PRETERM BIRTH

IVANDER T (201806010108)
CHITRA C (201806010125)
Definition
Preterm birth is (the presence of contractions of sufficient strength and frequency to
effect progressive effacement and dilatation of the cervix) delivered before 37 weeks
gestation counting from the first day of the last menstrual period.

Newborn born before 37 weeks suffer various morbidities due to organ system
immaturity.
Etiology
Four direct causes of preterm birth is

- spontaneous 40-45%
- PPROM 30-35%
- maternal and fetal indication 30-35%
- twins or multifetal births
1. Spontaneous preterm birth
More common with multifetal pregnancy, intrauterine infection, bleeding, placental
infarction, premature cervical dilatation, cervical insufficiency, hydramnion, uterine
fundal abnormalities and fetal anomalies.

The major causes are :

a. Uterine Distention

The expression of CAPs (Contraction Association Proteins) that are influenced by

stretch leads to early activation of the placental-fetal endocrine cascade and
initiate shift the timing of the uterine activation (cervical ripening).
b. Maternal fetal stress

Condition or adverse circumstance that disturb the normal physiological or

physiological functioning of an individual. For example nutrient restriction, obesity,
infection, and diabetes.

The mechanism stress induced preterm is because premature activation of the

placental-adrenal endocrine axis that increase cortisol and increase steroid hormone
production and loss of uterine quiescence. Maternal estrogen level than elevated
and accelerate cervical ripening..

c. Cervical dysfunction

Premature cervical remodelling precedes premature labor onset. The underlying

cause is cervical dysfunction of either epithelial and stromal extracellular matrix. An
intact cervical epithelial barrier is critical to prevent ascending infection. Disruption
of this barrier predispose to ascending infection and preterm birth.
d. Infection

Ascending infection is considered to be the most common entry route. Bacteria can
gain access to intrauterine through : transplacental transfer of maternal systemic
infection, retrograde flow of infection into the peritoneal cavity via the fallopian
tubes, or ascending infection with bacteria from the vagina and cervix.
2. PPROM (preterm premature rupture of membrane)
It is spontaneous rupture of the fetal membranes before 37 completed weeks and
before labor onset. PPROM caused by intrauterine infection, oxidative stress induced
DNA damage and premature cellular senescence. The associated factor are
socioeconomic factor, Birth mass index < 19,8 , nutritional deficiency, and cigarette
smoking. Increased apoptosis or necroptosis of membrane cellular components and
greater levels of specific proteases in membranes and amniotic fluid related to
PPROM.

3. Multifetal Pregnancy
Twins or multifetal births increase the frequency of preterm labor.
Contributing Factors
- Genetic → familial and ras
- Lifestyle → cigarette smoking, inadequate maternal weight and drug
- Periodontal disease
- Prior preterm birth
- Infection → Bacterial Vaginosis
Diagnosis
The goals of diagnostic evaluation are to detect the conditions that predispose to
premature labor (ascending infection, placental insufficiency, amniotic fluid changes,
and others) and to provide an objective measure of the extent to which premature
labor has already begun (characteristics of contractions, effect of contractions on the
cervix, premature rupture of the membranes). Moreover, the condition of the fetus
must be assessed, so that it can be determined whether there is a need to deliver the
baby.

A diagnosis of preterm labor should be made in a patient between 20 weeks and 36

weeks, six days of gestation if uterine contractions occur at a frequency of four per 20
minutes or eight per 60 minutes, and are accompanied by one of the following: PROM,
cervical dilation greater than 2 cm, effacement exceeding 50 percent, or a change in
cervical dilation or effacement detected by serial examinations.
•Symptoms :
-Pelvic pressure, menstrual-like cramps, watery vaginal discharge, lower back pain
→ associated with impending birth
-Contractions that are associated with cervical change

•Cervical change
- Asymptomatic cervical dilatation after midpregnancy is suspected to be a risk
factor for preterm delivery. Based on study from Parkland Hospital, 25% of
women whose cervix was dilated 2-3 cm delivered before 34 weeks.
Diagnostic test Purpose

Cardiotocography Objectification of uterine contractions and their frequency;

assessment of the condition of the fetus

Vaginal examination

● cervical smear for microbiology Diagnosis of infection

● measurement of vaginal pH Diagnosis of infection

● amniotic fluid testing where Biochemical test of amniotic fluid proteins

indicated
● fibronectin test Biochemical marker of cervical stage

● palpation for cervical assessment Subjective assessment of cervical stage

(bishop score)
Treatment
The goal of all interventions is not just to prolong pregnancy, but rather to
give the newborn infant the best chance of surviving with as few
complications as possible. Thus, depending on the particular clinical situation,
the treatment of choice might be either to prolong the pregnancy or to deliver
the baby.

