 weeks, no ROM, no maternal of fetal complication, reassuring FHT 3 contractions/30 min, 1cm dilated, 80% effaced Eligible for discharge when contractions < 2 in 30 minutes, no digital cervical change, one hour apart, Preterm labor if cervical change of dilation of 1 cm or effacement of 25% Terbutaline with 1-2 hour less triage stay No significant outcome differences between Observation, Hydration of 500cc crystalloid then 200 cc/hour, Terbutaline one Subcutaneous dose of 0.25mg
42. Contractions what to do? 4 (7%) 4 (6%) 5 (9%) PTB < 34 wks $687 $966 $717 Mean cost < 24 hours 5 (8%) 8 (13%) 7 (13%) admitted 8 (13%) 8 (13%) 10 (18%) More tocolysis 79% 57% 64% Triage < 4hrs 4.1 5.1 hrs 6.0 5.7 hrs 5.2 5.1 hrs Mean time to discharge Terbutaline x1, n=61 Hydration N=62 Observation N=56
43. Case #2 now with contractions Presents 28 weeks with contractions every 5 minutes, Repeat exams and labs Digital cervix some change 1 cm long, medium consistency, posterior, -3 station, closed Fetal Fibronectin now positive US length repeated slightly progressed, 1.2 cm length, 0.7 cm from tip of funnel to external os, GBS culture done, (at 24 hours is positive) Hematocrit 29.5 What approach now with short US cervix, positive fetal fibronectin, and slight clinical shortening?
44. Case #2, Threatened PTL in High Risk (contracts, +FFN, short cervix) GBS prophylaxis: Penicillin Given Terbutaline 0.25mg SQ/dose tocolysis to allow 48 hours steroids Given Betamethasone 12mg IM q 24 hours times 2 doses ? FeSO4 325mg TID Observe in hospital with level 3 NICU
46. CDC GBS algorithm for Threatened Preterm Delivery Suggested algorithm for management of threatened preterm delivery (labor or rupture of membranes at <37 weeks’ gestation) which does not proceed rapidly to delivery: Culture and start IV antibiotics Culture negative at 48 hrs: stop antibiotics Culture positive: no data on duration of antibiotics before active labor, when active labor begins give IAP Culture negative and undelivered within 4 wks: re-screen
47. Agents for intrapartum prophylaxis Recommended agents for women with documented penicillin allergy: Not at high risk for anaphylaxis: cefazolin At high risk for anaphylaxis: Clindamycin or erythromycin if susceptibility testing feasible Vancomycin if erythromycin or clindamycin not options
48. Antenatal Steroids Intact Membranes and PTL 24-34 weeks Cochrane shows benefit 26 to 34 & 6/7 weeks PPROM and no chorioamnionitis, 24-32 wk Single course recommended Cochrane 2006 Doses 2 doses Betamethasone 12mg q 24 hours 4 doses Dexamethasone 6mg q 12 hours
50. Repeat courses of Antenatal Steroids Cochrane 2006 subgroup weekly repeats, n = 5-900 Less perinatal death RR 0.63 (.48-.92) NNT 7 Less RDS RR 0.55 (.43-.72) NNT 9 Less Chronic Lung RR 0.72 (.54-.96) NNT 15 Lancet 2006, RTC single repeat dose, n = 982 Less RDS RR 0.82 (.71-.95) NNT = 12 Severe lung disease RR 0.60 (.42-.79) NNT = 12 Pediatrics Feb 2007, single repeat dose, n = 249 No difference in neonatal death, RDS or IVH Increased RDS if delivers in first 24 hours after second dose of steroids
