Preterm Labor or Premature Labor

By Tuan Ahamed
Cassim (Group 19)

Definition
Preterm labor (PTL) is defined as one where the labor
starts before the 37th completed week (< 259 days),
counting from the first day of the last menstrual period.
Preterm birth is the significant cause of perinatal
morbidity and mortality.
The lower limit of gestation is not uniformly defined;
whereas in developed countries it has been brought
down to 20 weeks, in developing countries it is 28
weeks.

Etiology
In about 50%, the cause of preterm labor is not known.

Due to History
Previous history of induced or spontaneous abortion or preterm
delivery;
Pregnancy following assisted reproductive techniques (ART)
Asymptomatic bacteriuria or recurrent urinary tract infection
Smoking habits
Low socioeconomic and nutritional status;
Maternal stress HPA Axis Stress hormones PTL

Due to complications in present

pregnancy
Maternal
Fetal
Placental
Maternal complications:
(a) Pregnancy complications: Preeclampsia, antepartum hemorrhage, premature rupture of
the membranes (due to inflammation and enzymes), polyhydramnios;
(b) Uterine anomalies: Cervical incompetence, malformation of uterus;
(c) Medical and surgical illness: Acute fever, acute pyelonephritis, diarrhea, acute appendicitis,
toxoplasmosis and abdominal operation. Chronic diseases: Hypertension, nephritis, diabetes,
decompensated heart lesion, severe anemia, low body mass index (LBMI);
(d) Genital tract infection: Bacterial vaginosis, beta-hemolytic streptococcus, bacteroides,
chlamydia, mycoplasma.
Fetal complications: Multiple pregnancy Uterine distension Cervix
dialated (Cervix insufficiency), congenital malformations, intrauterine death.
Placental complications: Infarction, thrombosis, placenta previa or abruption
Uterine contraction Decrease blood PTL

Etiology (continued)
Iatrogenic: Indicated preterm delivery due to medical or
obstetric complications.
Idiopathic: (Majority)Premature effacement of the
cervix with irritable uterus and early engagement of the
head are often associated. In the absence of any
complicating factors, it is presumed that there is
premature activation of the same systems involved in
initiating labor at term.

Diagnosis
(1)Regular uterine contractions with or without pain (at
least one in every 10 minute); (Brax and Hicks
constractions)
(2)Dilatation (> 2 cm) and effacement (80%) of the
cervix;
(3)Length of the cervix (measured by TVS) < 2.5 cm and
funneling of the internal os (see p. 169)
(4)Pelvic pressure, backache and or vaginal discharge or
bleeding. It is better to overdiagnose preterm labor
than to ignore the possibility of its presence.

Here the functional cervix length shown by

yellow arrow is shortened (cervical
Insufficiency)

Another Example:-

Management of Preterm Labor

The management includes:
(1) To prevent preterm onset of labor, if possible;
(2) To arrest preterm labor, if not contraindicated;
(3) Appropriate management of labor;
(4) Effective neonatal care.

Predictors of preterm labor:

A. Clinical predictors: (i) Multiple pregnancy; (ii) History
of preterm birth; (iii) Presence of genital tract
infection; (iv) Symptoms of PTL (p. 314).
B. Biophysical predictors: (i) Uterine contractions (UC) >
4/hr; (ii) Bishop score > 4; (iii) Cervical length (TVS) <
25 mm.
C. Biochemical predictors: (i) Fetal fibronectin (fFN) in
cervico vaginal discharge (ii) Others IL-6, IL-8, TNF-a.

Fibronectin
Fibronectin is a glycoprotein that binds the fetal
membranes to the decidua. Normally it is found in the
cervicovaginal discharge before 22 weeks and again
after 37 weeks of pregnancy. Presence of fibronectin in
the cervicovaginal discharge between 24 and 34 weeks
is a predictor of preterm labor.
When the test is negative it reassures that delivery will
not occur within next 7 days.