Therapeutic measures :

● Inhibition of uterine contraction with drugs

● Glucocorticoid administration to promote fetal lung maturation
● Antibiotics to treat infections, if present
inhibition of uterine contractions with drugs (tocolysis)
Indications

● generally, from GW 24 + 0 onward until GW 34 + 0 at the latest

● spontaneous premature contractions
● painful, palpable contractions that last longer than 30 seconds each and occur more than 3 times in 30
minutes

and

● functional cervix length (transvaginal measurement) <25 mm and/or cervical dilatation

Contraindications

● fetal indication for delivery

● maternal indication for delivery
● amniotic infection syndrome
● developmentally malformed, non-viable fetus
Contraindications for specific tocolytic agents
Beta-mimetic agents Indomethacin (Indocin)

● Maternal cardiac rhythm disturbance ● Asthma

or other cardiac disease ● Coronary artery disease
● Poorly controlled diabetes, ● Gastrointestinal bleeding (active or
thyrotoxicosis or hypertension past history)
● Oligohydramnios
Magnesium sulfate ● Renal failure
● Hypocalcemia ● Suspected fetal cardiac or renal
● Myasthenia gravis anomaly
● Renal failure Nifedipine (Adalat, Procardia)

● Maternal liver disease

The induction of lung maturation with glucocorticoids
Corticosteroid therapy is presently the only treatment shown to improve fetal survival
when given to a woman in preterm labor between 24 and 34 weeks of gestation.
Studies have shown a decrease in intraventricular hemorrhage, respiratory distress
syndrome and mortality even when treatment lasts for less than 24 hours, although
optimal benefits begin 24 hours after therapy and last for seven days. Corticosteroid
therapy is also beneficial in pregnant women of less than 30 to 32 weeks of gestation
with PPROM (Preterm Premature Rupture of Membrane) and no evidence of
chorioamnionitis. Treatment regimens include betamethasone, in a dosage of 12 mg
given intramuscularly every 24 hours for two days, or dexamethasone, in a dosage of 6
mg given intramuscularly every 12 hours for two days.
Antibiotics to treat infections
Vaginal infections are considered to be the main cause of premature labor and
premature rupture of the membranes. It thus seems reasonable to treat vaginal
infections with antibiotics in order to prevent preterm birth. For women with
premature rupture of the membranes, a meta-analysis of 22 studies with a total of 6800
women demonstrated the benefit of antibiotics both for lowering the frequency of
chorioamnionitis (OR 0.66, 95% CI 0.46–0.96) and for preventing preterm birth within
48 hours (OR 0.71, 95% CI 0.58–0.87) or seven days (OR 0.79, 95% CI 0.71–0.89).
When antibiotics are given for preterm labor without premature rupture of the
membranes, the rate of maternal infection is lower (OR 0.74, 95% CI 0.64–0.87), but
pregnancy is not prolonged, nor is there any reduction of the rate of neonatal
complications. For these reasons, the routine administration of antibiotics in
premature labor is currently not recommended.
Management of PPROM
Management of Preterm labor with Intact Membranes
● If possible, delivery before 34 weeks is delayed.
● Amniocentesis to detect infection
● Corticosteroid for fetal lung maturation
● Antimicrobials
● Bed rest
● Cervical pessaries
● Tocolysis to treat preterm labor :
- beta-adrenergic = ritodrine, terbutaline

- prostaglandine inhibitor = indomethacin

- calcium-channel blocker = nifedipine, magnesium sulfate

References
1. Williams Obstetrics 25th edition
2. Rundell K, Panchal B. Preterm Labor: Prevention and Management [Internet].
American family physician. U.S. National Library of Medicine; 2017.
3. Schleußner E. The prevention, diagnosis and treatment of premature labor. Dtsch
Arztebl Int. 2013 Mar;110(13):227-35;