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• Full and microscopic examination of urine (urine feme): to assess renal function in general.
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• Full and microscopic examination of urine (urine feme): to assess renal function in general.
• Wet mount for evaluation of vaginal ecology.
• High Vaginal Swab (HVS) for evaluation of vaginal discharge for culture and sensitivity.
Management of Threatened Premature Labor
The choice of means to arrest premature labor is limited, as in majority of cases premature labor is associated with maternal and/or fetal complicating factors when the early expulsion of the fetus may be beneficial.
In cases when the fetus is not compromised, the maternal condition remains good and membranes are intact the following regimen may be administered to arrest premature labor.
Absolute bed rest is indicated, the patient should lie preferably on the left side.
In women with a singleton pregnancy, no history for preterm birth, and cervical length is 20 mm or less before or at 24 weeks vaginal progesterone 8% gel (90 mg daily) orMicronized progesterone capsules (200 mg vaginally daily) should be administered.
17 hydroxy progesterone caproate may be administered in dose 250 to 500 mg weekly by intramuscular injection during the first half of pregnancy.
Progesterone is a substance produced by the ovary and placenta that acts to prepare for and maintain pregnancy. Progesterone has been shown to help prevent the cervix from shortening in women with TPTL.
Tocolysis for preterm labor
Tocolysis is an inhibition of uterine contractions.
Tocolytic drugs may delay birth and allow: a). administration of corticosteroids; b). administration of Magnesium Sulfate for neuroprotection; c). in-utero transfer to an appropriate level facility.
There are contraindications for tocolysis:
- Acute fetal distress
- Chorioamnionitis
- Eclampsia or severe preeclampsia
- Fetal demise (singleton)
- Fetal maturity
- Maternal hemodynamic instability (eg, bleeding)
Indications for tocolysis:
- TPTL with intact amniotic membranes,
- cervical dilation < 4 cm,
- cervical effacement less than 80%.
Medications used as tocolysis:
- Ritodrine (Yutopar), Terbutaline (Bricanil) - β 2-adrenergic receptor agonists sympatomimetis, decrease free intracellular calcium ions.
- Magnesium sulphate -intracellular calcium antagonist.
- Indomethacin (Indocin) - prostaglandin inhibitor.
- Nifedipine (Epilate) - Calcium channel blocker.
- Atosiban (Tractocile) - inhibitor of the hormones oxytocin and vasopressin.
- Etanol
Ritodrine or Yutopar regimens:
Ritodrine Hydrochloride may be prepared for intravenous infusion by dilution of 150 mg in 500 mL of 5% Dextrose to produce a solution containing 300 mcg (0. 3 mg) of ritodrine hydrochloride per mL. Initial dose: IV, 50 to 100 mcg (0. 05 to 0. 1 mg) per minute, increased every ten minutes as necessary in increments of 50 mcg (0. 05 mg) to the effective dose that balances uterine response and unwanted effects (increased maternal heart rate and decreased blood pressure and increased fetal heart rate), or until the maternal heart rate reaches 130 beats per minute. Maintenance: IV, 150 to 350 mcg (0. 15 to 0. 35 mg) per minute at the lowest dose that maintains a relaxed uterus.
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Ritodrin (Yutopar) orally for tocolysis: start oral therapy 30 minutes before termination of IV infusion at 10 mg every 2 hours for 24 hours. Subsequently, 10-20 mg every 4-6 hours according to patient's response. Max oral dose 120 mg daily.
Bricanil / Terbutaline regimens:
1 ml solution for injection contains 0. 5mg of terbutaline sulfate.
If a syringe pump is available, the concentration of the drug infused should be 0. 1 mg/ml (10 ml Bricanyl Injection should be added to 40 ml of 5% dextrose). At this dilution:
5 mcg/min ≡ 0. 05 ml/min and
10 mcg/min ≡ 0. 1 ml/min
If no syringe pump is available, the concentration of the drug should be 0. 01 mg/ml (10 ml Bricanyl Injection should be added to 490 ml of 5% dextrose. At this dilution:
5 mcg/min ≡ 0. 5 ml/min and 10 mcg/min ≡ 1 ml/min.
