PRETERM LABOR

FK UNTAR ©2018
Definition and Classification
• Preterm or premature infant was defined by birthweight < 2500 g.
• Infants born before term can be small or large for gestational age but
still fit the definition of preterm.
• Low birthweight refers to neonates weighing 1500 to 2500 g;
• Very low birthweight refers to those between 500 and 1500 g; and
• Preterm infants were those delivered before 37 completed weeks.
• before 33 6/7 weeks are labeled—early preterm
• between 34 and 36 completed weeks—late preterm.
• Those births 37 weeks through 38 weeks are now defined as early term and
0/7 6/7

those 39 weeks 0 days through 40 weeks 6 days are defined as term.

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
Etiology
• There are four main direct reasons for • Other etiology:
preterm births: - multifetal pregnancy,
1. Spontaneous unexplained preterm labor
with intact membranes - intrauterine infection,
2. Idiopathic preterm premature rupture of - bleeding,
membranes (PPROM) - Placental infarction,
3. Delivery for maternal or fetal indications - premature cervical dilatation,
4. twins and higher-order multifetal births. - cervical insufficiency,
• Of all preterm births: - hydramnios,
• 30 to 35% are indicated,
• 40 to 45% are due to spontaneous preterm labor,
- uterine fundal abnormalities, and
and - fetal anomalies.
• 30 to 35% follow preterm membrane rupture
(Goldenberg, 2008).
• The end result in preterm birth is the same as
at term, namely cervical ripening and
myometrial activation

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
Major causes of spontaneous preterm labor
• uterine distention, maternal–fetal 1. Uterine Distention
stress, premature cervical - Stretch  coding for connexin 43,
changes, and infection. for oxytocin R and prostaglandin
• Risk factor lead to an increased synthase  Initiate expression of
risk of preterm birth  multifetal CAPS in the myometrium
pregnancy and hydramnios - Gastrin-releasing peptides
(GRPs)↑ with stretch 
myometrial contractility
- Early rise in maternal CRH and
estrogen levels  myometrial CAP
genes

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
Major causes of spontaneous preterm labor
2. Maternal-fetal stress
• Stress  disturbs the normal
physiological or psychological
functioning of an individual.
• Last trimester  ↑ maternal serum
levels of placental-derived CRH +
ACTH to ↑ adult and fetal adrenal
steroid hormone production stimulate
fetal (DHEA-S)  ↑ maternal plasma
estrogens(estriol)
• A premature rise in cortisol and
estrogens results in an early loss of
uterine quiescence

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
Major causes of spontaneous preterm labor
3. Infections
• bacteria can gain access to
intrauterine tissues through:
(1) Transplacental transfer of maternal
systemic Infection,
(2) Retrograde flow of infection into
the peritoneal cavity via the
fallopian tubes,
(3) Ascending infection with bacteria
from the vagina and cervix.
Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
• Intrauterine infection categories
into four stages of microbial
invasion
1. include bacterial vaginosis—
stage I
2. decidual infection— stage II,
3. amnionic infection—stage III,
4. fetal systemic infection—stage IV.
As expected, progression of
these stages is thought to
increase rates of preterm birth
and neonatal morbidity.
 ANTECEDENTS AND CONTRIBUTING FACTORS
Threatened Abortion Periodontal Disease
• Vaginal bleeding in early pregnancy  • Gum inflammation is a chronic anaerobic
associated with subsequent preterm labor, inflammation
placental abruption, and loss before 24
weeks. Interval between Pregnancies
• < 18 months and > 59 months were
Lifestyle Factors associated with increased risks for both
• Cigarette smoking, inadequate maternal preterm birth and small-for gestational age
weight gain, and illicit drug use newborns.
• Overweight and obese mothers Prior Preterm Birth
• young or advanced maternal age, poverty,
short stature, and vitamin C deficiency
• psychological factors such as depression,
anxiety, and chronic stress
Genetic Factors
• Immunoregulatory genes in potentiating
chorioamnionitis in cases of preterm
delivery due to infection

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
DIAGNOSIS

Sign & Symptoms

• Early differentiation between true and • Addition:
false labor is difficult before there is • contractions, appeared only within 24
demonstrable cervical effacement and hours of preterm labor.
dilatation.
• Braxton Hicks contractions: irregular, • The signs and symptoms signaling
nonrhythmical, and either painful or preterm labor, including uterine:
painless, can cause considerable • painful or painless uterine
confusion in the diagnosis of true contractions,
preterm labor. • symptoms such as pelvic pressure,
• regular contractions before 37 weeks menstrual-like cramps,
that are associated with cervical • watery vaginal discharge, and lower
change. back pain

