Preterm Birth & Preterm Labor

Valleria
Definition

 Preterm Birth
 Before 37 weeks

 Preterm Labor
 Contractions and
cervical change
before 37 weeks
Why do we care?
 Incidence
 ~12% of births in US
 ~2% before 32 weeks

 Significance
 2nd leading cause of infant mortality
 50% of deaths occurred among the 1.5% of infants
<1500g, and 70% of deaths occurred among the
7% of infants <2500g
 35% of all US health care spending goes to care for
preterm infants
 Among 26wk survivors – 60% disability
 Among 31wk survivors – 30% disability
Magnitude of the Problem
 The infant mortality rate for very preterm infants
(delivered < 32 weeks of gestation) was 186.4,
nearly 75 times the rate for infants born at term
(2.5) (37–41 weeks of gestation)

 20% all infants born <32 weeks do not survive

the first year of life

Mathews TJ. et al. National Vital Statistics Reports 2004;53:1-32

Magnitude of the Problem

 2004: more than 500,000 neonates were

born preterm
 Frequency: 12.5 %
Did you know…
 Rate of preterm birth in African-Americans is
significantly higher
 It is the leading cause of neonatal death (PTB
and low birth weight)

 PTB in Hispanic Americans is only slightly

increased over Caucasian population

 Women who change their partner between 2

pregnancies are twice as likely to deliver
preterm
Frequency of preterm birth by gestational age
(1995-2000)

 < 28 weeks : 0.82 %

 < 32 weeks: 2.2 %
 33-36 weeks: 8.9 %
 < 37 weeks: 11.2

IOM Report-July 2006- page 72/2006

Alexander GR et al 2006 (under review)
The Prognosis of Preterm Neonates is a Function of
Gestational Age at Birth

© PJS
Acute morbidity by gestational age among surviving
infants

Results of a community-based evaluation of 8523 deliveries, 1997–1998, Shelby County, Tennessee

Mercer BM Obstet Gynecol 2003;101:178 –93.
IOM Report – July 2006
Babies born before 32 weeks have the greatest
risk for death and poor health outcomes, however,
infants born between 32 and 36 weeks, which
make up the greatest number of preterm births, are
still at higher risk for health and developmental
problems compared to those infants born full term

IOM Report page 72

Phases of parturition

 Quiescence

 Activation

 Stimulation

 Involution
Phases of parturition

BIRTH
fertilization

PHASES:
quiescence activation involution
stimulation
The preparatory stage of labor

Quiescence

0 Weeks 36 40

Quiescence

0 24 28 40
Weeks
Causes for preterm birth
30-50%

PTL
Cervical Multiple 10-30%
8-9% Incomp Gest

Preterm
Birth
2-4% IUGR PPROM 5-40%

AP Pre-e/
6-9% bleeding E 12%
Pathogenesis of PTL

 Activation of maternal or fetal HPA axis

 Infection

 Decidual hemorrhage

 Pathological uterine distention

 The Preterm Parturition Syndrome

Uterine Cervical
Overdistension Disease

Vascular Hormonal

Immunological
Infection
Unknown

© VR RR MM
HPA axis activation
 Increased release of corticotropin-releasing
hormone (i.e. placental clock)

 Increased release of fetal pituitary ACTH

secretion stimulates production of placental
estrogenic compounds that activate
myometrium and initiate labor

 CRH enhances PGD production by amnion,

chorion and decidua
Inflammation

 Clinical and subclinical chorioamnionitis are

much more common in preterm deliveries

 Response is characterized by the presence of

activated PMNs and macrophages that induce
proinflammatory mediators such as cytokines
and matrix metalloproteinases
Infection

 Some bacteria…

 Pseudomonas
 Staph
 Strep
 Enterobacter
 Bacteroides

…can produce proteases, collagenases and

elastases that can degrade fetal membranes…
Decidual hemorrhage

 bleeding from decidual Vaginal

hemorrhage is associated with high risk
of PTL and PPROM

 VB in more than one trimester increases

risk of
 PPROM  7x
 PTL  3x
Uterine distention

 Multiple gestation
 Polyhydramnios

 Enhanced stretching of myometrium

induces formation of gap junctions,
upregulation of oxytocin receptors and
production of prostaglandins
Who’s at risk?
 Placental pathology  Cervical factors
 Placenta previa  h/o cervical surgery
 Abruption  Cervical
 Vaginal bleeding insufficiency

 Infection  Uterine distention

 STDs  Multiple gestation
 Systemic infections  Polyhydramnios
 Pyelonephritis  Uterine anomaly or
 Bacteriuria fibroids
Placental Pathology in Prematurity

Acute
Chorioamnionitis
42%

Chronic villitis
0.8%
Villous edema
1.7%

Normal placenta
13.3%
Vascular
Lesions
20%
Mixed (inflammation
+ vascular)
20%
© PJS

Arias et al. Obstet Gynecol 1997;69:285.

