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A small number of poor quality studies have examined the outcome of specialist teenage antenatal services order pregabalin 75mg without prescription. Some show that antenatal care in schools improves earlier booking and attendance whilst others show that a hospital setting improves attendance purchase pregabalin from india. Again, there is no strong evidence to recommend hospital care, but the benefit of providing continuity of care through a specialist services is recognized. Compared with routine community midwifery care, teenagers who have received antenatal care from a specialist midwife were more likely to have received information and advice on sexual health screening, income support, maternity grants and benefits. With regards to pregnancy outcome, there is little evidence that specialist care has a positive effect but the studies conducted in this area are poor. In providing this care, the quality of life and outcome for the teenage mother and her child can be improved. Teenage pregnancy and social disadvantage: systematic review integrating controlled trials and qualitative studies. Teenage antenatal clinics may reduce the rate of preterm birth: a prospective study. Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors, 2010. Specialist antenatal services for teenagers should be provided to raise awareness and reduce the complications associated with teenage pregnancy. Close links should be developed with a range additional support services including the family nurse partnership. Therapeutic strategies for the prevention and treatment of pre-eclampsia and intrauterine growth restriction Charlotte Oyston Philip N Baker Abstract Intrauterine growth restriction and pre-eclampsia are common pregnancy complications that contribute significantly to maternal and perinatal morbidity and mortality, and long term health outcomes. The underlying aetiology of these conditions involves placental underperfusion and placental ischaemia. Most prophylactic and treatment measures for these conditions are hypothesized to have effect through improved placental perfusion, or reduced oxidative stress and subsequent placental damage. However, while many therapies have biologic plausibility, there is a lack of high quality evidence that they substantially improve important outcomes such as birth weight, prematurity, mortality or serious morbidity. This review will describe and evaluate therapies currently available in clinical practice for the prevention and treatment of pre-eclampsia and intrauterine growth restriction, and outline some promising new therapies, which may change the way these conditions are managed in the future. Modified spiral arteries lose their muscular wall, the vessel lumen becomes distended, and the vessels become flaccid, funnel shaped and void of vasoconstrictor ability. Functionally, this allows large volumes of maternal blood to pool in the intervillous space where it surrounds the fetal vessels, allowing transfer of oxygen and nutrients to occur between mother and fetus. The vascular adaptation of the spiral arteries is thought to be complete by the mid to late second trimester. If these changes are incomplete or inadequate, placental perfusion may become compromized and result in placental ischaemia. Aspects concerning screening, diagnosis, antenatal surveillance and timing of delivery are beyond the scope of this review and will not be discussed. Her previous pregnancy was complicated by severe growth restriction and she delivered a 2. The placenta from this pregnancy was small with multiple infarcts and features of maternal vasculopathy at histology. Aspirin inhibits the production of prostacyclin (a vasodilator) and thromboxane (a vasoconstrictor), both of which are present in the uteroplacental circulation. When given at low doses, aspirin selectively inhibits thromboxane, but not prostacyclin production. However, these studies were small and more recent, comprehensive data suggest the effect of aspirin is less than first thought. While they are distinct conditions, they may occur together, and are often considered together as they share a common aetiology of inadequate placental perfusion. In normal pregnancy, the terminal vessels of the maternal uterine circulation (the spiral arteries) undergo an ordered progression of changes from the first trimester.

