Department of Obstetrics and Gynecology

I. AS TO SIZE
Small-for-gestational age / fetal growth
restriction / intrauterine growth restriction
(SGA/IUGR)
newborns with birthweight below the 10th
percentile for gestational age
Large-for-gestational age (LGA)
birthweight above the 90th percentile
Appropriate-for-gestational age (AGA)
newborns with weight between the 10th and 90th
percentiles

II. AS TO AOG
Preterm or premature birth
neonates born too early
delivery before 37 completed weeks
Term
37 42 weeks
Post term
> 42 weeks

III AS TO WEIGHT
Low birthweight
refers to births 500 to 2500 g
Very low birthweight
refers to births 500 to 1500 g
Extremely low birthweight
refers to births 500 to 1000 g.

A.Delivery for maternal or fetal indications in

which labor is induced or the infant is
delivered by prelabor cesarean delivery
B.Spontaneous unexplained preterm labor
with intact membranes
C.Idiopathic preterm premature rupture of
membranes (PPROM)
D.Twins and higher-order multifetal births

Medical and ObstetricaL Indications

Defined as rupture of the membranes

before labor and prior to 37 weeks
Preterm premature rupture of membranes
can result from a wide array of pathological
mechanisms, including intra-amnionic
infection
Risk factors

low socioeconomic status

low body mass indexless than 19.8

nutritional deficiencies

cigarette smoking

Pathogenesis of preterm labor

(1) progesterone withdrawaL
(2) oxytocin initiation
(3) decidual activation

I.
II.
III.
IV.
V.
VI.
VII.
VIII.

IX.
X.

Threatened Abortion
Lifestyle Factors
Racial and Ethnic Disparity
Work During pregnancy
Genetics
Periodontal diseases
Birth Defects
Interval Between pregnancies and preterm
birth
Prior preterm birth
Infection

I. THREATENED ABORTION

Vaginal bleeding or spotting is associated

with increased incidence of subsequent
pregnancy loss prior to 24 weeks, preterm
labor, and placental abruption

III. LIFESTYLE FACTORS

A,Cigarette smoking
B. Inadequate maternal weight gain during
pregnancy
C. Illicit drug

D. Other maternal factors

young or advanced maternal age
poverty
short stature
Vitamin C deficiency
occupational factors: prolonged walking or
standing, strenuous working conditions, and
long weekly work hours
E.depression, anxiety, and chronic stress
F.Women injured by physical abuse

IV RACIAL AND ETHNIC

DISPARITY
Black, African-American, and Afro-Caribbean
are consistently reported to be at higher
risk of preterm birth
Other associations include low
socioeconomic status and educational
status

V. WORK DURING PREGNANCY

working long hours and hard physical

labor are probably associated with
increased risk of preterm birth

VI GENETICS
Recurrent, familial, and racial nature of
preterm birth has led to the suggestion that
genetics may play a causal role

Immunoregulatory genes in potentiating

chorioamnionitis in cases of preterm
delivery due to infection

VI PERIODONTAL DISEASE

associated with preterm birth

VII BIRTH DEFECTS

associated with preterm birth

INFECTION

ETIOLOGY

Periodontitis Fusobacterium
nucleatum and
Capnocytophaga
species

DIAGNOSTIC
FEATURES

MANAGEMENT

Teeth cleaning
and polishing;
deep root
scaling and
planning plus
metronidazole

VIII. Interval between

Pregnancies and Preterm Birth

intervals shorter than 18 months and

longer than 59 months were associated
with increased risks for both preterm

VII BIRTH DEFECTS

associated with preterm birth and low
birthweight

VIII. Interval between

Pregnancies and Preterm Birth

intervals shorter than 18 months and

longer than 59 months were associated
with increased risks for both preterm birth

IX.Prior Preterm Birth

The risk of recurrent preterm
delivery for women whose first
delivery was preterm was increased
threefold compared with that of
women whose first neonate was born
at term

X. INFECTION
Two microorganisms, Ureaplasma
urealyticum and Mycoplasma
hominis, have emerged as important
perinatal pathogens

POTENTIAL ROUTES OF INTRAUTERINE INFECTION

BACTERIAL VAGINOSIS
normal, hydrogen peroxide-producing,
lactobacillus-predominant vaginal flora is
replaced with anaerobes that include
Gardnerella vaginalis, Mobiluncus species, and
Mycoplasma hominis
Diagnosis by gram stain and Nugent score
associated with spontaneous abortion, preterm
labor, preterm rupture of membranes,
chorioamnionitis, and amnionic fluid infection
susceptible TNF-alpha genotype had a
ninefold increased incidence of preterm birth

