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Premature birth is the most common abnormal time frame of pregnancy and the leading cause of morbidity and mortality in perinatal and infants

Published: 2019-09-27 Author: Blue Spirit Parenting Network editor Parenting Network h20pulse.com

Consensus on common problems in preterm birth, this article is all!

Premature birth is the most common abnormal time frame of pregnancy and the leading cause of morbidity and mortality in perinatal and infants. Because the issue of preterm birth is so important, there are endless guidelines in various countries. In 2016, the World Health Organization (WHO) identified the prediction and prevention of preterm birth as a “priority research topic”.

In February 2018, a team of professors Zarko Alfirevic from the University of Liverpool, UK, a renowned obstetrician scientist, performed a meta-analysis on 49 preterm birth guidelines worldwide, including the "Guidelines for the Clinical Diagnosis and Treatment of Preterm Birth" published in 2014 in China. The authors analyzed the consensus in the guide, summarized their common recommendations, and published it in BJOG.

早产是最常见的妊娠时限异常,也是围产儿及婴幼儿发病与死亡的主要原因

Figure: Screenshot of the article published

In the mother and fetus forum branch of the Third Oriental Obstetrics and Gynecology Forum yesterday, Professor Hu Yali from the Drum Tower Hospital of Nanjing University School of Medicine delivered a keynote speech entitled "Progress in Research on Prevention and Treatment of Preterm Birth".

早产是最常见的妊娠时限异常,也是围产儿及婴幼儿发病与死亡的主要原因

Professor Hu focused on introducing the seven recommendations common to the major guides presented in this article, and explained the key points in dealing with common problems in preterm labor based on consensus.

早产是最常见的妊娠时限异常,也是围产儿及婴幼儿发病与死亡的主要原因

Figure: 49 guidelines highly recommend 7 treatment principles for preterm birth

Consensus 1: Prediction of Premature Birth with Cervical Length Measurement, Limited to Populations at High Risk of Preterm Birth

For patients with a previous spontaneous spontaneous abortion or a history of preterm birth, vaginal ultrasound measurements of cervical canal length are performed at 16-24 weeks (mid-term). The measurement of the length of the cervix helps to grasp the indications for vaginal progesterone use.

The standard measurement method of the cervical canal is divided into "four steps": ① empty the bladder and perform transvaginal ultrasound measurement; ② the mid-sagittal section to clearly show the endometrial line; ③ enlarge the image to 75% of the entire screen; ④ continuous measurement 3 Times, take the shortest value.

早产是最常见的妊娠时限异常,也是围产儿及婴幼儿发病与死亡的主要原因

Figure: Vaginal ultrasound, median sagittal view

Consensus 2: If the cervical length is significantly shortened before 24 weeks, vaginal progesterone should be given

For a single child without a history of premature birth, and those with cervical ≤ 20 mm in the second trimester, special vaginal progesterone should be used to prevent preterm birth. Specific usage: Micronized progesterone 200 ug or natural progesterone vaginal suppository 90 ug, vaginal, once a day, until 34 weeks of pregnancy.

A 2011 review published in the journal Am J Obstet Gynecol showed that special progesterone for vagina can improve the prognosis of preterm infants, reduce the hospitalization rate of NICU and reduce the hospitalization rate of NICU regardless of the gestational week (up to 28, 30, or even 35 weeks) The occurrence of mechanical ventilation, neonatal death, and low birth weight.

It is worth noting that in 2017, the American College of Obstetricians and Gynecologists (ACOG) reiterated that for patients with a single pre-existing history of preterm birth, this time no symptoms of preterm birth, vaginal progesterone is less effective than progesterone intramuscular injection. Specific usage: 16 to 36 weeks of pregnancy, given 17 mg of progesterone 250 mg intramuscularly Q7D

Consensus 3: For those who are at risk for preterm birth, a tocolytic inhibitor can be used for a short period of time for 48 hours.

The short-term use of tocolytics is an important method to prevent immediate preterm labor. Its purpose is to complete:

Promote fetal lung maturation

Magnesium sulfate protects the fetal nervous system

Referral of a pregnant woman to a unit with a NICU condition

Professor Hu pointed out that the indications of uterine contraction inhibitors need to be clearly understood: it should only be used for prolonged gestational weeks, which is beneficial to mothers and children, who have frequent uterine contractions and significant changes in the cervix. For those who have only regular contractions and no obvious changes in the cervix, most of them can deliver at full term, and the incidence of true preterm birth is very low.

Before applying tocolytics, obstetricians need to consider the following:

① Is pregnant woman a true premature birth?

② Are there any contraindications for continuing pregnancy? Such as stillbirth, lethal malformation, unstable fetal status, severe preeclampsia / eclampsia, maternal hemorrhage, cashmere inflammation, premature rupture of the membrane that cannot be ruled out, although premature rupture of the membrane, but no benefit for perinatal extension for 48 hours

③ Is the gestational age correct?

⑤ Is it possible to promote fetal lung maturity?

⑥ Can I be transferred?

如何 What is the willingness of the mother?

