Conservative management of Thr preterm labour

What may be  causes, Investigations , available management options for ? Irritable uterus –What may be causes where there are no signs of active PTL at 31 weeks (dating scan done) but she complains of continued painful frequent contractions for last 2 weeks??

Causes of Irritable uterus or Thr PTL:_: Inflammatory conditions, such as 1) subclinical chorioamnionitis, 2) upper genital tract infection 3) urinary tract infections or pyelonephritis are the common causes of  irritable contractions. The other causes for uterine Irritability include 4) subchorionic placental bleeding.  Likewise,5) gastrointestinal problems, such as gastroenteritis with vomiting and

diarrhoea or 6) even significant constipation may also trigger uterine irritability.

Examination & List of Investigations: Any woman presenting with such painful regular contractions should be admitted and evaluated .She should be offered adequate analgesia and assessed for imminent delivery.  Routine systemic physical assessment of the mother, Scrutiny of ANC records , followed by  abdominal palpation and 1) cervical assessment via a speculum examination, 2) vaginal

Examination 3) better still àa transvaginal ultrasound scan for cervical length (TVCL) should be undertaken if feasible  4) as well as tests such as fetal fibronectin (fFN) detection to establish the likelihood of delivery.4B) genital and cervical culture swabs

  Misc investigations:-Assessment should include investigations for inflammatory conditions as stated earlier including 5) Urine analysis 6) ultrasound scan for fetal growth and well-being and examination of the placenta for evidence of concealed bleeding have be performed in conjunction

with TVCL assessment as stated.

 Management :  Admission, CTG, Analgesics, Laxative if warranted  1) tocolysis 2)  steroid cover& 3) Mag so4 for neuroprotection f she is < 32 weeks .4) Vaginal progesterone may play a role in prolonging pregnancy to 34 weeks.^.5)  Group B streptococcal infection prophylaxis and women in preterm labour should receive antibiotic prophylaxis.

  Dilemma 1 :-Should we continue tocolysis is pain/irritability subsides and she is back home undelivered?? But by and large maintenance tocolysis (say Nifedipine) is not recommended for uterine irritability. Not only have studies demonstrated that they are of questionable value in terms of prolonging the pregnancy, but it is also suggested that women with uterine irritability may demonstrate resistance to commonly used tocolytics. Further analysis is still required to determine if improvement in neonatal

outcomes warrants this intervention for women with irritable uterus uterine irritability is associated with a higher rate of preterm delivery than the general population (although lower than for women with other preterm labour risk factors).^.  It is possible that a woman with ongoing irritable uterine contractions may develop preterm labour, but fail to recognise it until ‘too late'. Thus the question facing clinicians revolves around how to mitigate these risks.

 Dilemma 2: Should we repeat corticosteroids if labour is decayed upto say 37 weeks (initial dose was at 31 weeks)??  Administering corticosteroids for fetal lung maturity is a routine part of managing preterm labour. It has been demonstrated that a single course of corticosteroids administered after 27 weeks is as efficacious as multiple ‘rescue' doses. It could be proposed that all women presenting with contractions after 27 weeks gestation

be given corticosteroids at their initial presentation, regardless of

Cervical assessment or likelihood of imminent delivery, in order to

ensure optimal fetal lung maturity.

Dilemma   3: Group B streptococcal prophylaxis: Dose duration, type of drug??  Group B streptococcal     infection  Infants delivered prior to 37 weeks gestation are at increased risk from group B streptococcal infection and women in preterm labour should receive antibiotic prophylaxis. Antibiotic cover needs to be initiated at least hours prior to delivery in order to have the full protective effect. The key to management remains careful surveillance. Many women will self-refer for assessment due to concerns  regarding the changing nature of their ‘regular' uterine irritability,

suspected ruptured membranes, bleeding or altered fetal movement patterns.

Dilemma 5: Any member is in favour of regular TVCL measurement & repeat fFN assessment?? Please do express your practice pattern & share your views and opinion. Women with other risk factors for preterm labour, regular TVCL measurement may be necessary and repeat fFN assessment may be warranted. Our primigravida is almost certainly experiencing an irritable uterus. She was given corticosteroids at her first admission at 28 weeks, and evidence suggests her baby will not benefit from any further

Opinion of members warranted No 1: How many members are favour of repeating another course of rescue corticosteroids at about 36 weeks is pains don’t ensue meanwhile?

Opinion of members warranted: 2: What antibiotics is worthy for Group B Srepto prophylaxis ??

Dilemma : : What is the drug of choice for acute tocolysis in irritable uterus at 31 weeks or for Thr PTL at 31 weeks?

Dilemma 4: How many us believe that continued tocolysis is not harmful and we should take advantage of such prophylaxis?? Kindly expres your opinions freely .

Conclusion:--Threatened preterm labour (TPL) is a serious complication of pregnancy and should be treated according to best practice guidelines. While some women who experience preterm contractions will settle spontaneously, some will continue to experience painful contractions, without cervical changes, for the remainder of their pregnancy. The management of the ‘irritable uterus' represents a dilemma in management for clinicians. Depending on gestation and local facility guidelines, it may be appropriate to consider tocolysis and steroid cover. A number of women will not demonstrate any of the features of labour and a diagnosis of irritable uterus may be entertained. Irritable uterine activity may commence at any stage during a pregnancy and persist for its entirety or be only a transient experience.

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Identification and, where possible, treatment of underlying causes

of uterine irritability may allow for complete resolution. Admission to the antenatal ward for ongoing observation and assessment is often warranted. Occasionally, contractions thought to be associated

with TPL (threatened Preterm Labour) or uterine irritability may be the result of pseudo-labour, a poorly understood variant of conversion disorder, often associated with anxiety and emotional disturbance.^. For women experiencing ongoing uterine irritability without any obvious cause, antenatal care can usually proceed in the normal

manner.

.. Management at this presentation should consist of analgesia and routine assessment, including CTG monitoring. She should have cervical assessment incorporating swabs for fFN, vaginal and endocervical cultures. Cervical dilatation should be checked and urine analysis performed.

If it is determined she is in labour, she will require antibiotics and possibly transfer to an appropriate facility. If the assessment does not suggest imminent delivery, she should have an ultrasound scan arranged, including TVCL. Admission to the antenatal ward may be appropriate and any possible underlying causes of uterine irritability should be identified and treated.

Her ongoing antenatal care should involve careful assessment of uterine activity and causes of uterine irritation should continue to be explored. There is no indication for prophylactic tocolysis; however, vaginal progesterone may be of benefit. Her management should include assessment of any contributing psycho-social factors, in addition to providing reassurance that her concerns are being taken seriously. Encouragingly, many women with this presentation will continue their pregnancy to term and deliver without complications.