You are on page 1of 8

preterm infants pose various complex medical,

Preterm Birth social, and ethical considerations.


Lourdes R. Abeleda,MD
 Infants now considered to be at the threshold of
June 16, 2014
viability are those born at 22, 23, 24, or 25
weeks (ACOG, 2012a,b). These infants have
I. INTRODUCTION been described:
o As fragile and vulnerable because of
Birthweight their immature organ systems.
 Low birthweight = neonates who are born too o High risk for brain injury from hypoxic-
small ischemic injury and sepsis.
o Births 500 to 2500 g
 Cesarean delivery at the threshold of viability is
 Very low birthweight controversial.
o Births 500 to 1500 g
 Extremely low birthweight Policy for threshold of viability at Parkland hospital
o Births 500 to 1000 g  At 25 weeks
o All fetal indications for cesarean
Preterm or premature births: delivery in more advanced pregnancies
Define neonates who are born too early
 At 23 weeks
o Cesarean delivery is not offered for fetal
Respect to size: indications
 Appropriate for gestational age (AGA)  At 24 weeks
o Weight is between the 10th and 90th
o Cesarean delivery is not offered unless
percentiles
fetal weight is estimated ≥750 g
 Small for gestational age (SGA) o Growth restriction: aggressive
o Categorize newborns whose birthweight obstetrical management
is usually below the 10th percentile for
gestational age Late preterm birth
o Fetal-growth restriction or intrauterine
 Infants 34-36 weeks : approximately 75% of all
growth restriction
preterm births
 Large for gestational age (LGA)  Late preterm births accounted for 3/4 of all
o Categorize newborns whose birthweight
preterm births
is above the 90th percentile for
 Approximately 80 percent of these were due to
gestational age.
idiopathic spontaneous preterm labor or
prematurely ruptured membranes
Preterm birth
 Complications such as hypertension or placental
 Delivery before 37 completed weeks
accidents were implicated in approximately 20%
 Prematurity responsible for incomplete
of cases
development of various organ system
Early Preterm
III. REASONS FOR PRETERM DELIVERY
 Births 37 6/7 weeks through 38 6/7 weeks Four Main Reason for Preterm Delivery
Term  Spontaneous unexplained preterm labor with
 39 weeks to 40 6/7 weeks intact membranes
Late preterm births  Idiopathic preterm premature rupture of
 Delivery between 34 to 36 weeks' gestation membranes (PPROM)
 70% of all preterm birth  Twins and higher-order multifetal births.
 Maternal or fetal indication
II. MORBIDITY IN PRETERM INFANT
Basic Science of SPONTANEOUS LABOR.
 Largely due to system immaturity
 Pregnancies with intact fetal membrandes and
 Very small infants suffer disproportionately not spontaneous preterm labor must be distinguished
only the immediate complications of prematurity from those complicated by PPROM.
but also long-term sequelae such as
 More common associated findings are multifetal
neurodevelopmental disability.
pregnancy, intrauterine infection, bleeding,
 After achieving a birthweight of ≥1000 g or a placental infarction, premature cervical
gestational age of 28 weeks females to 30 weeks dilatation, cervical insufficiency, hydramnios,
males: survival rates reach 95% uterine fundal abnormalities
 Severe maternal illness as a result of infections,
Mortality & Morbity at extremes of prematurity autoimmune diseases, and gestational
 There has been uncertainty and controversy as to hypertension also increases preterm labor risks.
the lower limit of fetal maturation compatible
with extrauterine survival. Major causes of spontaneous preterm labor
 Resulted in continual reassessment of the  Uterine distension
threshold of viability.
 Maternal-fetal stress
 Births before 26 weeks are generally considered
 Premature cervical changes
at the current threshold of viability, and these
 Infection

