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Significance
Pathogenesis
A birth that occurs before 37
Clinical and laboratory
Taken together with its
Approximately 70 to
completed weeks of gestation.
evidence suggest that a
sequelae,
PTB
is
by
far
80
percent
of
PTBs
Subclassifications of PTB are
number of pathogenic
the leading cause of
occur spontaneously.
variably and inconsistently
processes can lead to a final
infant mortality in the
preterm labor (PTL)
defined as:
common pathway that results
United
States.
accounts
for
40
to
50
Late preterm = 34 to 36 weeks
in preterm labor and delivery.
percent of all PTBs
Moderately preterm = 32 to 34 PTB is also a major
determinant of shortand preterm
weeks
The four primary processes
and
long-term
premature rupture of
Very preterm = <32 weeks
are:
morbidity in infants and
membranes (PPROM)
Extremely preterm = <28
children.
accounts for 20 to 30 1. Activation of the maternal
weeks
or fetal hypothalamicpercent.
INCIDENCE
In
the
PTB can also be defined by
pituitary-adrenal axis
United States, 12.8
The remaining 20 to
birth weight (BW):
percent of births in
30 percent of PTBs are 2. Infection
Low birth weight (LBW) BW
2006 occurred preterm
due to intervention for 3. Decidual hemorrhage
less than 2500 g
4. Pathological uterine
and 3.66 percent were
maternal or fetal
Very low birth weight (VLBW)
distention
less than 34 weeks of
problems
BW less than 1500 g
gestation
Extremely low birth weight
(ELBW) BW less than 1000 g
RISK FACTOR, CLINICAL MANIFESTATIONS AND DIAGNOSIS FACTORS
PTL is one of the most common reasons for
Uterine contractions are a normal finding at all stages of
hospitalization of pregnant women.
pregnancy, thereby adding to the challenge of distinguishing true
from false labor. The frequency of contractions increases with
In one systematic review, approximately 30
gestational age, the number of fetuses, and at night.
percent of preterm labors spontaneously
resolved.
The diagnosis of PTL is generally based upon clinical criteria of
Signs and symptoms of early PTL include
regular painful uterine contractions accompanied by cervical
menstrual-like cramping, constant low back
dilation and/or effacement. Specific criteria, which were initially
ache, mild uterine contractions at infrequent
developed to select subjects in research settings, include
Physical examination
The uterus is examined to
assess firmness,
tenderness, fetal size, and
fetal position.
A sterile speculum
examination is performed
to rule out ruptured
membranes, to visually
examine the vagina and
cervix
A digital examination to
assess cervical dilatation
and effacement is
performed after placenta
previa and PPROM have
been excluded
Interventions to prevent PTB generally have not been successful, with some exceptions (eg, supplemental
progesterone).
Women with risk factors for PTB are sometimes followed with serial ultrasound measurement of cervical length. A cervical
length 35 mm is generally considered normal and reassuring; as cervical length decreases below 35 mm, the risk of PTB
increases
We manage asymptomatic patients at high risk of PTB similar to the way we manage symptomatic patients, but with a
higher cervical length threshold for intervention. This minimizes overtreatment of high risk asymptomatic patients and
undertreatment of symptomatic patients. Surveillance with serial cervical length measurements is begun at 22 weeks.
Cervical length 35 mm - The risk of PTB is low. See these patients in routine follow-up in one to two weeks.
Cervical length 25 to 34 mm - obtain a fFN concentration. If the test is positive (level greater than 50 ng/mL), then actively
manage the pregnancy to prevent morbidity associated with PTB.
Cervical length <25 mm - The risk of PTB is increased. We actively manage the pregnancy to prevent morbidity associated
with PTB, as described above.
Outcome
Refers to membrane
rupture before the
onset of uterine
contractions; preterm
PROM (PPROM) is the
term used when the
pregnancy is less than
37 completed weeks of
gestation.
PPROM occurs in 3
percent of pregnancies
and is responsible for,
or associated with,
approximately onethird of preterm births.
In management of PPROM,
Points of contention
include:
1. Expectant
management versus
intervention
2. Use of tocolytics
3. Duration of
administration of
antibiotic prophylaxis
4. Timing of
administration of
antenatal
glucocorticoids
The pathogenesis of
PPROM is not
completely understood.
There are multiple
etiologies, mechanical
and physiological, that
probably share a final
common pathway
leading to membrane
rupture.
Risk factors for PPROM
are similar to those for
preterm labor
A history of PPROM in a
previous pregnancy
Genital tract infection
Antepartum bleeding
Cigarette smoking have a
particularly strong
association with PPROM
Although a small
randomized trial suggested
vitamin C
supplementation might
lower the risk of PPROM , a
larger randomized trial in
which both vitamin C and E
were given refuted this
finding and suggested the
risk of PPROM may actually
1.
2.
3.
4.
5.
Approximately one-third of
women with PPROM develop
potentially serious infections,
such as intraamniotic
infection (chorioamnionitis),
endometritis, or septicemia.
Endometritis is more common
after cesarean than vaginal
delivery.
The fetus and neonate are at
greater risk of PPROM-related
morbidity and mortality than
the mother.
The majority of pregnancies
with PPROM deliver preterm
and within one week of
membrane rupture.
Preterm infants are especially
vulnerable to a variety of
problems, such as hyaline
membrane disease,
intraventricular hemorrhage,
periventricular leukomalacia
and other neurologic
sequelae, infection (eg,
sepsis, pneumonia,
meningitis), and necrotizing
enterocolitis. The rates of
these morbidities vary with
PPROM is also
associated with
increased risks of
abruptio placentae and
prolapse of the
umbilical cord. Fetal
malpresentation is
common, given the
preterm gestational age
and the frequent
occurrence of reduced
amniotic fluid volume.
The risk of cord
prolapse is especially
high (11 percent in one
study) in the setting of
both nonvertex fetal
presentation and
PPROM.
Early, severe, prolonged
oligohydramnios can be
associated with
pulmonary hypoplasia,
facial deformation, and
orthopedic
abnormalities. Such
complications are most
likely when membrane
rupture occurs at less
than 23 weeks of
be increased with
antioxidant
supplementation .
gestation.
Management
The management of pregnancies complicated by PPROM is based upon
Initial evaluation
Expeditious delivery of women with
Timing of delivery
Tocolysis
Gestational age <34 weeks In general, prematurity
is the greatest risk to the fetus with PPROM. As
Hospitalization
discussed above, we administer a course of antenatal
Tissue sealants (A variety of tissue sealants (eg, fibrin
glucocorticoids, prophylactic antibiotics for seven
glue, gelatin sponge) have shown some success in
days, and tocolytics for 48 hours, as indicated.
stopping leakage in case reports. Neither the safety nor
the efficacy of these sealants has been established ).
Gestational age greater than 34 weeks
Method of delivery Cesarean delivery is performed
Supplemental progesterone (There is no evidence that
for standard indications; otherwise labor is induced.
administration of supplemental progesterone has any
Favorable Cervix vs Unfavorable cervix
beneficial effects in women with PPROM )