Management of Threatened Preterm Birth PTB Learning Objectives

Management of Threatened Preterm Birth (PTB)

Learning Objectives At the end of session, the learners will be able to: • Describe the identification of threatened preterm birth (PTB) • Explain the management of threatened PTB • Explain the need for antenatal corticosteroids (ANCS), type of corticosteroid, dose and when to give 2

Preterm Birth is a Leading Cause of Neonatal Deaths in India Causes of neonatal deaths Others 5% Birth asphyxi a 19% Infectio ns 34% Malfor mations 8% Preterm 34% Mortality and morbidity due to prematurity can be prevented by providing PTB care & interventions: • To all pregnant women- primary prevention & reduction of risk of PTB e. g. smoking cessation program • To pregnant women with known risk factors e. g. on progestin agents, cervical cerclage • To pregnant women in which PTB is inevitable - most beneficial • Essential & additional care to preterm newborns to prevent or treat potential complications 3

Criteria for Management of Threatened PTB • • Accurate gestational age assessment Accurate diagnosis of conditions leading to PTB Rapid identification and treatment of maternal infection Adequate preterm newborn care, including: § Resuscitation § Thermal care § Feeding support § Infection treatment § Safe oxygen use 4

Correct estimation of GA for identification of PTB Source: Helping Mothers & Babies Survive If < 37 weeks, and birth expected in next 7 days: Plan for PTB care 5

Conditions leading to PTB • • • Antepartum Haemorrhage (APH) Preterm Pre-labour Rupture of Membranes (PPROM) Severe Pre-eclampsia/Eclampsia (PE/E) Infection of genital tract Conditions leading to over distension of uterus If < 37 weeks, and birth expected in next 7 days: Plan for PTB care 6

Plan for PTB care depending on GA and condition Source: Helping Mothers & Babies Survive 7

Antenatal Corticosteroids § Estimation of correct gestational age is a critical function before administering ANCS § For preterm labour between 24 -34 weeks gestation give antenatal corticosteroids to mother for baby’s lung maturity § Antenatal corticosteroid therapy has maximal effect if the foetus is delivered 24 hours after the last dose and up to 7 days thereafter § Partial effect is evident within a few hours before birth Drugs and dosage Injection Dexamethasone 6 mg intramuscularly, 12 hourly 4 doses OR Injection Betamethasone 12 mg intramuscularly, 24 hours apart 2 dose 8

Which corticosteroid should be given § Dexamethasone is a more appropriate option and recommended over Betamethasone because o Easily available (included in WHO essential drug list) o Inexpensive o Heat stable (no need to refrigerate) § Oral Preparations of steroids are not to be used § ANCS have a role even if surfactant replacement is available § Repeated courses/more frequent doses are not useful. Multiple courses in fact could have harmful neuro-developmental effects in the baby 9

When to give Antenatal Corticosteroid? Indications 1. True preterm labour (between 24 -34 weeks of gestation) 2. Conditions that lead to imminent delivery (between 24 -34 weeks of gestation) • Antepartum haemorrhage • Preterm pre-labour rupture of membrane • Severe preeclampsia/Eclampsia Contraindications Frank Chorioamnionitis (absolute contraindication) Signs and symptoms of chorioamnionitis • H/O fever, lower abdominal pain • Foul smelling vaginal discharge • Tender uterus • Maternal and foetal tachycardia 10

Other medications for PTB management Source: Helping Mothers & Babies Survive 11

Key Messages • Preterm birth is a leading cause of neonatal deaths • Mortality due to PTB can be prevented by giving PTB care & interventions • Important maternal interventions for threatened PTB are: use of ANCS, Mg. SO 4, Antibiotics & Tocolysis to delay labour • Accurate estimation of GA is crucial for deciding intervention • Important newborn interventions for PTB are: Newborn Resuscitation, Thermal Care, Feeding Support, Infection Treatment & Safe Oxygen Use 12