INFECTION

ETIOLOGY

DIAGNOSTIC
FEATURES

MANAGEMENT

Bacterial
vaginosis

Gardnerella
vaginalis,
Mobiluncus
species, and
Mycoplasma
hominis

-Vaginal pH > 4.5

-Homogenous
vaginal discharge
- Amine odor when
vaginal secretions
are mixed with KOH
- Vaginal epithelial
cells heavily coated
with bacilli clue
cells
- Gram staining of
vaginal secretions
show few white cells
along with mixed
flora as compared
with the normal
predominance of
lactobacilli

Metronidazole 500
mg BID for 7 days

Trichomoniasis and Trichomonas

Candida Vaginitis
vaginalis

- demonstration of
Trichomonads by wet
mount of vaginal
secretions;
Trichomondas are
identified most
accurately by culture
using Diamond medium,
Direct
immunoflorescent,
Monoclonal Ab staining
is sensitive and specific
alternative

- Routine screening
and treatmetn for this
condition cannot be
recommended
- Metronidazole 250
mg TID for 7 days
- Miconazole,
Clotrimazole and
nystatin are effective
for vaginal candidiasis

Lower genital tract

infection

- Genitourinary
Chlamydial infection at
24 weeks but not at 28
weeks detected via
ligase chain reaction
assay was associated
with a 2-fold increase in
subsequent
spontaneous preterm
birth

Erythromycin 500 mg
PO QID for 7 days

Chlamydia
trachomatis

painful or painless uterine contractions

pelvic pressure
menstrual-like cramps
watery vaginal discharge
pain in the low back

Braxton Hicks contractions

- contractions, described as irregular,
nonrhythmical, and either painful or painless, can
cause considerable confusion in the diagnosis of
true preterm labor

Contractions four in 20 minutes

or eight in 60 minutes plus
progressive change in the cervix
Cervical dilatation greater than
1 cm
Cervical effacement of 80
percent or greater

A. CERVICAL DILATATION

Short cervix by itself was

the poorest predictor of
preterm birth, whereas
funneling plus a history of
prior preterm birth was highly
predictive.

recurrent, painless cervical dilatation and

spontaneous midtrimester birth in the absence of
spontaneous membrane rupture, bleeding, or
infection

an external tocodynamometer is belted around

the abdomen and connected to an electronic
waist recorder
Uterine activity is transmitted via telephone
daily
Women are educated concerning signs and
symptoms of preterm labor, and clinicians are
kept apprised of their progress
ACOG concluded that the use of this expensive,
bulky, and time-consuming system does not
reduce the rate of preterm birth

glycoprotein produced in 20 different molecular forms

by hepatocytes, fibroblasts, and endothelial cells, and
by fetal amnion
Present in high concentrations in maternal blood and
in amnionic fluid which play a role in intercellular
adhesion during implantation and in the
maintenance of placental adhesion to the
decidua
detected in cervicovaginal secretions in women who
have normal pregnancies with intact membranes at
term, and it appears to reflect stromal remodeling
of the cervix prior to labor

fibronectin detection in cervicovaginal secretions

prior to membrane rupture was a possible
marker for impending preterm labor
measured using an enzyme-linked
immunosorbent assay
values exceeding 50 ng/mL are considered
positive
positive value for cervical or vaginal fetal
fibronectin assay, as early as 8 to 22 weeks powerful predictor of subsequent preterm birth

A. PROGESTERONE
Maternal plasma progesterone levels
increase throughout pregnancy
Maintain uterine quiescence and "block"
labor initiation

Progesterone therapy should

be limited to women with a
documented history of a
previous spontaneous birth
at less than 37 weeks

American College of Obstetricians

and Gynecologists (2008)

B.CERVICAL CERCLAGE
INDICATIONS FOR CERCLAGE
history of recurrent midtrimester losses and
who are diagnosed with an incompetent
cervix
women identified during sonographic
examination to have a short cervix.
"rescue" cerclage, done emergently when
cervical incompetence is recognized in the
women with threatened preterm labor

I.DIAGNOSIS PRETERM RUPTURED

MEMBRANES
A history of vaginal leakage of fluid should
prompt a sterile speculum examination
to visualize gross vaginal pooling of
amnionic fluid, clear fluid from the cervical
canal, or both
Confirmation by ultrasonographic
examination to assess amnionic fluid
volume; to identify the presenting part; and
if not previously determined, to estimate
gestational age

Fever is the only reliable indicator for this

diagnosis, and temperature of 38C
(100.4F) or higher accompanying ruptured
membranes implies infection
Maternal leukocytosis alone has not been
found to be reliable
During expectant management, monitoring
for sustained maternal or fetal tachycardia,
for uterine tenderness, and for a malodorous
vaginal discharge is warranted.

