Preterm Labor and Delivery

Dr.Samuel Bezabih

Nehassie 2006 EC

Gondar

Preterm Birth
Preterm birth (PTB) is delivery prior to the
completion of 37 weeks (259 days) of
gestation.
it is the most common cause of perinatal
morbidity and mortality the United States,
Incidence-11% to 12% of babies born
prematurely
Account for 75% of all perinatal mortality and
50% of long-term neurologic impairment in
children

Preterm Birth
Preterm births may be spontaneous or
indicated.
Approximately 40% to 50% of PTBs result from
spontaneous preterm labor with intact
membranes;
25% to 40% result from preterm premature
rupture of membranes (PROM)
The remaining 20% to 30% occur following
deliberate intervention for a variety of
maternal or obstetric complications (e.g.Pre
eclampsia, eclampsia, IUGR, APH----).

Complications of preterm delivery

Common neonatal complications in

premature infants include: respiratory distress syndrome (RDS),
intraventricular hemorrhage (IVH),
bronchopulmonary dysplasia (BPD),
patent ductus arteriosus (PDA),
Necrotizing enterocolitis (NEC),
Sepsis,
Apnea, and retinopathy of prematurity.

Complications of preterm delivery

Long-Term Outcomes
Follow up studies of infants born preterm and
LBW infants reveal increased rates of
chronic lung disease,
cerebral palsy,
neurosensory impairment-vision and hearing
impairment
reduced cognition and motor performance
academic difficulties, and attention deficit disorders

The incidence of long-term morbidity in survivors

is especially increased for those born before 26
weeks

Preterm Labor (PTL)

Preterm labor (PTL) is defined as
the presence of regular uterine contractions
associated with cervical changes before 37
weeks of gestation
PTL may represent a final common pathway for a
number of pathogenic processes.
The four main processes include:1. Activation of the maternal or fetal hypothalamic
pituitary- adrenal axis due to maternal or fetal
stress,
2. Decidual-chorioamniotic or systemic inflammation
caused by infection,
3. Decidual hemorrhage, or
4. Pathologic uterine distention

PRETERM LABOR-Dx
Labor at GA>20wks & < 37wks
Frequent + Regular ux contractions
may manifest as abdominal pain /tightening, back pain
or pelvic pressure

Cervical change (E&D) along with the contractions

NB. At least 4cont/hr is required to cause cx

change
Late Preterm --------34-36 wks
Moderately PT-------32-34
Very PT---------------28 - 32
Extremely PT---------<28

PTL Risk Factors

1.Obstetric complications (in previous or current PX.)
Previous premature or low-birth-weight infant
(2x increase in subsequent pregnancy)
Severe hypertensive state of pregnancy
Anatomic disorders of the placenta
eg, abruptio placentae, placenta previa, circumvallate
placenta

Placental insufficiency
PROM
AFV disorders-Poly/oligo
Low socioeconomic status
Maternal age < 18 years or > 40 years
Low pre-pregnancy weight

PTL Risk Factors

2. Medical complications

Pulmonary or systemic hypertension

Renal disease
Heart disease

3. Infection systemic or FGT:(mainly at earlier

GA, <32wk)

acute systemic infection, (eg, pneumonia, influenza,

malaria, periodontal infection ),
UTI,Pyelonephritis,
GT infection( gonorrhea, H. simplex, mycoplasmosis--)
Bacterial Vaginosis
fetotoxic infection (CMV, toxoplasmosis, listeriosis maternal intra-abdominal sepsis (eg, appendicitis,
cholecystitis, diverticulitis)

PTL Risk Factors

4.Surgical complications
Any intra-abdominal procedure
Conization of cervix

Previous incision in uterus or cervix (eg,

cesarean delivery)

PTL- Prediction
A number of factors are used to predict the
potential to develop preterm labor.
1. Fetal fibronectin ( f FN) in cervicovaginal
secretions
A preterm rise in the concentration of fFN may be
associated with an increased likelihood of birth
between 22 and 34 weeks of gestation and birth
within 714 days of the test.
However, data combined from several studies reveal
that the positive predictive value for delivery within a
week is only 18%.

