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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
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 • Intrauterine infection categories
• bacteria can gain access to into four stages of microbial
intrauterine tissues through: invasion
(1) Transplacental transfer of maternal 1. include bacterial vaginosis—
systemic Infection, stage I
(2) Retrograde flow of infection into 2. decidual infection— stage II,
the peritoneal cavity via the
fallopian tubes, 3. amnionic infection—stage III,
(3) Ascending infection with bacteria
from the vagina and cervix. 4. fetal systemic infection—stage IV.
As expected, progression of
these stages is thought to
increase rates of preterm birth
and neonatal morbidity.
Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
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
Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
DIAGNOSIS & PREVENTION
• 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.
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
Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York: McGraw-Hill Education, 2014
Tocolysis to Treat Preterm Labor
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