51. Tocolytics: Ca Channel Blockers: dihydropryridines Cochrance 12 trials of 1,029 versus any tocolytic, 9 versus betamemetics, Outcomes Less birth in 48 hrs (vs agonist) RR 0.72 Less birth in 7 days RR 0.76 (0.60-0.97) Less birth < 34 weeks RR 0.83 (0.69-99) Less RDS RR 0.63 (0.46-.88) NNT 14 Less NEC RR 0.21 (0.05-0.96) Less IVH RR 0.59 (0.36-.98) NNT 13 Less Adverse Effects NNT of 3 Conclusion: “calcium channel blockers should be preferred to betamimetics”
52. Tocolytics: Magnesium Sulfate Cochrane with 9 of 23 trials of 2000 women No difference in birth < 48 hrs RR 0.85 CI 0.58-1.25), 11 trials of 881 women No difference in birth < 37 or <34 weeks Increase risk of fetal and pediatric mortality RR 7.82 (1.20-6.62), 7 trials 727 infants No difference in neonatal morbidity Non-significant reduction in CP in one trial of 99 infants RR 0.14, (CI 0.01-2.60) Conclusion: Mg Sulfate is ineffective as tocolysis and has increased infant mortality
53. Tocolytics: - mimetics 2004 Cochrane Review: 17 trials, 11 trials with 1,320 women are placebo controlled No benefit for Perinatal death RR 0.84 (CI 0.46-1.55) Neonatal death RR 1.00 (CI 0.48-2.09) RDS RR 0.87 (CI 0.71-1.08)
54. Tocolytics: - mimetics Did reduce delivery within 48 hours 118/541 mimetic, 158/460 Control OR 0.56, (CI 0.42-0.74) Allows time for antenatal steroids Had more side-effects requiring discontinuation of treatment 3 RTCs, 25/88 (28%) mimetic, 0/86 control OR 11.5 (CI 4.8-27.5)
55. COX Inhibitors 2005 Cochrane review: 13 trials of 713 women, 10 trials of indomethacin Trials are small, and there is insufficient evidence Placebo controlled one trial 36 women Birth < 37 weeks, 3/18 indomethacin vs. 14/18 placebo, RR 0.21 (CI 0.07-.62) Versus another tocolytic, 3 trials 168 women Birth < 37 weeks, 13/85 COX vs 24/83 other, RR 0.53 (CI .31-.94)
56. Tocolytics: ACOG 5/2003 “ All have demonstrated limited benefit”, “may prolong pregnancy 2-7 days- Level A “ No clear first-line tocolytic drug” Level A “ Neither maintenance treatment nor repeated acute tocolysis improve perinatal outcome, neither should be undertaken” Level A “ Bedrest, pelvic rest, hydration, antibiotics should not be routinely recommended” Level B Goals of tocolytic therapy Allow administration of steroids, Level A Allow Maternal transport to tertiary care facility, level A Allow for imminent GBS chemoprophylaxis, Level A
57. Tocolytics Uncontrolled thyroid or Diabetes Cardiac arrhythmia 0.25mg SQ q 20min-3hr Hold if P>120 Mimetic Terbutaline Myasthenia gravis Also using Calcium channel Blocker 4-6 gm IV bolus in 20 min, then 2-3gm/hr Mag Sulfate Renal failure, Active Ulcer Coagulation disorders NSAID asthma trigger 50 rectal, 50-100 mg PO, then 25-50 orally q6 x 48 hrs NSAID Indomethacin (<32 weeks) Maternal hypotension Also using Magnesium 30-40 mg load PO 10-20 q 4-6hrs CCB Nifedipine Contra- indication Dose and Route Agent
58. Case #3, PPROM 30 year old G4P3 at 30 weeks feels a “pop and gush” and has leakage of clear fluid from the vagina Her risk factors include previous PPROM at 32 weeks, smoker, anorexia nervosa but no vaginal infections What is the management approach?