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Nonreassuring findings buy generic pregabalin 150mg on line, which may indicate need for delivery buy discount pregabalin 150 mg line, are absent diastolic flow and reversed diastolic flow. Normal Umbilical Artery Diastolic Flow With permission, Institute for Advanced Medical Education, Absent Umbilical Artery Diastolic Flow With permission, Institute for Advanced Medical Education, It is held together by the following 4 joints: bilateral sacroiliac joints, the symphysis pubis, and the sacrococcygeal joint. The anterior superior edge of the first sacral vertebra is called the sacral promontory. The pelvis is divided by the linea terminalis into the false pelvis above and the true pelvis below. The false pelvis is bordered by lumbar vertebrae posteriorly, by the iliac fossa laterally, and by the abdominal wall anteriorly. The true pelvis is a bony canal formed by posterior sacrum and coccyx, lateral ischial, and anterior pubis. The inlet is triangular with convergent side walls, shallow sacral curve, and narrow subpubic arch. Assessment: the fetal head engages anterior-posteriorly, often in occiput posterior position, making delivery difficult. Assessment: the fetal head engages transversely and delivers occiput transverse position. Transverse Fetal Lie Presentation Portion of the fetus overlying the pelvic inlet. This is the only kind of breech that potentially could be safely delivered vaginally. It is expressed in terms stating whether the orientation part is anterior or posterior, left or right. Landmarks and Positions 112 Chapter 13 l Fetal Orientation in Utero Synclitism the condition of parallelism between the plane of the pelvis and that of the fetal head. Increasing frequency of contractions is associated with the formation of gap junctions between uterine myometrial cells. These events are correlated with increasing levels of oxytocin and prostaglandins along with multiplication of specific receptors. The contractile upper uterine segment, containing mostly smooth muscle fibers, becomes thicker as labor progresses, exerting forces that expel the fetus down the birth canal. The lower uterine segment, containing mostly collagen fibers, passively thins out with contractions of the upper segment. Cervical softening and thinning occur as increasing levels of oxytocin and prostaglandins lead to breakage of disulfide linkages of collagen fibers, resulting in increasing water content. This occurs as the passive lower uterine segment is thinned and pulled up by the contractile upper segment. In early labor (latent phase), the rate of dilation is slow, but at 6 cm of dilation, the rate accelerates to a maximum rate in the active phase of labor. The classic studies in defining normal labor (Friedman, 1954) were conducted on 500 women at a single U. These studies established norms for various parts of labor that have been used by obstetricians for decades. More recent studies (Zhang et al, 2010) are based on over 60,000 women in labor at 19 U. Stage 1 begins with onset of regular uterine contractions and ends with complete cervical dilation at 10 cm. Latent phase begins with onset of regular contractions and ends with the acceleration of cervical dilation. Latent phase rate of dilation is slower than previous studies showed and is similar in both multiparas and nulliparas. Active phase begins with cervical dilation acceleration, usually by 6 cm of dilation, ending with complete cervical dilation. The cardinal movements of labor occur in the active phase with beginning descent of the fetus in the latter part. Whereas in Stage 1 uterine contractions are the only force that acts on cervical dilation, in Stage 2 maternal pushing efforts are vitally important to augment the uterine contractions to bring about descent of the fetal presenting part.

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Conclusion Although the majority of women who have had a previous preterm birth will deliver at term in a subsequent pregnancy pregabalin 75 mg for sale, a history of previous preterm birth is a risk factor for another preterm birth purchase pregabalin from india. As the causes of preterm birth are diverse, it is unlikely that a single preventative measure will reduce rates of preterm delivery. Nevertheless, primary prevention through lifestyle advice and nutritional supplementation has potential to be an effective strategy. Predicting which women will spontaneously deliver preterm is problematic due to the lack of specificity of tests. Cervical length ultrasound and biochemical screening tests of preterm labour may be useful in identifying which women are unlikely to deliver preterm. However, although it is clear that preterm birth has major adverse consequences, there is no evidence that there is benefit to prolonging pregnancy where spontaneous preterm birth would otherwise have occurred. Preterm labour could represent a survival mechanism for the fetus, escaping a hostile intrauterine environment and evidence that a reduction in the rate of preterm birth is accompanied by neonatal benefit is lacking. There is significant potential for worsening outcome and further research in this area is essential before policies of screening and treating preterm birth can be routinely introduced. Universal maternal cervical length screening during the second trimester: pros and cons of a strategy to identify women at risk of spontaneous preterm delivery. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of individual patient data. Screening to prevent spontaneous e preterm birth: systematic reviews of accuracy and effectiveness literature with economic modelling. Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length. In the vast majority of women, the recommended method of induction of labour is by the use of vaginal prostaglandin E2. Induction of labour is associated with less maternal satisfaction and potentially increased rates of instrumental delivery and caesarean section compared with spontaneous vaginal delivery. Therefore, the decision for induction of labour should not be undertaken lightly and appropriate counselling of the mother and appropriate documentation of the provision of information in addition to the indications, risks, benefits and alternatives to induction of labour is advocated. It is therefore imperative that women be counselled appropriately antenatally regarding induction of labour, risks, benefits and alternatives. The human cervix consists mainly of extracellular connective tissue with the predominant molecules of the extracellular matrix being type 1 and type 3 collagen. Intercalated among the collagen molecules are glycosaminoglycans and proteoglycans, hyaluronic acid, dermatan sulphate and heparin sulphate. Fibronectin and elastin also run among the collagen fibers and it is the release of fibronectin from the interface between the chorion and the decidua that is utilized in tests used to predict preterm labour. It is necessary for the cervix to undergo several changes in order to stimulate the onset of labour and allow dilatation to occur. This process is known as cervical ripening and is the result of a series of complex biochemical reactions resulting in the cervix becoming soft and pliable. Late in pregnancy, hyaluronic acid, cervical collagenase and elastase increase in the cervix. This results in an increase of water molecules which intercalate among the collagen fibers. The amount of dermatan sulphate and chondroitin sulphate decreases, leading to reduced bridging among the collagen fibers. These changes, combined with decreased collagen fiber alignment, decreased collagen fiber strength, and diminished tensile strength of the extracellular cervical matrix, result in the ripening process. Near term, collagen turnover increases and degradation of newly synthesized collagen increases, resulting in decreased collagen content in the cervix. This is followed by myometrial contractions which result in cervical dilatation as the cervix is pulled over the presenting fetal part. The process of cervical ripening is induced by cytokines, nitric oxide synthesis enzymes and prostaglandins and hormones such as progesterone, relaxin and oestrogen.

