Alexandra Niken Larasati

FK UKI 0861050024

A birth at less than 245 days after conception, or, by menstrual dating, at
or after 20 and before 37 weeks (259 days) of gestation from the first day
of the last normal menstrual period, is commonly defined as preterm or
premature.
Births at or after 37 0/7weeks are considered to be term. Infants who
weigh less than 2500g at birth, regardless of gestational age, are
designated as low birth weight (LBW). Infants who weigh less than 1500g
are called very low birth weight (VLBW), and those below 1000g are
extremely low birth weight (ELBW).
Preterm and LBW infants have in the past been considered together, but
advances in the accuracy of pregnancy dating increasingly allow
outcomes related to gestational age to be distinguished from outcomes
related to birth weight.
This is important, because perinatal and infant morbidities vary
substantially according to age and maturity as well as weight.4 Obstetric
data are reported by gestational age. Traditionally reported by birth
weight, newborn and infant data are increasingly described by gestational
age as well.

Births before 37 weeks in the United States increased

annually from 9.4% in 1980 to a peak of 12.8% in 2006.
The rate has since fallen each year to just under 11.99% in
2010. Preliminary data from 2011 show a further decline to
11.72% (Fig. 40-1).

More than 70% of preterm births occur between 34 and

36 weeks (Fig. 40-2).

Although these late preterm infants experience significant morbidity, most

perinatal mortality and serious morbidity occurs among the 16% of preterm
infants (<3.5% of all births) who are born before 32 weeks gestation,
commonly called very preterm births (Fig. 40-3).

Preterm birth has been called multifactorial because of

the numerous obstetric and medical conditions that
accompany it.
Traditional obstetric taxonomy has not distinguished the
clinical presentations of preterm parturition (e.g.,
preterm labor, pPROM, cervical insufficiency) from
causative mechanisms such as infection, hemorrhage,
uterine distention, trauma, or fetal compromise, or from
risk factors (e.g., multiple gestation, prior preterm birth,
preeclampsia, abruptio placentae, placenta previa, fetal
growth restriction, maternal diabetes, hypertension,
pyelonephritis).

PERINATAL AND INFANT MORTALITY

Preterm birth is the leading cause of perinatal and infant mortality for infants born
to women of all races and ethnic backgrounds, and particularly for non-Hispanic
black women. The perinatal mortality rate is defined in two ways according to the
boundaries of the fetal and neonatal data reported.
Perinatal definition I begins with fetal deaths at 28 weeks of gestation and
extends to infant deaths at less than age 7 days. Perinatal definition II is more
inclusive, including all fetal deaths at 20 weeks gestation or more, and all infant
deaths less than age 28 days. The denominators for both perinatal rate
computations are per 1000 live births and fetal deaths for their respective time
periods.
Perinatal definition I is most useful when data are compared between states,
whereas definition II more accurately represents the combined effects of prenatal,
intrapartum, and neonatal care. The infant mortality rate is the number of deaths
of liveborn infants before 1 year of age per 1000 live births; stillbirths are not
included in the denominator. Rates of fetal, perinatal, and infant mortalities have
declined since 19902 (Fig. 40-5).
Fetal deaths account for more than half of perinatal deaths and are almost as
frequent as infant deaths. In 2005, there were 25,894 fetal deaths (51.6% between
20 and 27 weeks, and 48.7% after 28 weeks), and 18,782 neonatal deaths (79.9%
before 7 days, and 20.1% between 7 and 28 days after birth) (Fig. 40-6)

Gestational Age
especially between 22 and 32 weeks

Birth Weight
Very-Low-Birth-Weight Infants and Extremely-Low-Birth-Weight Infants

Maternal Race
The perinatal mortality rate in 2004 for infants born to non-Hispanic
black women in the United States was 20.17 (per 1000 live births plus
fetal deaths), compared with 10.73 for all other racial and ethnic groups.

Other Factors
Mortality rates for preterm and VLBW infants are lower if the child is female,
or was treated with antenatal corticosteroids, Intrauterine infection adversely
influences survival and morbidity.

Bleeding
Multiple Gestational
Uterine Volume
Uterine Contractions
Cervical Length

Symptoms and Signs

- Preterm labor must be considered whenever abdominal or pelvic symptoms
occur after 16 weeks gestation.
- pelvic pressure, increased vaginal discharge, backache, and menstrual-like
cramps occur commonly during normal pregnancy, and they suggest
preterm labor more by their persistence than their severity.
- Contractions may be painful or painless, depending on the resistance offered
by the cervix.

Accurate diagnosis of early preterm labor is difficult,

because the symptoms and signs of preterm labor occur
commonly in normal women who do not deliver before
term, and because digital examination of the cervix in
early labor (at <3cm dilation and <80% effacement) is not
highly reproducible.

Regionalized Care
- Hospitals and birth centers caring for normal mothers and infants are
designated level I.
- Larger hospitals that care for the majority of maternal and infant
complications are designated level II centers; these hospitals have neonatal
intensive care units staffed and equipped to care for most infants with birth
weights greater than 1500g.
- Level III centers typically provide care for the sickest and smallest infants,
and for maternal complications requiring intensive care.

Strategies to reduce morbidity

- Antenatal Corticosteroids
Antenatal corticosteroids promote maturation over growth of the developing
fetus. In the lung, corticosteroids promote surfactant synthesis, increase lung
compliance, reduce vascular permeability, and improve the postnatal
surfactant response. Also, antenatal corticosteroids have similar maturational
effects on other organs including the brain, kidneys, and gut.
More recently, clinical trials support the notion that administration of a single
rescue course of steroids before 33 weeks improves neonatal outcome (e.g.,
decreased respiratory distress syndrome, ventilator support, and surfactant
use) without an apparent increase in short-term risk. A rescue course may be
considered if the initial treatment was given more than 2 weeks before, and if
the gestational age is less than 32 6/7 weeks, in a woman judged to be at risk
for imminent delivery.
However, regularly scheduled repeat courses or multiple courses (more
than two) are not recommended.

Tocolytic Therapy
Because the contracting uterus is the most easily recognized antecedent of
preterm birth, stopping contractions has been the focus of therapeutic
approaches. This strategy is based on the naive assumption that clinically
apparent contractions are commensurate with the initiation of the process of
parturition; by logical extension, successfully inhibiting contractions should
prevent delivery.
The inhibition of myometrial contractions is called tocolysis, and an agent
administered to that end is referred to as a tocolytic

Numerous trials of various agents (lowdosage aspirin, antioxidant vitamins C and E,

and fish oil have been conducted to test
their effects on the rates of preeclampsia,
fetal growth restriction, and preterm birth.
Antenatal Care