PRETERM

LABOUR
MUHAMMAD HANIF
Final Year MBBS
 PRETERM LABOR
 Delivery between 24(20) & 37 weeks gestation

 Different from Low birthweight (LBW)

 LBW < 2500gm
 Very LBW < 1500gm
 Extremely LBW < 1000gm
 Major cause of fetal, perinatal & Infant death
 High cost of survival
PRETERM LABOR

Incidence : 6- 10%
 Spontaneous : 40-50%

 PROM : 25-40%

 Obstetrically indicated : 20-25%

PRETERM LABOR

Most mortality and morbidity is

experienced by babies born
before 34 weeks.
PRETERM LABOR
Major Fetal Risks Of
Preterm Delivery
 Death
 Respiratory distress syndrome
 Hypothermia
 Hypoglycemia
 Necrotising enterocolitis
 Jaundice
 Infection
 Retinopathy of prematurity
 PRETERM LABOR
ETIOLOGY (I)

 Amnionic fluid infection

 Cervical incompetence
 Placenta praevia
 Placental abruption
 Uterine anomalies, fibroids
 Polyhydramnios
 PRETERM LABOR
ETIOLOGY (II)
 Hypertension
 Fetal anomalies
 Immunological
 Trauma or surgery

 IDIOPATHIC - Cause undetectable

 PRETERM LABOUR

CLASSIFICATION
1. Complications of pregnancy that mandate
delivery (fetal / maternal risk )
2. Spontaneous preterm labor with intact
membranes – true / false labour
3. Preterm / premature rupture of membranes
(PROM)
Prediction
1. Assessment of risk factors
2. Vaginal examination to assess the
cervical status
3. Ultrasound visualization of
cervical length and dilatation
4. Detection of biological markers
1. Assessment of risk
factors
RISK FACTORS OF PRETERM LABOR
Risk assessment –
There is strong evidence that
intrauterine infection plays a
role in preterm labor.
Bacterial vaginosis increases the
risk of preterm delivery >2-fold .
RISK FACTORS OF PRETERM LABOR
(I)

 Poor socioeconomic/ education/ hygiene/

nutritional status
 Young (<16 y.) or advanced age (>35y.)
 Nuliparity or grand multiparity
 Short stature or low weight (BMI < 19.0)
 Medical or surgical illness in pregnancy
 Antiphospholipid syndrome
 RISK FACTORS OF PRETERM LABOR
(II)

 Previous preterm delivery: risk 20- 40%

 Obstetric complications: hypertension in
pregnancy, antepartum hemorrhage,
infection, polyhydramnios, fetal
abnormalities.
 Cigarette smoking: risk 20-30%
 Multiple pregnancy: risk >50%
 Cervical incompetence
 Uterine abnormalities
 2. Vaginal
examination to
assess the cervical
status
Digital examination is the traditional method
used to detect cervical maturation, but
quantifying these changes is often difficult.
3. Ultrasound assessment of cervical
length and dilatation

Vaginal ultrasonography → a
more objective examination of
the cervix .
Transvaginal sonogram in early pregnancy showing a
normal cervix. Arrows point to the internal and
external os
4. Detection of biological markers

Testing with biological markers

(24-36 weeks):
 Fetal Fibronectin (FFN) - in
cervico-vaginal secretions (>
50ng/mL)
 Salivary estriol (E3).
 DIAGNOSIS OF
IMPENDING
PRETERM DELIVERY
(Active preterm labor)
IMPENDING PRETERM DELIVERY
(Active preterm labor)

3 criteria for active preterm labour (20-

36w):
• uterine contractions - 4 in 20 min. or 8 in 1
h.
+
• cervical changes over time (effacement
80%) or
• dilatation ≥ to 2 cm
Prevention
 Prevention
of Preterm Labor
• Antenatal care
• Self-monitoring of uterine activity at
home: external tocodynamometer
• Reduce work, smoking, stress, travel,
sexual activity, bed rest, improve
nutrition
 PREVENTION OF PRETERM LABOR
Specific obstetric treatment

 Bed rest (in hospital)

 Cerclage of the cervix
 Antibiotics: urinary infection
(asymptomatic bacteriuria), local infection
(bacterial vaginosis), occult infection
 Progesterone
Treatment
of active preterm labor
1. Inhibition of uterine
contractions
2. Corticosteroids
3. Antibiotics
Treatment
of active preterm labor
1.Inhibition of
uterine
contractions
 Bed rest - hospitalisation
 Hydration and sedation
 Tocolytics
Choice Of Tocolytic Drug
1. Beta –Sympathomimetic agents
2. Magnesium sulphate
3. Nonsteroidal anti-inflammatory drugs
4. Calcium channel blockers
5. Nitric Oxide Donors (Nitroglycerin)
6. Oxytocin receptor antagonist (Atosiban)
Choice Of Tocolytic Drug
Most authorities do not recommend use of
tocolytics at or after 34 weeks'.
Corticosteroids
 Antenatal corticosteroids are associated with
a significant reduction in rates of RDS,
neonatal death and intraventricular
hemorrhage.

 The optimal interval between treatment and

delivery is 24 hours.
Treatment of active preterm labor

CORTICOSTEROIDS (GA = 24-34 weeks)

• 2 doses of Betamethasone
• 12 mg I.M. at 24 hours interval or
• 4 doses of Dexamethasone
• 6 mg i.m./i.v. at 12 hours interval
 Treatment of active preterm
labour
ANTIBIOTICS
•Ampicillin / Clindamycin / Erythromycin
Screen All Pregnant Women for GBS - All
patients in preterm labor are considered
at high risk.
 Intra Partum Managements of
Preterm Labour
Minimise Maternal Hypotension and Fetal hypoxia
and acidosis < Respiratory Distress Syndrome

 If Fetal distress - CS?

Below 28 weeks - NO CS
Below 32 weeks - ? 
Above 32 weeks - CS
Vertical uterine incision