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There is conflicting evidence from observational studies as to whether type of work or level of physical activity affects preterm delivery discount pregabalin 75 mg fast delivery. There is some evidence that shift work (particularly night shift) and heavy physical labour under stressful conditions may increase preterm delivery rates cheap 75 mg pregabalin amex. Nutritional supplements: low levels of micronutrients such as folate, zinc and iron have been associated with decreased duration of gestation. Evidence that folate supplementation in pregnancy can decrease preterm birth has been conflicting. Although the effect of preconceptual zinc supplementation on preterm birth has not been studied, a Cochrane review of zinc supplementation initiated prior to 27 weeks gestation has shown a small but significant reduction in preterm birth (relative risk 0. This risk reduction was predominantly seen in trials involving women of low income. Studies of other multinutrient supplements taken preconceptually or in early pregnancy, have not reduced preterm birth rates. Antibiotics: it has been hypothesized that subclinical intrauterine infections originating around the time of conception may be involved in the pathogenesis of recurrent preterm birth. For this reason, strategies of antibiotic treatments between pregnancies have been evaluated. However, these have not been shown to be beneficial in reducing subsequent preterm birth. Surgical procedures: it is thought that the mechanism through which uterine anomalies predispose to preterm birth is through overdistension of a reduced capacity uterus or uterine horn by the developing pregnancy. Correction of uterine abnormalities in an attempt to restore normal anatomy would seem a plausible way of improving pregnancy outcome. There have been no randomized controlled trials of surgical correction of uterine anomalies. Observational trials have suggested that hysteroscopic resection of uterine septae may improve pregnancy outcome. The pros and cons of other surgery must be carefully evaluated on a case-bycase basis, as research in this area is lacking. Pre-pregnancy laparotomy and abdominal placement of a cervical suture is sometimes undertaken in women with suspected cervical incompetence, particularly when previous vaginally placed sutures have failed. A systematic review of 13 case series and one non-randomized study reported a reduced risk of perinatal death or delivery prior to 24 weeks in women who had a transabdominal cerclage placed following failed transvaginal cerclage compared to women having repeat transvaginal cerclage. Transabdominal cerclage was associated with a significantly higher incidence of serious maternal morbidity. It is currently recommended that abdominal cerclage is only carried out in a research setting. The plan for antenatal management will usually involve supportive management and increased monitoring. There is some evidence that screening and treating infections may improve outcomes. Methods of predicting preterm birth and interventions to prevent or treat preterm labour are more contentious. Screening and treatment of infection Intrauterine infection is an important and common cause of preterm labour, and is associated with over one third of cases of preterm birth. In most cases infections are thought to ascend from the lower genital tract, but can also arise from haematogenous spread of pathogens. Rare causes are after iatrogenic introduction during intrauterine procedures, or from retrograde spread down the Fallopian tubes. Lower genital tract infection: strategies of vaginal microbial decontamination have been proposed as a way of preventing ascending infections that can cause in preterm birth. Unfortunately, in most cases, clinical trials have been disappointing in improving pregnancy outcome, and some have suggested worsening outcome. A randomized controlled trial of metronidazole for the prevention of preterm birth in high-risk women (identified by a positive fetal fibronectin test) was stopped early due to safety concerns over an increase in preterm births in women treated with metronidazole over placebo (relative risk 1. A metaanalysis of studies of antibiotic prophylaxis in asymptomatic women at risk of preterm birth (identified either through history of previous preterm birth, positive fetal fibronectin test results, or presence of abnormal bacterial flora) showed no benefit in terms of reduction of preterm labour. There is some evidence that selective treatment of infection may reduce preterm birth. One large randomized control trial has evaluated a program of screening and treatment of lower genital tract infections (bacterial vaginosis, trichomoniasis and candidiasis). This showed a reduction in preterm birth before 37 weeks with a relative risk of 0.