Risk factors for preterm birth

 Fetal factors  Miscellaneous

 Congenital anomaly  Previous preterm
 Growth restriction delivery
 Smoking
 Substance abuse
 Stress
 Socioeconomic
factors
 Occupational
hazards
How short is too short

Cervical Length RR of PTD

<35mm 2.35
<30mm 3.79
<26mm 6.19
<22mm 9.49

<13mm 13.99
Risk of PTB

 Induced abortion
 OR 1.89, 2.66, and 2.03 w/ 1, 2, or >3 previous
pregnancy terminations

 Delayed ovulation (prolonged follicular phase)

 OR 1.5

 Interpregnancy interval
 Short interval = inc risk
More interesting “factoids”
 Genotypes
 Male infants – maternal immune rxn?

 Periodontal disease
 ? Seeding of the placenta

 Malaria
 Bad… treat it…

 Anemia
 <9.5 at 12 wks +  OR 1.68
To treat or not to treat…

 Yeast
 Treat it

 BV
 Treat it

 Trich
 Treat if symptomatic
How do we find those at risk?

 Prediction of PTL/delivery
 Fetal Fibronectin
 Cervical Length

 CRH

 AFP and HCG

 Alk phos
Fetal Fibronectin
 Trophoblast Glue
 Promotes cellular adhesion at uterine-placental and
decidual-fetal membrane interfaces

 Before collection:
 Intact membranes?
 CVX <3cm?
 GA 24-34 wks?
 Intercourse/cvx check/bleeding last 24 hrs?
 Collect from posterior fornix
FFN
 - FFN
 Negative predictive value of 99%

 + FFN
 Positive predictive value of 13-30%

99.5% of symptomatic women with

negative FFN are undelivered at 7 days

99.2% of symptomatic women with

negative FFN are undelivered at 14 days
Can we prevent it?
 Supplemental progesterone
 17OHP – start 2nd tri, continue until 36 weeks if prior delivery
before 34 wks

 QUIT SMOKING

 Just say NO! (especially to cocaine)

 Cervical cerclage (for cvx insufficiency)

 Diagnose infection
 Asymptomatic bacteriuria, BV, GC, chlam
What do we do in real life?

 Triage evaluation

 CEFM/Toco
 SSE - ?ROM, ?VB. Collect FFN

 Collect GC/Chlamydia cultures

 Collect GBS culture

 Cervical exam

 Check UA/Urine cx
Dx: PTL – now what?

 While in the hospital

 CEFM/toco
 Yeah baby, steroids!
 BMTZ 12mg IM Q24 x 2 doses
 Antibiotic prophylaxis for GBS
 PCN, Cefoxetin, Clinda, Vanc
 Tocolysis
 PNV/Colace/FeSO4/SCDs
Dx: PTL – now what?
 Tocolysis – inhibit myometrial contractility
 Magnesium
 Terbutaline
 Indocin
 Nifedipine

 Contraindications to tocolysis:
 IUFD, lethal fetal anomalies, NRFHT
 Severe IUGR, chorio, hemorrhage
 Severe pre-e/eclampsia
Tocolytics

MgSO4 Terbutaline Indocin Nifedipine

Class Β-agonist Cox inhibitors CCB

Action Competes for ↑ cAMP ↓ PGD Block Ca

Ca ↓ intracellular production influx
Ca
Side Effect Pulm edema, Tachy, ↓BP, N/V, gastritis, ↓BP, reflex
? ↑ ped M&M palp, ↓K, narrowing of tachy, ? ↓ of
pulm edema DA, oligo blood flow
Efficacy Not very No ↓ of PTB Appears to ↓ # of women
good! @ 7 days, sx be more giving birth at
relief effective than 7 days
placebo
Corticosteroids rule!
 Why?
 Reduce the risk of neonatal RDS, IVH, NEC, and
mortality by 50% (FIFTY!)
 Benefit observed 18 hours after 1st dose, max
benefit @ 48 hours
 Give 24-34 wks (?24-32wks if PPROM)

 How?
 Enhance maturation of lung architecture
 Induce lung enzymes resulting in biochemical
maturation
Cervical cerclage

 For cervical insufficiency which complicates

0.1-2% of all pregnancies and is responsible
for 20% of late 2nd trimester losses

 Prophylactic cerclage – 12-14wks

 Rescue cerclage – when cvx changes already

detected
Cerclage
 Uterine Pathologic
Progesterone State (infection,
Deficiency State vascular, uterine)

Common Terminal Common Terminal

Pathway Pathway

Preterm Labor Preterm Labor