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1、Improving Preterm Labor ManagementEric M. BuenviajeLCDR MC USNNaval Hospital BremertonThe CaseBR is a 23 year-old G1P0 at 31+3 weeks EGA who presented to the APTUReported contractions of worsening severity and increasing frequency over 12 hours since intercourseNo LOF or bleeding, + Positive fetal m

2、ovementsNo foul-smelling discharge or abdominal painThe CaseUncomplicated prenatal courseNo tobacco, EtOHMeds: PNVPMH, PSurgH, OBHx, GynHx, Soc Hx: UnremarkableThe CaseExam:Vitals: Within Normal Limits Cervical: 8cm/Complete/? Station (bulging bag)FHT pattern overall reassuringLabs:GBS unknown; O po

3、sitive; otherwise unremarkableInitial TreatmentTrendelenburgTerbutaline 0.25mg SQ x1Dexamethasone 6mg IM x 1 administeredMagnesium Sulfate 4g load and 2g/hour IV infusion startedAdmitted secondary to advanced cervical dilatationInitial Evaluation and TreatmentPatient was counseled regarding the risk

4、s of preterm labor and the risks and benefits of Tocolysis for fetal considerationsUnasyn 3g IV q6h started for exposed membranes and unknown GBS statusBiometry: Vertex Male, estimated FW 2113 grams, posterior placenta, +GFMInitial contact made with Peds, MAMC MFM and NICUHospital CourseDexamethason

5、e administered at q12 hour dosing schedule.Clinically, stable with no signs of magnesium toxicityMagnesium increased progressively to 4g/hour when contractions continued. Hospital Course (contd)Magnesium infusionLater that day: Nausea treated with IV antiemetics. Contractions essentially resolved.12

6、 hours into admission: extreme nausea, fatigue, diplopia, hyporeflexia (Mag level 10.8)Decreased magnesium to 1g/hour with improved sx, but return of contractions.Magnesium d/cd, Nifedipine started.Hospital Course (contd)After 24 hours, decision was made to AROM and deliver the child vaginallyBy ear

7、ly afternoon of that day, an infant male with apgars of 8/9 weighing 1927 grams was delivered and transferred to MAMC.Process ImprovementNHB 2nd Year Resident Process Improvement ProjectsBased on Standard Process Improvement Model - FOCUS-PDCAExercise in process analysis, implementation of improveme

8、nts, and the appropriate application of leadership in the military hospital settingThe ProjectProcess ImprovementMethod of examining processes and making them more effectiveBenefits patients by providing better, more efficient careBenefits the command by reducing waste, cost, errors, and variability

9、; and increasing efficiencyFOCUS - PDCAFind a process to improveOrganize a team and its resourcesClarify current knowledge about the processUnderstand sources of variation and clarify steps in the processSelect an improvement or interventionFOCUS - PDCAPlan analyze the process, determine changes tha

10、t would improve the processDo Put your change into motion on a small scale/trial basisCheck/Study check to see if the change is workingAct if the change works, implement on a larger scale; if not, refine/reject, and try againPreterm LaborThe presence of contractions with progressive cervical effacem

11、ent and dilation between 20-37 weeks gestation11-12% of all births in the U.S. are pretermAccounts for 70% of neonatal mortalityEstimated cost: $6 billion annuallyWhen Tertiery Care is not an optionLiterature Search OVID SearchSystematic ReviewsOB ReviewsOB LiteratureACOG Practice Guidelines/Technic

12、al BulletinsTocolytics for Preterm LaborDelay DeliveryAdministration of CorticosteroidsReduces risk of neonatal RDS and mortalityGoal is 48 hours, although some benefit is seen at 18 hoursTocolyticsThe EvidenceMagnesium SulfateCalcium Channel BlockersBetamimeticsCOX InhibitorsTocolyticsContraindicat

13、ionsNon-reassuring fetal assessmentIntra-uterine fetal demiseSevere IUGRChorioamnionitisMaternal hemorrhage with hemodynamic instabilitySevere preeclampsia or eclampsiaLethal fetal anomalyMagnesium SulfateEfficacyFailed to demonstrate benefit vs placebo for prolongation of pregnancy. Cochrane review