59. Incidence and Natural Hx PROM @ term 10 % PPROM 2 % Prolonged > 24 hours 10% of term Prolonged latency > 48 hrs 62% of preterm Chorioamnionitis will develop in 10% of those lasting beyond 24 hours at term, and in 25% of expectantly managed preterm Increased incidence of abruption, cord accident, infection
60. PROM Risks Malnutrition, esp vit C and zinc Smoking and substance abuse Infections esp staph aureus, GBS, Chlamydia, GC, Trichomonas, Bacteroides 1st and 3rd Timester Bleeding Incompetent cervix Genetic weak collagen Overdistension or trauma PPROM recurs 25%
61. Diagnosis Typical History , “pop and gush” 90.3% specific Nitrazine , ( false positive for blood, BV, semen, turns at pH 6.4-6.8) 98.9% sensitive, and 90.3% accurate Fern, 87% accurate, onset after 20 weeks,ok with meconium or blood unless 1 to 1 ratio, cervical mucous (fine) vs amniotic (coarse), Pooling
62. Diagnosis AFI , to be used as an adjunct if suspicious, Amniocentesis with instillation of indigo carmine dye Vaginal Pool lung maturity tests, PG accurate, LS will decrease with blood, (accurate if Hct <3) and Meconium, FLM not tested on vag pool Cultures, GBS, GC, Chlamydia, wet mount
63. Sterile Speculum The time clock starts with the first digital exam Studies have shown that infection rate rises with the number of digital exams ( 3 is statistically significant, and 7 exams is worse than 3) visual estimation on sterile speculum is accurate for cervical effacement and dilation Keep our fingers out of there !!! Accurate Dates, term (>34 weeks) vs preterm <34 weeks Presentation, breech or unstable lie with polyhydramnios with risk of cord prolapse, premie breech calls for C/section route of delivery, use Leopolds or bedside Ultrasound
64. Assessment of Fetal Lung Maturity L/S Ratio 2.0/1 (Lecithin/Sphingomyelin) Predictive value for mature 95-100%, Predictive valule for immature 33-50% L/S of blood in 2.0, meconium interferes, should process within one hour decreases with time Phosphastidylglycerol (PG), present Predictive value for mature 95-100% Predictive value for immature 23-53% Not effected by blood/meconium, ok vaginal pool Flourescence Polarization (FLM) 55 mg/g Predictive value for mature 96-100% Predictive value for immature 47-61% Vaginal pool accuracy not known, affected by blood and meconium
65. Expectant vs Intervene Fetal risks prematurity with RDS, IVH, NEC etc asphyxia due to cord compression, prolapse, or placental abruption neonatal sepsis in micropremies, aplasic lungs Maternal Risks infections, chorioamnionitis, sepsis abruption
66. Antibiotics for Preterm PROM 2003 Cochrane 22 trials, >6,000 women, Maternal Benefits Less chorioamnionitis : RR 0.57 (CI 0.37-0.86) Neonatal Benefits Prolonged latency : > 48 hours RR 0.71, (CI 0.58 to 0.87), > 7 days RR 0.80, (CI 0.71 to 0.90) Neonatal infection : RR 0.68, (CI 0.53 to 0.87) US abnormality at discharge : RR 0.82, (CI 0.68 to 0.98) Oxygen need: RR 0.88, (CI 0.81 to 0.96) Neonatal Harms NEC with Amoxicillin Clavulanate: RR 4.60, 95% CI 1.98 to 10.72
67. 4/07 ACOG PPROM 34-36 weeks, “near term ”: same as term, proceed to delivery, GBS chemoprophylaxis 32-33 & 6/7 weeks : expectant management, antibiotics to prolong latency, GBS chemoprophylaxis, +/- steroids < 32 weeks : expectant management, single course steroids, antibiotics to prolong latency, GBS chemoprophylaxis Antibiotics: recommend 7 total days, with 1st 48 hours Ampicilln/Amoxicillin and Erythromycin IV, then 5 more days PO