MANAGEMENT
If chorioamnionitis is diagnosed, prompt
efforts to effect delivery, preferably
vaginally, are initiated.

ACCELERATE FETAL SURFACTANT

PRODUCTION
chronic renal or cardiovascular disease
hypertensive disorders
heroin addiction
fetal-growth restriction
placental infarction
chorioamnionitis
preterm ruptured membranes

Meta-analysis indicated that only three of 10 outcomes

were possibly benefited:
(1) fewer women developed chorioamnionitis,
(2) fewer newborns developed sepsis
(3) pregnancy was more often prolonged 7 days in women
given antimicrobials.
Neonatal survival, however, was unaffected, as was the
incidence of necrotizing enterocolitis, respiratory distress,
or intracranial hemorrhage.

Mercer and Arheart (1995)

There is no consensus regarding

treatment between 32 and 34
weeks. They are not
recommended prior to 24 weeks.

The cornerstone of treatment is to avoid

delivery prior to 34 weeks, if possible.
1. Amniocentesis to detect infection
2. Steroid therapy to enhance fetal lung
maturation
3.Antimicrobials
4.Emergency or rescue cerclage

1. Bed rest
2. Hydration and sedation
3. Beta adrenergic receptor agonist(ex
Ritodrine, Isoxsuprine)
5. Magnesium sulfate
6. Prostaglandin inhibitors (ex.
Indomethacin)
7. Calcium channel blockers
Nifedipine
8. Atosiban (oxytocin antagonist)
9. Nitric oxide donors (nitroglycerin) not
effective

 Ritodrine
Terbutaline, Isoxuprine

inhibiting prostaglandin synthesis or by

blocking their action on target organs
associated with early closure of patent
closure of ductus arteriosus

 The

combination of nifedipine with

magnesium for tocolysis is potentially
dangerous

Ben-Ami and co-workers reported that

Nifedipine enhances neuromuscular
blocking effects of magnesium that can
interfere with pulmonary and cardiac
function

The following considerations should be given to

women in preterm labor:
1. Confirmation of preterm labor
2. For pregnancies less than 34 weeks in women
with no maternal or fetal indications for
delivery, close observation with monitoring of
uterine contractions and fetal heart rate is
appropriate, and serial examinations are done
to assess cervical changes.
3. For pregnancies less than 34 weeks,
glucocorticoids are given for enhancement of
fetal lung maturation.

4.Consideration is given for maternal

magnesium sulfate infusion for 12 to 24
hours to afford fetal neuroprotection
5. For pregnancies less than 34 weeks in
women who are not in advanced labor,
some practitioners believe it is reasonable
to attempt inhibition of contractions to
delay delivery while the women are given
corticosteroid therapy and group B
streptococcal prophylaxis.

6.For pregnancies at 34 weeks or beyond,

women with preterm labor are monitored
for labor progression and fetal well-being
7.For active labor, an antimicrobial is given
for prevention of neonatal group B
streptococcal infection.

1. Labor
Continuous electronic monitoring is preferred
Fetal tachycardia, especially with ruptured
membranes, is suggestive of sepsis
2. Prevention of neonatal group B
Streptococcal infections
Either penicillin G or ampicillin intravenously
every 6 hours until delivery for women in
preterm labor(ACOG)

3. Delivery
Staff proficient in resuscitative techniques
commensurate with the gestational age of the newborn
and fully oriented to any specific problems should be
present
4. Prevention of neonatal intracranial hemorrhage
Preterm newborns have germinal matrix bleeding that
can extend to more serious intraventricular hemorrhage
It was hypothesized that cesarean delivery to obviate
trauma from labor and vaginal delivery might prevent
these complications
Avoidance of active-phase labor is impossible in most
preterm births because the route of delivery cannot be
decided until the active phase labor is firmly established

Far Eastern University

Dr. Nicanor Reyes Medical Foundation
Department of Obstetrics and Gynecology

Postmature -relatively uncommon specific

clinical fetal syndrome in which the infant
has recognizable clinical features indicating
a pathologically prolonged pregnancy.
Postterm or prolonged preferred expression
for an extended pregnancy
According to ACOG(1997) : 42 completed
weeks (294 days) or more from the first day
of the last menstrual period.