14、 of 23 trials showed no evidence of clinically important effect and did not significantly reduce the proportion of deliveries within 48 hours.Magnesium SulfateSide EffectsFewer maternal side effects vs beta-mimeticsDiaphoresisFlushingNausea, vomiting, headaches, visual disturbancesLoss of DTRsPulmon

15、ary edemaPossible increased fetal/neonatal complicationsSlight decrease in baseline FHR and variabilityIncreased risk of total perinatal deathsRecommendation: Magnesium Sulfate should not be used for tocolysisMagnesium SulfateContraindicationsMyasthenia gravisKnown myocardial compromise or hx of con

16、duction abnormalitiesImpaired renal functionNifedipineEfficacyNo placebo-controlled trials. Nifedipine has been compared vs other tocolytics.Reduced #s giving birth within 7 days (RR 0.76 95%CI 0.60-0.97). More effective than beta-mimetics in delaying delivery for 48 hours. Also noted were apparent

17、reduction trends in NN RDS, NEC, and IVH.NifedipineSide EffectsMaternal: Nausea, flushing, headaches, dizziness, palpitations, decreased MAP (often with associated reflex tach)Fetal: Animal studies reveal decreased uterine blood flow, but human doppler studies have not demonstrated this.Contraindica

18、tionsConcurrent use of other tocolytics, esp MgSO4 could be synergistic, resulting in respiratory paralysis and/or cardiovascular collapseNifedipineBottom lineMay be used as a first-line tocolytic with less severe side-effect profile than Magnesium or beta-mimetics -mimetics(terbutaline and ritodrin

19、e)Efficacy2 meta-analyses (890 and 1000 patients) demonstrated decreased likelihood of delivery within 48 hours of therapy initiation without significant increase in infant death rates -mimeticsSide effectsMaternal: Cardiotropic effects (increase heart rate, decreased stroke vol).Chest discomfort, p

20、alpitations, SOB. Myocardial ischemia and pulmonary edema are rare.Hypokalemia, hyperglycemiaFetalTachycardiaHypoglycemia-mimeticsContraindicationsCardiac diseaseHyperthyroidismDiabetes MellitusSpecial ConsiderationsCheck serum K+ and glucose periodicallyCOX inhibitors(Indomethacin)EfficacySystemati

21、c review found that COX inhibitors were effective in reducing birth before 37 weeks of gestation (RR 0.53, 95%CI 0.31-0.94)More effective than placebo in inhibiting PTL over a 24 hour course of therapyCOX inhibitorsSide Effects:Maternal: Nausea, reflux, gastritis, and emesis (approx 4%)Fetal:Ductus

22、arteriosus:Premature narrowing or closureMore severe PDA post-partumOligohydramniosDecreased fetal urine outputOther possibleBronchopulmonary dysplasia, NEC, IVH?COX inhibitorsContraindicationsPlatelet dysfunctionBleeding disorderAsthmaGI ulcerative diseaseRenal dysfunctionSonography q week for olig

23、ohydramnios and ductus arteriosus constriction if therapy 48 hoursSummarySelect agent based on efficacy and safety particular to each patientBeta-mimetics and indomethacin are more effective than placebo in prolonging gestation. Nifedipine has not been compared vs placebo, but appears to be as effic

24、acious as other tocolytics (with a more desirable side effect profile).Know risks and side effects of each agentCaution with concurrent useOther IssuesPediatricsNo NICU, limited nursery capabilitiesNo in-house peds after hoursEquipment requirements for preterm deliveryIsoletteAppropriate sizes for E

25、TT, NGT, bladesSurfactant availabilityAppropriate concentration/dose of medsReferencesAmerican College of Obstetricians and Gynecologists. Management of Preterm Labor. ACOG Practice Bulletin #43. American College of Obstetricians and Gynecologist, Washington, DC 2005.Anotayanonth, S. Betamimetics for inhibiting preterm labor, Cochrane Database of