68. PPROM Interventions Antenatal steroids Recommend use in PPROM @ 30-32 weeks Cochrane 2006 Subgroup Analysis Less neonatal death RR 0.58 (.43-.80) NNT 15 Less RDS RR 0.67 (.55-.82) NNT 10 Less NEC RR 0.39 (.18-.86) NNT 23 No difference in chorioamnionitis
69. PPROM interventions Antibiotics goals GBS prophylaxis Prolong latency >48hrs, 73%, >7d to 41% less chorio 16 vs 25%, neonatal + blood culture 2 vs 10%, & neonate infxn 11 vs 15% same abnormal cranial US, death, RDS, NEC
70. Oracle 1 trial 4826 women <37 weeks randomized to erythromycin, 250mg QID augmentin, 250/125mg QID both or placebo Gives short term benefit without short term harm Delivery delay 48 hours 98.8% treated vs 95.6% control NNT = 33 Delivery delay by 7 days 63.3% treated vs 57.7% control NNT = 18
71. Oracle 1 trial No significant differences in treat vs placebo for Low birth weight rate RDS Need for O2 at 36 weeks post conception Positive neonatal blood cultures Short term harm Augmentin with more necrotizing colitis 1.8% Augmentin vs 0.7%, NNH = 91 Long term harm unknown Histologic chorioamnionitis is correlated with more US neonatal brain abnormalities, ? If we keep them in longer how will they do in kindergarten
72. Cerebral Palsy Retrospective Case control study mentioned in discussion in Oracle 1 trial 59 born < 32 weeks with Cerebral palsy Risk factors Prolonged ROM > 24 hours OR 2.3 (1.2-4.3) Chorioamnionitis OR 4.2 (1.4-12.0) Maternal infection OR 2.3 (1.2-4.5)
73. Conclusions Preterm birth has multi-factorial causes For prevention of Preterm Birth Optimize lifestyle and nutrition Screen for asymptomatic Bacteriuria Progesterone holds promise in high risk populations Threatened Preterm Labor is a common problem, yet 50% deliver at term Before using reactive tocolytics evaluate for possible causes, Preterm contractions due to what? Interventions that are bottom-line in threatened preterm labor are: Antenatal steroids Maternal Transport and delivery at tertiary care center GBS prophylaxis
74. Conclusions Prevent PPROM with good nutrition, smoking and drug cessation, rx infections secure the diagnosis & keep your fingers out of there secure the dates, transfer premies to appropriate level NICU/maternal unit, induce near-term PROM ≥ 34 weeks Antibiotic and Steroid use Betamethasone 32 weeks Erythromycin for 48 hours for latency for steroids <32 weeks GBS prophylaxis
75. References Epidemiology/Reviews Hollier, Lisa, Preventing Preterm Birth, What works, what doesn’t, Obstetrical and Gynecological Survey, 2005, Vol 60, #2, p124-131 Siman, H & Caritis S, Review Article, Drug Therapy, Prevention of Preterm Delivery, NEJM 2007, Aug 2 nd , 357; p 477-87 Tonse, R, Epidemiology of Late Preterm (Near-term) Births; Clinical Perinatology 2006, 33: p751-763 ACOG Practice Bulletins : October 2001, #31, Assessment of Risk Factors for Preterm Birth May 2003, #43, Management of Preterm Labor Nov 2003, #48, Cervical Insufficiency April 2007, #80 Premature Rupture of the Membranes