PRINCIPLES OF MANAGEMENT OF
WOMEN WITH PRETERM LABOR
(1)Glucocorticoids to the mother to reduce neonatal RDS, IVH and NEC
(2)Antenatal transfer of the mother with fetus in utero to a center
equipped with NICU
(3)Tocolytic drugs (see p. 507) to the mother for a short period unless
contraindicated (p. 316).
(4)Antibiotics to prevent neonatal infection with Group B Streptococcus
(GBS)
(5)Careful intrapartum monitoring, minimal trauma and presence of a
neonatologist during delivery
(6)Vaginal delivery is preferred, unless otherwise indicated for cesarean

PREVENTION OF PTL
In about 50%, the cause remains unknown. Among the remaining
complicated groups, decision has to be taken whether to allow the
pregnancy to continue or not. The risk of delivery of a low birth weight
baby has to be weighed against the risks involved to the fetus and/or to
the mother in continued pregnancy. However, the following guidelines
are adopted.
Primary care is aimed to reduce the incidence of preterm labor by
reducing the high-risk factors (e.g. infection, etc.).
Secondary care includes screening tests for early detection and
prophylactic treatment (e.g. tocolytics).
Tertiary care is aimed to reduce the perinatal morbidity and mortality
after the diagnosis (e.g. use of corticosteroids).

MEASURES TO ARREST PRETERM

LABOR

The scope to arrest preterm labor is limited, as majority is associated with maternal
and/or fetal complicating factors where the early expulsion of the fetus may be
beneficial. It is indeed unwise to attempt to arrest the onset of labor in such cases.
Thus, in only negligible proportion of cases (about 1020%) where the fetus is not
compromised, the maternal condition remains good and membranes are intact, the
following regime may be instituted in an attempt to arrest premature labor.
Bed restThe patient is to lie preferably in left lateral position though the benefits
are doubtful.
Adequate hydration is maintained. Prophylactic antibiotic is not routinely given. It is
recommended when infection is evident or culture report suggests.
Prophylactic cervical circlage for women with prior preterm birth and short cervix in
the present pregnancy may be beneficial.
Tocolytic agents: Various drugs including progesterone (micronized) have been used
to inhibit uterine contractions. The tocolytic agents can be used as short term (13
days) or long-term therapy. Tocolytics should preferably be avoided as there is no clear
benefit.

Short-term therapy: It is commonly employed with success. The objectives

are:
(1) To delay delivery for at least 48 hours for glucocorticoid therapy to the
mother to enhance fetal lung maturation;
(2) In utero transfer of the patient to a unit with an advanced neonatal
intensive care unit (NICU)
Contraindications are;
A. Maternal: Uncontrolled diabetes, thyrotoxicosis, severe hypertension, cardiac disease,
hemorrhage in pregnancy, e.g. placenta previa or abruption.
B. Fetal: Fetal distress, fetal death, congenital malformation, pregnancy beyond 34 weeks.
C. Others: Rupture of membranes, chorioamnionitis, cervical dilatation more than 4 cm.
Glucocorticoid therapy: Maternal administration of glucocorticoids is advocated where the pregnancy
is less than 34 weeks. This helps in fetal lung maturation. This is beneficial when the delivery is
delayed beyond 48 hours of the first dose. Benefit persists as long as 18 days. Either
betamethasone (Betnesol) 12 mg IM 24 hours apart for two doses or dexamethasone 6 mg IM every
12 hours for 4 doses is given. Betamethasone is the steroid of choice

Risks of antenatal corticosteroid use:

(a)Premature rupture of the membranes specially with
evidence of infection as the infection may flare-up;
(b)(b) Insulin dependent diabetes mellitus where patients
need insulin dose readjustment;
(c) (c) Transient reduction of fetal breathing and body
movements.

The principles in management of preterm labor are:

(1) To prevent birth asphyxia and development of RDS;
(2) To prevent birth trauma. Duration of labor is usually
short.

Immediate management of the

preterm baby following birth
PROGNOSIS: Preterm labor and delivery of a low birth
weight baby results in high perinatal mortality and
morbidity. However, with neonatal intensive care unit, the
survival rate of the baby weighing between 10001500 g
is more than 90%. With the use of surfactant (see p.
475), survival rate of infants born at 26 weeks is about
80 percent.

Thank you!