PREMATURITAS

AETIOLOGY OF PRETERM
LABOUR

a 'syndrome' associated with multiple

pathological processes :
intrauterine infection
uterine ischaemia
overdistension
abnormal allogenic reaction against
the fetus
cervical abnormalities
uterine malformations
endocrine disorders.

Four broad pathogenic

pathways
activation of the maternal/fetal
HPA axis
increased maternal or fetal stress
release of placental-amniochoriondecidual corticotrophin releasing
hormone (CRH) and estrogen as a
result release of prostaglandins
and estrogen activates the
myometrium.

 Infection/inflammation
2040% of spontaneous preterm labours
activation of cytokines that stimulate
production of uterotonins
(prostaglandins, leukotrienes,
endothelins) and proteases (matrix
metalloproteinases) within the
membranes, myometrium and cervix.

 Pathologic uterine distension

such as polyhydramnios, multiple
pregnancy or uterine abnormalities
restricting normal uterine
expansion.

 decidual haemorrhage
Patholigical uterine distension stretching
of the myometrium and fetal membranes
myometrial activation and enhanced
gap junction formation between
myometrial cells, increases in oxytocin
receptors and increased synthesis of
prostaglandins. Abruption and smaller
bleeds at the choriodecidual interface lead
to generation of thrombin, which enhances
protease and prostaglandin production

Prediction of Preterm
Labour

Aim of ANC
To identify ways of predicting those
at risk of preterm delivery
To improve perinatal outcome.

INCLUDING
Risk scoring systems based on
maternal factors
Uterine activity monitoring
Assessment of cervical length by
clinical examination and, more recently,
by ultrasound assessment
Screening for asymptomatic bacteriuria
and genital tract infection, and the use
of various biochemical markers.

INTERVENTION
The early administration of tocolytics
Cervical cerclage
Antibiotic treatment of asymptomatic
infection
Administration of progesterone

History and Risk

Assessment
Previous preterm delivery
Previous preterm premature rupture of
membranes (PPROM)
Mid-trimester pregnancy loss
Congenital uterine anomalies
Multiple pregnancy
Vaginal bleeding
Suspected cervical incompetence or a
history of fetal growth restriction (FGR).

Assessment of Uterine
Activity
A number of studies have examined
the value of monitoring contraction
frequency by self-palpation
Increased uterine activity appears to
precede a preterm labor by less than
24 hours

Assessment of Uterine
Activity
Inexpensive
Subjective
Has poor sensitivity and positive
predictive value.

Assessment of Uterine
Activity
Some studies examining the role of
home monitoring using a uterine
contraction monitor have suggested
that in high-risk pregnancies this
increases the diagnosis of preterm
labour and may improve the
efficiency of tocolytic agents

Digital assessment of
cervical length
Serial digital examination of the cervix has
been used to predict the risk of
subsequent preterm birth in a number of
studies.
Dilatation, softening and effacement of
the cervix has been associated with an
increased risk of preterm labour, but the
sensitivity and positive predictive value of
the technique to detect preterm birth is
low

Ultrasound (US)
assessment of cervical
length

Ultrasound (US)
assessment of cervical
length

Role of cervical ultrasound

in prediction of preterm
labour
The examination should be performed over
a period of at least three minutes and the
shortest measurement taken.
Transabdominal scanning is less reliable
and the cervix may not be seen in up to
50% of cases unless the bladder is full.
Filling the bladder, however, increases the
length of the cervix.
Transperineal scanning has also been
advocated but, again, is limited by poor
visualisation of the cervix and
inconsistencies in measurements.

