Preterm Labor

Obstetrics & Gynecology Hospital of Fudan University

Xu Huan

Introdution

Labor and delivery between 28 36+6 weeks

5%-10%
be the leading cause of perinatal morbidity and
mortality
Survival rates have increased and morbidity has
decreased because of technologic advances

Survival by gestational age among

live-born resuscitated infants

In: Creasy, Resnik . Maternal Fetal Medicine, 2009

Pathophysiology

The preterm parturition syndrome. Multiple pathologic

processes can lead to activation of the common pathway of
parturition.
In: Creasy, Resnik . Maternal Fetal Medicine, 2009

Ascending intrauterine infections

stage I changing flora vagina/cervix,
II Microorganism alocated between
the amnion and chorion, III intra
amniotic infection, IV fetal invation

Infections associated with preterm delivery

Genital

Intra-uterine

Extra-uterine

* Bacterial vaginosis (BV)

* Group B streptococcus
* Chlamydia
* Mycoplasmas
* Ascending (from genital tract)
* Transplacental (blood-borne)
* Transfallopian (intraperitoneal)
* Iatrogenic (invasive procedures)
* Pyelonephritis
* Malaria
* Typhoid fever
* Pneumonia
* Listeria
* Asymptomatic bacteriuria
In:Jane Norman.Preterm labor 2005

Stret
ch
Integrins

Inflammati
on
IL-1
TNF-

Abrupti
on
Thrombin

COX2
PGDH
PR-B

Stre
ss
CRH
Estrogen

MMPs
IL-6
and 8

PTL or PPROM
Principal biomechanical mechanisms responsible for chain pathways of
preterm parturition COX2=cyclooxygenase2, PGDH=prostaglandin dehydrogenase PRB=Progesteron receptorB.CRH=corticotropin releasing hormon MMPs=matrix metallo
proteinase
In: Creasy, Resnik . Maternal Fetal Medicine, 2009

Risk Factors(1)

Previous preterm delivery

Low socioeconomic status
Maternal age <18 years or >40 years
Preterm premature rupture of the membranes
Multiple gestation
Maternal history of one or more spontaneous
second-trimester abortions
Maternal complications (medical or obstetric)

Lack of prenatal care

Risk Factors(2)

Uterine causes
Myomata

(particularly submucosal or subplacental)

Uterine septum
Bicornuate uterus
Cervical incompetence

Abnormal placentation

Risk Factors(3)

Infectious causes
Chorioamnionitis
Bacterial

vaginosis
Asymptomatic bacteriuria
Acute pyelonephritis
Cervical/vaginal colonization

Fetal causes
Intrauterine

fetal death
Intrauterine growth retardation
Congenital anomalies

Diagnosis
Documented uterine contractions(4 per 20
minutes or 8 per 60 minutes)
Documented cervical change (cervical
effacement of 80% or cervical dilatation of
2cm or more)

Forecast
uterine activity monitoring.
Ultrasound Examination of Cervical length
Fetal Fibronectin

PRETERM LABOR
Most mortality and
morbidity is
experienced by babies
born before 34 weeks

Major Risks of Preterm Delivery

Goldenberg, Obstetrics & Gynaecology 11-2002

Treatment(1)
An initial assessment: ascertain cervical
length and dilatation and the station and
nature of the presenting part
Bed Rest : be placed in the lateral
decubitus position

Although bed rest is often prescribed for

women at high risk for preterm labor and
delivery, there are no conclusive studies
documenting its benefit.
A recent meta-analysis found no benefit to
bed rest in the prevention of preterm labor
or delivery.

Treatment(2)

Tocolytic therapy
Magnesium

sulfate (Intracellular calcium

antagonism) has become the drug of choice
for initiating tocolytic therapy.
Terbutaline (Bricanyl) Beta2-adrenergic
receptor agonist sympathomimetic; decreases
free intracellular calcium ions
Nifedipine(Procardia) Calcium channel
blocker

Tocolytic Therapy
Prostaglandin

synthetase inhibitors:
indomethacin, administered both orally and
rectally
Ritodrine (Yutopar) Same as terbutaline
Nifedipine Indomethacin (Indocin)
Prostaglandin inhibitor

Tocolytic therapy may offer some short-term

benefit in the management of preterm labor.
A delay in delivery can be used to administer
corticosteroids to enhance pulmonary maturity
and reduce the severity of fetal respiratory
distress syndrome,

also be used to facilitate transfer of the

patient to a tertiary care center
No study has convincingly demonstrated
an improvement in survival, long-term
perinatal morbidity or mortality, or neonatal
outcome with the use of tocolytic therapy
alone.

Potential Complications Associated With the Use of

Tocolytic Agents :
Magnesium sulfate
Pulmonary edema
Profound hypotension*
Profound muscular paralysis*
Maternal tetany*
Cardiac arrest*
Respiratory depression*

Beta-adrenergic agents
Hypokalemia
Hyperglycemia
Hypotension
Pulmonary edema
Arrhythmias
Cardiac insufficiency
Myocardial ischemia
Maternal death

Indomethacin (Indocin)
Renal failure
Hepatitis
Gastrointestinal bleeding
Nifedipine (Procardia)
Transient hypotension

Treatment(3)

Corticosteroid Therapy
Dexamethasone

and betamethasone
for fetal maturation reduces mortality, respiratory
distress syndrome and intraventricular hemorrhage
in infants between 28 and 34 weeks of gestation.
benefits start at 24 hours and last up to seven days
after treatment
The potential benefits or risks of repeated
administration of corticosteroids after seven days
are unknown.