Major global guidelines recommend that the duration of tocolytic inhibitors is 48 hours. Prolonged medication does not significantly reduce preterm birth rate and increases adverse drug reactions, so continuous tocolytic therapy after 48 hours is not recommended

In 2016, the ACOG guidelines for managing preterm labor clearly stated that no matter what kind of tocolytic inhibitors, there is no direct help for neonatal outcomes. Its most important purpose is to promote fetal lung maturity and facilitate smooth transfer to hospital.

Consensus 4: antibiotics for premature delivery of premature rupture of membranes

Premature premature rupture of membranes (PPROM) is a clinically difficult problem, accounting for about one-third of premature births, and 50% to 60% of PPROMs are delivered within 1 week. The complications of PPROM are very many. The incidence of concurrent velvet sheep is 13% ~ 60%, the incidence of placental abruption is 4% ~ 12%, and the umbilical cord is compressed and fetal distress. In addition, newborns are prone to complications such as RDS, sepsis, and necrotizing enteritis.

After PPROM, it is important to assess the condition. Clinicians need to evaluate factors such as infection, placental abruption, and umbilical cord compression, and consider the intrauterine safety of the fetus to determine whether they can expect treatment. International guidelines have not yet been conclusive on the appropriate interval between repeated assessments.

If PPROM occurs, there is no obvious cashmere inflammation and conditions are expected to be treated, antibiotics need to be applied clinically to prevent infection, to reduce the incidence of neonatal complications, reduce maternal infection, and prolong the gestation week. The specific antibiotic recommendation is the recommendation given by the Institute of Child Health and Human Development (NICHD) in 1997: ampicillin 2.0 g Q6h combined with erythromycin 0.25 g Q6h ivgtt is maintained for 48 hours, and amoxicillin 0.25 g orally administered Q8h combined Erythromycin 333 mg Q8h to day 7.

Consensus 5: Magnesium sulfate helps protect fetal neurodevelopment and can reduce the severity of cerebral palsy and cerebral palsy

The 2016 ACOG guidelines state that magnesium sulfate as a fetal neuroprotective agent is recommended for routine use of premature birth before 32 weeks (type A evidence), and does not exceed 48 hours.

According to the 2011 SOGC guidelines, the specific use of magnesium sulfate is: preterm labor before 32 weeks of pregnancy, administering magnesium sulfate after cervical dilation, a intravenous drip of 4.0 g, 30 minutes after completion, and 1 g / h until delivery.

In 2017, a meta-analysis published by the University of Auckland's Liggins Institute in PLOS Medicine showed that prenatal administration of magnesium sulfate to patients with preterm births could reduce perinatal mortality and reduce the incidence of cerebral palsy: an average of 41 pregnant women had preventive medication, reducing 1 Neonatal deaths / cerebral palsy. And, no matter what the cause of premature birth, no matter what the preterm birth week, this benefit exists. Therefore, researchers have advocated the worldwide promotion of magnesium sulfate use.

Consensus 6: glucocorticoids can be used to promote fetal lung maturation

The 2017 ACOG guidelines set out the following recommendations for prenatal glucocorticoids to promote fetal lung maturation:

1. For gestation within 24 to 33 + 6 weeks, who may give birth within 7 days, including premature rupture of membranes and multiple pregnancy, a single course of glucocorticoids (GS) is recommended; for those who are 23 weeks pregnant and may give birth within 7 days, according to the pregnant woman and her Family Opinion Recommended Single Course GS as appropriate

2. For pregnant women who have a smaller gestational week (near survival) and may give birth within 7 days, use GS as appropriate according to the willingness of the pregnant woman and family to recover.

3. For pregnant women who are 34 ~ 36 + 6 weeks pregnant and may give birth within 7 days, and who have not received antenatal GS before, a single course of GS is recommended.

Consensus 7: Cervical banding can be applied before 24 weeks for those who have had multiple preterm births and who have had a shortened cervix at the same time.

The indications for cervical cerclage to prevent preterm birth are: a history of advanced abortion / premature birth with premature cervix, single pregnancy, or painless cervix shortening during mid-pregnancy; meanwhile, those who continue to have contraindications to pregnancy such as vaccination It is worth noting that cervical cerclage is not effective for uterine dysplasia, twins, and cervical cone cutting.

Among the cervical cerclage methods, the modified McDonalds operation and Shirodkar operation performed via the vagina are still the first-line recommendations of the guideline, and the two effects are equivalent. Transabdominal cerclage is only suitable for those who cannot or can't transvaginally.

In 2017, Professor Zarko Alfirevic also performed a meta-analysis on cervical cerclage, showing that the biggest benefit of cervical cerclage is that it can reduce the delivery rate before 37 weeks (RR 0.66 ~ 0.89, high-quality evidence), and the impact on perinatal infants remains to be seen. Further research and observation.

references:

[1] Clinical guidelines for prevention and management of preterm birth: a systematic review, Br. J Obstet Gynecol 2018. PMID: 29460323

Finishing | Yu Xiaosu

Source | Medical Obstetrics and Gynecology Channel

The Third Oriental Obstetrics and Gynecology Forum inherits the spiritual characteristics of previous sessions, bringing together top experts and scholars in the field of obstetrics and gynecology from around the world, drawing on relevant clinical experiences at home and abroad, learning and sharing with fellow colleagues, bringing you a An academic feast. The "Medical World" reporter will show you more exciting content in the future, so stay tuned!

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