Role of cervical
ultrasound in prediction
of
preterm
labour
Features that predict preterm delivery are
progressive cervical shortening and funnelling
of the internal os.
Funnelling is much less reliable as it is subject
to inter and intra-observer variation and
artefact, as it is mimicked by contractions of
the lower segment above a normal cervix.
The significance of funnelling on scan in the
prediction of preterm delivery is controversial

Ultrasound assessment of
cervical length in low-risk
women

As more than half of preterm deliveries

occur in low-risk women, studies have
been performed to evaluate the use of
transvaginal ultrasound in the prediction
of subsequent preterm labour in this
group.
In low-risk women, the cervical length is a
continuous variable with the mean length
between 35 and 40 mm. 25 mm
represents the 10th percentile.

Ultrasound assessment
of cervical length in lowrisk women
Studies in asymptomatic singleton
pregnancies have demonstrated that
the shorter the cervical length, the
higher the risk for preterm birth.
In the study by Heath et al, the risk
of preterm delivery at less than 33
weeks of gestation was 1.5% overall.

Ultrasound assessment
of cervical length in lowrisk
women
The risk of early delivery increased with
decreasing cervical length.
Hence, risk was 0.2% at 60 mm, 1% at 25
mm, 4% at 15 mm and 78% at 5 mm.
However, the sensitivity and positive
predictive value of the test is low, probably
because of the low incidence of preterm
delivery in this low-risk population.
82% of patients found to have a short
cervical length at 24 weeks of gestation
delivered at or after 35 weeks of gestation
in one study.

Ultrasound assessment of
cervical length in high risk
women

In high-risk women, transcervcical ultrasound

assessment of cervical length is better at
predicting those women who will deliver
prematurely with positive predictive values of
over 70% reported.
In such patients there may be a role for serial
transvaginal ultrasound assessment of cervical
length between 16 and 24 weeks for
reassurance, as those high-risk patients with
normal cervical length measurement between
14 and 18 weeks, have only a 4% risk of
delivering preterm.
However the management of the high-risk
patient found to have a short cervix on
ultrasound is controversial.

Fetal fibronectin testing

Fetal fibronectin testing

Fetal fibronectin (fFN) is a glycoprotein, which
is found in high concentrations in
cervicovaginal secretions before fusion of the
membranes occurs at around 21 weeks of
gestation.
Disruption of the choriodecidual interface after
21 weeks of gestation, either due to
inflammation or mechanical trauma, results in
the secretion of fFN into the cervix and vagina.
Based on this, swabs taken from the posterior
fornix or ectocervix, which detect fetal
fibronectin by means of an enzyme linked
immunosorbent assay, can be used to predict
preterm birth between 22 and 34 weeks of
gestation.

Fetal fibronectin testing

Contraindications to testing:
EGA <24 weeks or >34 weeks GA
Preterm PROM
Multiple pregnancy
Cervix >3 cm dilated
Active vaginal bleeding
Vaginal exam or intercourse in previous 24 hrs
Use of lubricant cream

Other biochemical
markers
Insulin like growth factor binding protein1, interleukin-6, interleukin-8 and tumour
necrosis factor-alpha (TNF-).
At present these markers are not used in
routine clinical practice.
However, future tests may employ these
markers of inflammation combined with
other molecular biological techniques
(proteomics and genomics).

Management of reterm
Premature Rupture of
Membranes

 Tocolytic delaying delivery from an

infected environment
Tocolytic allow the administration of
steroids or to facilitate transfer of
women
Antibiotics following PPROM has been
shown to reduce the incidence of
neonatal infection, chorioamnionitis and
delivery within 48 hours and seven days

 expectant management is considered

beyond 34 weeks of gestation, women
should be counselled about the
increased risk of chorioamnionitis and
its consequences versus the decreased
risk of serious respiratory problems in
the neonate, admission for neonatal
intensive care and caesarean section.

 Digital vaginal examination should be avoided

due to the risk of infection
The nitrazine test not essential to confirm
the diagnosis.
A biophysical test should not be a routine first
line investigation in the management of
PPROM.
Antenatal corticosteroids reduce the risks of
respiratory distress syndrome, intraventricular
haemorrhage and necrotising enterocolitis

Thank You