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
DIAGNOSIS & PREVENTION

Cervical Change PRETERM BIRTH PREVENTION

• whose cervix was dilated 2 or 3 • Cervical Cerclage
• There are at least three circumstances when
cm delivered before 34 weeks  cerclage placement: Two are done
prophylactically and a third is done for
predictor of increased preterm treatment.
delivery risk 1. The first prophylactic cerclage is used : history of
recurrent midtrimester losses and who are
diagnosed with cervical insufficiency
Length 2. The second prophylactic cerclage is  short
cervix (USG  length < 25 mm)

• The mean cervical length at 24 3. “rescue” cerclage, done emergently when cervical
incompetence is recognized in women with
threatened preterm labor.
weeks was approximately 35 • Prior Preterm Birth and Progestin
mm  increased rates of Compounds
preterm birth. • progesterone withdrawal and is considered to be
a parturition-triggering
• the administration of progesterone to maintain
uterine quiescence may block preterm labor.

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
Diagnose Ruptured Membranes
• history of vaginal leakage of fluid
• speculum examination pooling
of amnionic fluid, clear fluid from
the cervical canal, or both. age.
• Amnionic fluid is alkaline (pH 7.1–7.3)
vs vaginal secretions (pH 4.5–6.0)
• Confirmation of ruptured
membranes  sonographic
examination, assess :
• amnionic fluid volume
• identify the presenting part
• estimate gestational age.

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
MANAGEMENT OF PRETERM LABOR WITH
INTACT MEMBRANES
If possible, delivery before 34 weeks is delayed. Drugs used to abate or suppress
preterm uterine contractions.

Corticosteroids for Fetal Lung

Maturation “Rescue Therapy”
• effective in incidence of RDS & • single rescue course of antenatal
neonatal mortality rates if birth corticosteroids should be
was delayed for at least 24 hours considered in women before 34
after initiation of betamethasone. weeks whose prior course was
administered at least 7 days
• repeated courses to be beneficial previously.
in  neonatal respiratory morbidity
rates • Choice of Corticosteroid
• betamethasone is superior to
• dose : 12-mg betamethasone dose dexamethasone forfetal lung
• not generally used after 33 weeks maturation

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
MANAGEMENT OF PRETERM LABOR WITH
INTACT MEMBRANES
Antimicrobials Cervical Pessaries
• Cochrane meta analysis by King and • being used to support the cervix in
colleagues no difference in the women with a sonographically
rates of newborn respiratory distress
syndrome or sepsis between placebo- short cervix ( ≤ 25 mm)
and antimicrobial-treated groups • Emergency or Rescue Cerclage
• Bed Rest • if cervical incompetence is
• No evidence supporting or refuting recognized with threatened
the benefit of either bed rest or preterm labor, albeit with risk of
hospitalization for women with
threatened preterm labor. infection and pregnancy loss.
• Bed rest for 3 days or more increased
thromboembolic complications

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
Tocolysis to Treat Preterm Labor

• tocolytic agents do not prolong β-Adrenergic Receptor Agonists

gestation but may delay delivery Ritodrine
in up to 48 hours. • Reduce intracellular ionized
• recommended tocolytic agents calcium levels & prevent activation
for short-term use (up to 48 hrs) of myometrial contractile proteins
• Beta-adrenergic agonists, • cause retention of sodium and
cause volume overload
• calcium-channel blockers, Pulmonary edema
• indomethacin

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
Tocolysis to Treat Preterm Labor

Magnesium Sulfate Prostaglandin Inhibitors

• high concentration can alter • Inhibiting prostaglandin synthesis
myometrial contractility. or by blocking their action on
• very-low-birthweight neonates target organsacetylsalicylate
whose mothers were treated with and indomethacin
magnesium sulfate for preterm • Indomethacin : orally or rectally
labor or preeclampsia 50-100 mg tdd, max dose of 200
incidence of cerebral palsy mg
• Dose : IV 4 gram loading dose • Limited use to 24 to 48 hours
followed by a continuous infusion oligohydramnios
of 2 g/hr

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
Tocolysis to Treat Preterm Labor

Calcium-Channel Blockers
• Myometrial activity is directly related
to cytoplasmic free calcium, and a
reduction in its concentration inhibits
contractions
• nifedipine, are safer and more
effective than are β-agonists
• Combination of nifedipine with
magnesium potentially dangerous
• nifedipine neuromuscular blocking
effects of magnesium that can
interfere with pulmonary and cardiac
function

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
Labor
• abnormalities of fetal heart rate & uterine contractions should be
sought
• Fetal tachycardia, with ruptured sepsis.
• intrapartum acidemia (umbilical artery blood pH <7.0) neonatal
complications attributed to preterm delivery severe respiratory
disease
• Prevention of Neonatal Intracranial Hemorrhage
• Magnesium Sulfate for Fetal Neuroprotection

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014