2. Cervical length
Shortened cervical length < 2.5cm in midpregnancy is
associated with the risk of preterm labor and delivery.

PTL- Management
The purpose in treating preterm labor is to
delay delivery, if possible, until fetal maturity

is attained
more than 50% of patients with preterm

contractions have spontaneous resolution of

abnormal uterine activity

PTL Management-Interventions
Non-pharmacologic methods of
Uncertain efficacy include: Bed rest
Abstinence from intercourse and orgasm
Hydration ( oral/parentral)

Rx of PTL.
Pharmacological methods : Tocolytics agents

Administer Steroids
Adjuvant antibiotics

PTL Mgt-Interventions
: TOCOLYSIS
pharmacologic inhibition of ux activity to suppress labor
at least for 48 hrs. after administration Of corticosteroids or
if possible to take pregnancy to >34wks

In those with high risk of preterm birth, i.e.

Hx of PT birth,
contraction sustained,
short cx
fibronectin positive
cervical dilatation change

*tocoytics may prolong gestation for 2-7 days ( time for steroid
adminstration & transportation to facility having NICU,no other clear
benefits)

PTL- Management
Tocolytics Agents: Magnesium sulfate

Prostaglandin synthetase inhibitors

(indomethacin)

Calcium-channel blockers (nifedipine)

-adrenergic agents (ritodrine, terbutaline)

Some Cases in Which Preterm Labor Should Not

Be Suppressed.
Maternal Factors
Severe HTN disease (eg,
acute exacerbation of
chronic HTN , eclampsia,
severe PE)

Pulmonary or cardiac
disease (eg, pulmonary

edema, adult respiratory

distress syndrome, valvular
disease, tachyarrhythmias)
Advanced cervical
dilatation (> 4 cm)
Maternal hemorrhage
(e.g, abruptio placentae,
placenta previa, DIC)

Fetal Factors
Fetal death or lethal
anomaly
Fetal distress
Intrauterine infection
(chorioamnionitis)
Therapy adversely affecting
the fetus (eg, fetal distress
due to attempted
suppression of labor)
EFW OF 2500 g
Erythroblastosis fetalis
Severe IUGR

Potential Complications of Tocolytics Agents

BETA-ADRENERGICS
Hyperglycemia
Hypokalemia
Hypotension
Pulmonary edema
Cardiac insufficiency
Arrhythmias
Myocardial ischemia
Maternal death
INDOMETHACIN
Hepatitisb
Renal failureb
GI bleedingb
NIFEDIPINE
Transient hypotension

Magnesium Sulfate
Pulmonary edema
Respiratory depression
Cardiac arresta
Maternal tetanya
Profound muscular
paralysisa
Profound hypotensiona

aEffect

is rare; seen with

toxic levels.
bEffect is rare; associated
with chronic use

PTL Mgt-intervention contd.

Steroid administration
for GA 24-34 weeks & for PPROM,
efficacy b/n 33-34 not clear, my be given esp if pulmonary immaturity
is documented ACOG 2013)
the most beneficial intervention for pts with true PTL
to facilitate lung maturity and reduce incidence and severity of
Neonatal RDS and
Reduce incidence of IVH and NEC
Indication- Risk of PTB (24-34wk GA) in one week
Regimen
Betamethasone 12mg Im/24hrx2 or
Dexamethasone 6mg IM BIDx4
No multiple regular doses
Rescue dose- 01 repeat course may be given if
2 weeks passed after the first dose
GA < 32 weeks
Delivery is anticipated within 01 week (ACOG 2013)

PTL Mgt-intervention contd.

Adjuvant antibiotcs
No evidence that Antibiotic administration
prolongs gestation or reduces neonatal

complications
May be used for GBS prophylaxis in those

delivery is imminent

THE

END
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