76. References: Cochrane Reviews: Anotayanonth, S et al, Betamimetics for inhibiting preterm labour, Oct 18 th 2004 Crowther, C et al, Magnesium Sulfate for preventing preterm birth in threatened preterm labor, Oct 21 st 2002 King, J et al, Cyclo-oxygenase (COX) inhibitors for treating pretem labour, Feb 2 nd 2005 King, J et al, Calcium Channel Blockers for inhibiting Preterm Labor, Jan 20 th , 2003 Roberts D, Dalziel, S; Antenatal Steroids for accelerating fetal lung maturation in women at risk of preterm birth, May 15 th 2006
77. References Preterm Labor Iams, J Prediction and Early Detection of Preterm Labor, OB/Gyn 2003: 101: 402-12 Slattery, M and Morrison J, Preterm delivery, Lancet, Vol 360, 11/9/2002, p 1489-1497 Gerdingen, D, Premature Labor Part 1; Risk Assessment, Etiologic Factors and Diagnosis, Journal American Board of Family Practice, Sept-Oct 1992 Vo 5, #5, p 498 Goldenberg, R and Rouse D, Prevention of Premature Birth, NEJM, July 30, 1998, Vol339, #5, P 313-320 Cervical Length Iams, J et al, The length of the cervix and the risk of spontaneous premature delivery, NEJM, Vol 334, #9, p567-96 Meekai S To, et al, Cervical cerclage for prevention of preterm delivery in women with short cervix: randomized controlled trial, Lancet, Vol 363, June 5 th 2004, p 1849-53
78. References Fetal Fibronectin Goldenberg, R et al, The Preterm Prediction Study: Toward a multiple marker test for spontaneous preterm birth,Am J Ob Gyn Sept 2001, Vol 185, #3, p 643-651 Honest, H, Accuracy of cervicovaginal fetal fibronectin test in predicting risk of spontaneous preterm birth: systemic review, BMJ, Vol 325, Aug 10 2002, p1-10 Tocolysis Gyetvai, Kristen, et al, Tocolytics for Preterm Labor: A Systematic Review, OB/Gyn Vol 94 (5 part 2) Nov 1999, p 869-877
79. References Infections: BV Hauth, J Reduced Incidence of Preterm Delivery with Metronidazole and Erythromycin in women with Bacterial Vaginosis, NEJM Dec 28, 1995, p 1732-1736 Carey, C et al, Metronidazole to prevent preterm delivery in pregnant women with asymptomatic Bacterial Vaginosis NEJM, Vol 342 (8) Feb 24 th 2000, pp 534-540 Riggs M & Klebanoff M, Treatment of vaginal infections to prevent preterm birth: a Meta-Analysis, Clinical Obstetrics and Gynecology, 2004 Vol47, #4, p796-807 Shennan A, et al, A Randomized controlled trial of metronidazole for prevention of preterm birth in women with positive Cevicovaginal fetal fibronectin: the PREMET study, BJOG 2006, 113:, p 65-74
80. References Infections BV USPSTF, Screening for Bacterial Vaginosis in Pregnancy, Recommendations and Rationale, Amer Fam Physician, March 15 th , 2002, Vol 65, #6 p 1147-1150 Ugwumadu, A et al, Effect of early oral clindamycin on late miscarriage and preterm delivery in asymptomatic women with abnormal vaginal flora and bacterial vaginosis: a randomised controlled trial, Lancet vol 361, 3/22/2003, p 983-988 Infections 2002 revised group B strep prevention guidelines. MMWR in Volume 51, RR-11.August 16 th 2002
81. References Preterm Contractions and Digital Cervix Iams, J et al, Requency of uterine contractions and the risk of spontaneous preterm birth NEJM 2002: 346: 250-5 Guinn, D et Al Management options in women with preterm uterine contractions: a randomized controlled trial, Am J Obstet Gynecol Vol 177, #4, 1997, p 814-815 Other Crowther, C et al, Neonatal Respiratory Distress Syndrome after Repeat exposure to antenatal corticosteroids: a randomized controlled trial; Lancet 2006, 367, p1913-19 Peltoniemi, O et al, Randomized Trial of a single repeat dose of betamethasone treatment in imminant preterm birth, Peds Feb 2007, vol 119, #2, p 290-298