Treatment(4)

Antibiotic Therapy
women

who received antibiotics sustained

pregnancy twice as long as those who did not
receive antibiotics
had a lower incidence of clinical amnionitis.
poor fetal outcome (death, respiratory
distress, sepsis, intraventricular hemorrhage
or necrotizing colitis) occurred less frequently
in women receiving antibiotics

Treatment(5)

Labor and deliverey

With modern neonatal care, the lower limit of potential
viability is 24 weeks or 500g, although these limits vary with
the expertise of the neonatal intensive care unit.
Continuous fetal heart monitoring and prompt attention to
abnormal fetal heart rate patterna are extremely important.
With a vertex presentation, vaginal delivery is preferred.
Use of outlet forceps and an episiotomy to shorten the
second stage are advocated.
Cesarean section for delivery of the very low birth weight
baby
For the breech fetus estimated at less than 1500g, neonatal
outcome is improved by cesarean section

Premature of membrane

Definition

Premature rupture of the membranes

(PROM) is defined as amniorrhexis
(spontaneous rupture of membranes) prior
to the onset of labor at any stage of
gestation

Incidence
PROM occurs in about 10-15% of all
delivery
PROM is associated with 10% of term
pregnancy

Cause of PROM(1)

The cause of PROM is not clearly

understood, perhaps associated with the
follow factors:
Trauma
Sexual

intercourse (particularly in the late

gestational weeks)
lax of internal os of uterine

Cause of PROM(2)

Vaginal infection due to bacteria, virus, TOXO, CMV,

HPV, HSV, et al STDs sexually transmitted diseases
play an important role in the cause of PROM, because
such infections are more commonly found in women with
PROM than in those without PROM
Increased of intra-uterine pressure (such as multiple
pregnancy and hydraminios)
Abnormalities in presentation and position

Cause of PROM(3)

Smoking the risk of PROM is at lease doubled in women

who smoke during pregnancy
Other factors for PROM include the follow
Prior PROM
A short cervical length
Prior preterm delivery
Bleeding in early pregnancy

Manifestation and Diagnosis

Fluid passing through the vagina suddenly, and then small amounts
of fluid flow through the vagina intermitently, particularly when the
increased of abdorminal pressure (cough, sneeze, et al)
Intermittent urinary leakage is common during pregnancy, especially
near term
Increased vaginal secretions in pregnancy
Perineal moisture
Increased cervical discharge
Urinary incontinence
Vesicovaginal fistula
May be mistaken for the fluid

Experimental Test(1)
The Nitrazine test uses pH to distinguish amniotic fluid
from urine and vaginal secretions, the paper turns dark
blue in response to the amniotic fluid
Amniotic fluid is quite alkaline having a pH above 7.0, but
vaginal secretions in pregnancy usually have pH values
of less 6.0

Experimental Test(2)

The fern test : placing a sample on a

microscopic slide, air drying, and examining
for ferning
The

amniotic fluid does fern

The other fluid does not fern

Risk of PROM
Preterm labor: 75%
Intrauterine infection(chorioamnionitis, 3050% of case)
Puerperal infection

Fetal and neonatal complications

Fetal and neonatal pneumonia, sepsis

Neonatal respiratory distress syndrone
Neurologic dysfunction
Intracranial hemorrhage
Prolapse of umbilical cord
Abruptio placenta

Evaluation

The gestational age( LMP, ultrasound and uterus fundal height

measurement)
The presence of uterine contractions (abdominal examination)
The amount of amniotic fluid (ultrasound)
Fetal heart rate (FHR monitor)
Fetal maturity (L/S or PG)
The likelihood of chorioamnionitis (white blood cell count)
The likelihood of prolapse of umbilical cord

Management(1)

Conservative expectant management

Management of chorioamnionitis
Tocolytic therapy
Use of corticosteroids
Labor and delivery
Surfactant therapy

Management(2)

If PROM occurs at term(37 weeks gestational age or more), awaiting

the onset of spontaneous labor for 12-24h should be considered,
because spontaneous labor will ensue in 90% of patients within 24
hours
If the time from PROM to the inset of labor exceeds 24h, induction of
labor should be considered by oxytocin
If the evaluation suggests intrauterine infection or chorioamnionitis,
antibiotic and delivery are indicated and the antibiotic prescribed
should have a broad spectrum of coverage
If the infant is a preterm breech, and the onset of PROM occurs after
30 weeks of gestational, possibly by ceasarean delivery

Management(3)
If the gestational age is less 30 weeks,
vaginal deliverly should be chosen
If the fetus is significantlypreterm and the
absence of infection, expectant
management is generally chosen

Management(4)

Patients must be assessed carefully

Uterine

tenderness daily
Electronic fetal monitoring used frequently
Fetal movement monitoring by the mother
Frequent ultrasound assessment helps to determine
amniotic fluid
Frequently WBC counts, usually daily for several days
Antibiotic should be used and antibiotic therapy may
prolong the latency period after preterm PROM and
improve the perinatal outcome

Management(5)

To enhance fetal pulmonary matrurity in

patients with preterm PROM
Corticosteroid

therapy (such as
betamethasone and dexamethasone) is
generally recommended in patients whose
gestational age is 34 weeks or less