Two categories of pregnancies that reach 42

completed weeks
(1) those truly 40 weeks past conception
(2) those of less advanced gestation but with
inaccurately estimated gestational age
There is no accurate method to identify
the truly prolonged pregnancy, all those
judged to be 42 completed weeks should be
managed as if abnormally
prolonged

Incidence of postterm pregnancy ranges

from 4 to 19 percent
There are contradictory findings
concerning the significance of maternal
demographic factors such as parity, prior
postterm birth, socioeconomic class, and age
They reported that only prepregnancy
body mass index (BMI) 25 and
nulliparity were significantly associated
with prolonged pregnancy

Infants, either live or stillborn,

demonstrating these clinical characteristics
are now diagnosed to be pathologically
postmature, or to have the postmaturity
syndrome
Many were seriously ill due to birth
asphyxia and meconium aspiration.

FEATURES OF POST MATURITY SYNDROME

wrinkled, patchy, peeling skin
long, thin body suggesting wasting
open-eyed, unusually alert,
appears old and worried

skin wrinkling can be particularly

prominent on the palms and soles

nails are typically long

Postmature infant delivered at 43 weeks' gestation. Thick, viscous

meconium coated the desquamating skin. Note the long, thin
appearance and wrinkling of the hands.

Clifford (1954) proposed

skin changes of postmaturity
were due to loss of the protective
effects of vernix caseosa.
He also attributed the
postmaturity syndrome to
placental senescence, although he
did not find placental
degeneration histologically

As consequence of cord compression

associated with oligohydramnios
It is not associated with late decelerations
characteristic of uteroplacental insufficiency.
Instead, one or more prolonged
decelerations preceded three fourths of
emergency cesarean deliveries for
nonreassuring fetal heart rate tracings. In all
but two cases, there were also variable
decelerations tracings
Although not ominous by itself, was the
saltatory baseline

AMNIOINFUSION
during labor as a
way of diluting
meconium

one third of the postterm stillbirths were

growth restricted
morbidity and mortality were significantly
increased in the growth-restricted infants

A.OLIGOHYDRAMNIOS
The smaller the amnionic fluid pocket, the
greater the likelihood that there was
clinically significant oligohydramnios
AFI overestimated the number of
abnormal outcomes in postterm
pregnancies.

B. MACROSOMIA
The velocity of fetal weight gain peaks at approximately 37 weeks

ACOG 2000

It is generally unwise to allow a pregnancy to

continue past 42 weeks if with
gestational hypertensive disorders
prior cesarean delivery
diabetes.

Performed twice weekly fetal testing until 42

weeks.
41 weeks with favorable cervix, induce
labor
41 weeks with unfavorable cervix,
antepartum fetal testing
42 weeks, whether the cervix is favorable or
not, labor is generally induced

Define as cervix that is closed, uneffaced

with a bishop score of less than 7
women in whom there was no cervical
dilatation at 42 weeks had a twofold
increased cesarean delivery rate for
"dystocia."
cervical length of 3 cm or less determined
by transvaginal ultrasonography was
predictive of successful induction
cervical length of 25 mm or less was
predictive of spontaneous labor or successful
induction.

CERVICAL RIPENING
Prostaglandin E2 (PGE2)
Prostaglandin gel
SWEEPING OR STRIPPING OF THE
MEMBRANES

Membrane stripping at 38 to 40 weeks

decreased the frequency of postterm
pregnancy

Drawbacks of membrane stripping

included pain, vaginal bleeding, and
irregular contractions without labor.

STATION OF VERTEX
cesarean delivery rate was directly related
to station

CESAREAN DELIVERY RATE

STATION

6 percent

STATION -1

20 percent

STATION -2

43 percent

STATION -3

77 percent

STATION-4

American College of Obstetricians and

Gynecologists (2007)

EVALUATION AND MANAGEMENT OF POSTTERM PREGNANCY

1. Postterm pregnancy is defined as a pregnancy that has extended to or beyond 42 completed

weeks.
2. Women with a postterm gestation who have an unfavorable cervix can either undergo labor
induction or be managed expectantly.
3. Prostaglandin can be used for cervical ripening and labor induction.
4. Delivery should be effected if there is evidence of fetal compromise or oligohydramnios.

5. It is reasonable to initiate antenatal surveillance between 41 and 42 weeks despite lack of

evidence that monitoring improves outcomes.
6. A nonstress test and amnionic fluid volume assessment should be adequate, although no
single method has been shown to be superior.
7. Many recommend prompt delivery in a woman with a postterm pregnancy, a favorable cervix,
and no other complications.
From the American College of Obstetricians and Gynecologists (2004)