82. References: Progesterone Meis, P et al, Prevention of Recurrent Preterm Delivery by 17 Alpha-Hydroxyprogesterone Caproate, NEJM Vol 348 #24, June 12 th 2003, p 2379-85 Da Fonseca, E et al, Prophylactic administration of progesterone by vaginal suppository to reduce the incidence of spontaneous preterm birth in women at increased risk: A randomized placebo controlled double blind study, Am J OB Gyn, Vol 188 (2) Feb 2003, pp 419-424 Coomarssamy, A et al, Progesterone and the prevention of preterm birth, a critical review of the evidence, European J OB/Gyn, 2006, 129: p111-118 Dodd, JM et al, Prenatal administration of progesterone for preventing preterm birth, Cochrane, Jan 25 th 2006
83. References PPROM Hartling, l et al, A systematic review of intentional delivery in women with premature prelabor rupture of membranes, j of Mat-fetal and Neonatal Med, March 2006 19 (3), 177-187 Wu, Y et al, Chorioamnionitis as a risk factor for Cerebral Palsy, a meta-analysis, JAMA, 2000, 284: p1417-24 Grier, M et al, Do antibiotics improve neonatal outcomes in PPROM, J of Fam Prac, Vol 50(7), July 2001, p626 Kenyon et al, Broad-Spectrum antibiotics for preterm prelabour rupture of fetal membranes: The ORACLE I randomized trial, Lancet 2001; 357: 979-88 Naef, R et al, PROM at 34 to 37 weeks gestation: aggressive vs conservative management, Am J OB/Gyn 1998; 178: 126-30
84. References Progesterone: Fonseca, E et al, Progesterone and the Risk of Preterm Birth among women with a Short Cervix, NEJM, 2007, Aug 2 nd , 357; p 462-9 Rouse, D et al, A Trial of 17 alpha-hydroxyprogesterone caproate to prevent prematurity in twins, NEJM, 2007, Aug 2 nd , 357; 454-61
86. PPROM 30-36 weeks: Metanalysis 4 studies, 389 women, 391 babies 1987-98, no steroids, no tocolysis, only one study gave antibiotics as GBS prophylaxis Intentional delivery with Less chorioamnionitis RR .16 (CI .10-.23) NNT 6 Maternal shorter length of stay, 1.4 days shorter No difference (induce/wait) in RDS 33/191 vs 36/200, IVH 6 vs 3, NEC 1 vs 2 Confirmed Neonatal sepsis 11/191 to 12/200 NICU stay 11 vs 11.7 days Perinatal mortality 0/191 to 3/200 (2 anomalies)
87. Risk of Preterm Birth < 35 weeks compared to cervical length of the 75% 1.0 1.0 75% 40 mm 9.5 6.7 10% 26 mm 13.9 9.5 5% 22 mm 24.9 14 1% 13 mm 28 weeks RR of PTB 24 weeks RR of PTB Percentile On Curve Length
88. Lifestyle: Drug Screening Self Report 3,142 Washington women, 40% participation Ever used IV Drugs 2% Ever Cocaine 15% Ever methamphetamine 11% This Pregnancy Marijuana 7% ETOH binge or daily use 2% Tobacco 18%
89. Vaginal Progesterone RTC of 142 High Risk singletons with prior preterm delivery in Brazil Vaginal Progesterone 100mg nightly 24-34 weeks 13/70 (18.6%) Placebo and 2/72 (2.8%) progesterone delivered before 34 weeks, RR of 0.11, NNT of 4
90. Tocolytics: - mimetics 2004 Systematic Review OR 0.79 CI (0.61-1.01) 5 RTC 55%, 332/601 mimetic 65%, 332/525 placebo LBW < 2,500 gms OR 0.76 CI (0.57-1.01) 6 RTC 18%, 117/639 mimetic 25%, 140/565 placebo RDS OR 1.08 CI (0.72-1.62) 7 RTC 9%, 62/682 mimetic 8%, 48/604 placebo Perinatal Mortality OR Sample Finding
Editor's Notes
Workshop 9/14/2004 32 nd Annual Advances in Family Practice and Primary Care: Perinatal Case Studies