Pathogenesis of

Spontaneous Preterm Birth

Agung Sunarko Putra

MFM Trainee Dr. Soetomo General Hospital

Preterm birth : Viability
• 1.1 million neonates die from prematurity
related complications
•toRates
37 weeks of GA
of PTB vary arround the world, with
US highest among them
• Devide into Spontaneous and caregiver-
initiated preterm birth
• 75% all PTB have spontaneous pathway
to delivery, about 45% (23.2% - 64.1%)
with intact membrane and 30% (7.1% -
51.2%) with PROM

New paradigm : 16 weeks to 38 weeks 6 days (112 to 272 days)

???

• Term and preterm labor share common pathway which include increased uterine contractility, and
membrane rupture
• However PTB results from a disease process (Pathological activation) that activates one or more
componens of the common pathway via similar or alternative mechanism
• Common pathway of parturition includes anatomic, biochemical, immunologic, endocrinologic, and
clinical changes/events
 Phenotype components of the preterm birth
Prostaglandin as key activators of the common pathway of parturition
Pathologic mechanism in preterm birth
Inflammation, stress, and term and
preterm parturition :
• Inflammation is highly orchestrated
process designed to ensure
survival of the host
• Inflammation process have
physiologic componen intended to
ensure maintenance of
homeostasis
 Preterm birth resulting from
intra-amniotic infection
• Preterm delivery is often associated with intra amniotic
infection —> Inflammation process

• Infection may not be obvious

• Culture based data suggest that a large number of

intraamniotic infection are polymicrobial

• Once the mechanical and complex innate immune barrier

of the cervix bypassed, microorganism infect the decidua
and penetrate the fetal membrane to enter amniotic fluid
Mechanical and immune barrier of the cervix
 Strech and Parturition
• During human pregnancy, significant physical and
biochemical adaptive transformations of the myometriom
are required to aid and development of the fetus

• Intra-amniotic pressure remains low through gestation

• Fetal membranes carry important protective and

biochemical function

• After 28 weeks of GA, intact fetal membranes are under

tension and in a state of active stretch
Stretch induced preterm labor
 Fetal Control of the Onset of Parturition
• The mechanism by which parturition is initiated in humans
is largely unknown (Drover and Casper)
• The placenta and fetal membranes appear to play the
major role in the initiation of labour, and the fetus may
influence the timing of labour (Drover and Casper)
• Compelling data indicate that the fetus actively
participated in controlling the timing of labor via production
of adrenal hormonal production
• Evidence support that at term before the onset of labor the
weight and volume of fetal adrenal gland equals that of the
adult —> enhancement placental estrogen production
(Lockwood and Co.)
 Spontaneous Preterm Parturition as a Syndrome
It is increasingly clear that a preterm labor is not a single
disease, but a syndrome with multiple causes :

• Maternal and local condition

• Myometrial contractility

• Cervical adaptation and remodeling during human

pregnancy

• Cervical adaptation and remodeling during preterm birth

• Decidual activation and bleeding

• pPROM
Phenotype Components of Preterm Birth Syndrome

Maternal Condition : Fetal Condition :

• Extrauterine infection • Intrauterine fetal demise

• Clinical chorioamnionitis • Intrauterine growth restriction

• Maternal trauma and uterine • Abnormal fetal heart rate or

rupture BPP

• Worsening maternal • Infection and FIRS

diseases including
preeclampsia • Fetal anomaly

• Maternal stress and anxiety • Polyhydramnios

• Cervical disorders • Multiple pregnancies

Placental Pathological
Condition :

• Histologic chorioamnionitis

• Placental abrubtion

• Placenta previa

• Other placental abnormality

 Thank You

Agung Sunarko Putra