Initially, 5 mcg/min should be infused during the first 20 minutes increasing by 2. 5 mcg/min at 20 minute intervals until the contractions stop. More than 10 mcg/min should seldom be given, 20 mcg/min should not be exceeded. The dose must be individually titrated with reference to suppression of contractions, increase in pulse rate and changes in blood pressure, which are limiting factors. These parameters should be carefully monitored during treatment. A maximum maternal heart rate of 120 beats per min should not be exceeded. The infusion should be stopped if labor progresses despite treatment at the maximum dose. If successful, the infusion should continue for 1 hour at the chosen rate and then be decreased by 2. 5 mcg/min every 20 minutes to the lowest dose that produces suppression of contractions.
Calcium antagonists (verapamil, finoptin, isoptin) in doses of 40-80 mg should be given 25 min before the beginning of infusion of b-adrenergic sympathomimetics to prevent side-effects of adrenomimetics to the heart system (maternal tachycardia). After infusion the same drug should be prescribed in tablets to prolong the effect. Usually 3 to 5 infusions are prescribed for treatment, one infusion daily.
Magnesium Sulfate regimen:
Loading dose: IV MgSO4 4g bolus over 10-15 minutes (16 ml of 25% solution MgSO4 + 34 ml of normal saline solution)
Maintenance infusionof 1 g/h for at least 24 hours after the last convulsion (30 ml of 25% MgSO4 + 220 ml of normal saline solution with the rate 10-11 Dpm).
Indomethacin regimen:
The initial recommended dose is 100 mg PR followed by 50 mg PO every 6 hours for 8 doses.
Nifedipine regimen:
A recommended initial dosage of nifedipine is 20 mg orally, followed by 20 mg orally after 30 minutes. If contractions persist, therapy can be continued with 20 mg orally every 3-8 hours for 48-72 hours with a maximum dose of 160 mg/d. After 72 hours, if maintenance is still required, long-acting nifedipine 30-60 mg daily can be used.
Atosiban regimen:
Each vial of 0. 9 ml solution contains 6. 75 mg atosiban (as acetate). Atosiban is administered intravenously in three successive stages: an initial bolus dose (6. 75 mg), performed with atosiban 6. 75 mg/0. 9 ml solution for injection, immediately followed by a continuous high dose infusion (loading infusion 300 micrograms/min) of atosiban 37. 5 mg/5 ml concentrate for solution for infusion during three hours, followed by a lower dose of atosiban 37. 5 mg/5 ml concentrate for solution for infusion (subsequent infusion 100 micrograms/min) up to 45 hours. The duration of the treatment should not exceed 48 hours. The total dose given during a full course of atosiban therapy should preferably not exceed 330. 75 mg of atosiban.
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Spasmolytics: papaverine hydrochloride, no-spa, actovegin, etc. are also used for tyreatment of TPTL
Glucocorticoid therapy is mandatory for patients with TPTL. Maternal administration of glucocorticoids is indicated at pregnancy term less than 34 weeks. This leads to fetal lung maturation so that the incidence of respiratory distress syndrome can be minimized. This is beneficial only when the delivery is delayed beyond 24 hours but less than 7 days. Treatment regimens include betamethasone, in a dosage of 12 mg given intramuscularly every 24 hours for two days, or dexamethasone, in a dosage of 6 mg given intramuscularly every 12 hours for two days.
In women with a singleton pregnancy, with a history of preterm birth at less than 34 weeks, already receiving progesterone since 16 weeks cervical cerclage should be considered if the cervical length is less than 25 mm before 24 weeks. Most often, isthmico-cervical incompetence is an indication for cervical cerclage during pregnancy.
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