1|O B S T E T R I C S , 2 0 1 4
©ILANO
 The earlier the onset of preterm labor the greater
Uterine distension the likelihood of documented infection
 Multifetal pregnancy and hydramnios  In preterm pregnancies – bacteria represent an
 Acts to initiate expression of contraction important cause of labor
associate proteins in the myometrium o Data that associayte chorioamnionitis
 CAP genes- influenced by stretch include those with preterm labor
coding for gap-junction proteins such as  The microbes may invaded
connexion 43, for oxytocin receptors and maternal tissue only and not
prostaglandin synthase. amniotic fluid.
 Gastrin-releasing peptides (GRP’s)- increase  Endotoxins can stimulate
with stretch to promote myometrial contractility amnionic cells to secrete
 GRP antagonists can inhibit uterine contractility cytokines that enter amnionic
 Stretch induced potassium channel—TREK-1— fluid.
that is upregulated during gestation and Sources of infection
downregulated in labor.  Bacteria can gain access intrauterine tissues
 Excessive uterine stretch causes premature loss through
of myometrial quiescence. o Transplacental transfer of maternal
 Leads to early activation of the placental-fetal systemic infection
endocrine cascade o Retrograde flow of infection into the
o Early rise in maternal corticotropin- peritoneal cavity via the fallopian tubes
releasing hormone and estrogen levels o Ascending infection with bacteria ffrom
can further enhance the expression of the vagina and cervix – MOST
myometrial CAP genes COMMON.
 Prematurely increased stretch and endocrine
activity may initiate events that shift the timing 4 Stages of microbial invasion
of uterine activation, including premature  Bacterial vaginosis
cervical ripening.  Decidual infection
 Amniotic infection
Maternal-fetal stress  Fetal systemic infection
 Stress is defined as a condition or adverse **progression of these stages is thought to increase rates
circumstance that disturbs the normal of preter birth and neonatal morbidity.
physiological or psychological functioning of an
individual. Ascending microorganisms colonize the cervix,
 Complexities of measuring ―stress‖. decidua, and possibly the membranes, where they then
 Maternal psychological stress and the placental– may enter the amnionic sac. Lipopolysaccharide (LPS)
adrenal endocrine axis that provides a potential or other toxins elaborated by bacteria induce immune-
mechanism for stress-induced preterm birth. cell recruitment into the reproductive tract and cytokine
 Last trimester- rising maternal serum levels of production by immune cells and by cells within the
placentalderived corticotropin-releasing cervix, decidua, membranes, or fetus itself.
hormone (CRH) works with
adrenocorticotropic hormone (ACTH) to LPS and cytokines then provoke prostaglandin
increase adult and fetal adrenal steroid hormone release from the membranes, decidua, or cervix. These
production, including the initiation of fetal may influence both cervical ripening and loss of
cortisol biosynthesis. myometrial quiescence.
 Rising CRH Cortisol stimulate fetal
adrenal dehydroepiandrosterone sulfate (DHEA- Microbes Associated with preterm birth
S) biosynthesis, which acts as substrate to  Garnerella vaginalis, Fusobacterium,
increase maternal plasma estrogens, particularly Mycoplasma hominis, and Ureaplasma
estriol. urealyticum
 Premature rise in cortisol and estrogen early  Fusobacteria – more capable of burrowing
loss of uterine quiascent and accelerate cervical through these tissues.
ripening.  Initial inflammatory response – specific
receptors on mononuclear phagocytes, dicidual
Infection cells, cervical epithelia, and trophoblast.
 Some cases – histological evidence of  Toll-like receptors represent a family that has
inflammation in the fetal membrances, deciduas evolved to recognize pathogen-associated
or umbilical cord molecules.
 Other cases – ―sublinical‖  Influence of ligands such as bacterial LPS
 Microbial invasion of the reproductive tract is influence of ligands such as bacterial LPS, these
sufficient to induce infection-mediated preterm receptors increase chemokine, cytokine, and
birth- more specifically, there is ongoing prostaglandin release as part of an inflammatory
―subcinical‖ infection. response. (Interleukin 1β).
 Women with amnionic fluid bacteria are more
likely to develop clinical chorioamnionitis and
preterm ruptured membranes compared with Intrauterine inflammatory response.
women with sterile cultures.
2|O B S T E T R I C S , 2 0 1 4
©ILANO
 Interleukin 1β (IL-1β) promote a series of  Cigarette smoking
responses.  Prior PPROM
o Increased synthesis of others, that is, IL-
6, IL-8, and tumor-necrosis factor alpha Molecular Changes
(TNF-α);  Related to increased apoptosis of membrance
o Proliferation, activation, and migration cellular components and to increased levels of
of leukocytes; specific proteases in membranes and amniotic
o Modifications in extracellular matrix fluid.
proteins;  Tensile strength of the membranes – provided by
o Mitogenic and cytotoxic effects such as the amniotic extracellular matrix and interstitial
fever and acute-phase response. amniotic collagens – primarily type I and III-
**IL-1 promotes prostaglandin formation in many which are produced in mesenchymal cell.
tissues, including myometrium, decidua, and amnion.  Matrix metalloproteinase (MMP) family is
 Prostaglandin inhibitors can reduce the rate of involved with normal tissue remodeling and
LPS-induced preterm birth in both the mouse particularly with collagen degradation.
and nonhuman primate.  MMP-1, MMP-2, MMP-3, and MMP-9
 Inhibition of cyclooxygenase-2 prevents members of this family are found in higher
inflammation-mediated preterm labor in the concentrations in amnionic fluid from
mouse. pregnancies with preterm prematurely ruptured
 Immunomodulators plus antibiotics delay membranes.
preterm delivery after experimental  MMP activity is in part regulated by tissue
intraamnionic infection in a nonhuman primate inhibitors of matrix metalloproteinases—TIMPs.
model.  The expression of MMPs can be increased by
treatment with IL-1, TNF-α, and IL-6.
Origin of cytokines  The amnion exhibits a higher degree of cell
 Transfer of cytokines such as IL-1 from decidua death and more apoptosis markers than that in
across the membranes into amnionic fluid term amnion.
appears to be severely limited.  PPROM cases result from collagen degradation,
 Cytokines produced in maternal decidua and altered collagen assembly, and cell death, which
myometrium will have effects on that side all lead to a weakened amnion.
 Cytokines produced in the membranes or in cells
within the amnionic fluid will not be transferred Infection
to maternal tissues.  Inflammatory-induced premature rupture of
 (+) infection leukocytes - mainly neutrophils, membrane
macrophages and T lymphocytes- infiltrate the  Inflammatory response that leads to membrane
cervix, lower uterine segment fundus, and weakening.
membranes at the time of labor.  Research is focused on mediators if this process
 Term labouring uterus have shown that both with a goal to identify early risk for PPROM.
invading leukocytes and certain parenchymal
cells produce cytokines Multifetal Gestation
o Leukocytes appear to be the primary  Increased rate of multifetal births is due to the
source of myometrial cytokines, increased number of women having babies after
including IL-1, IL-6, IL-8, and TNF-α. the age of 30 at which time the risk to conceive
o IL-8 is considered a critical cytokine in multiples rise.
cervical dilation, and it is produced in  Use of fertility treatments has contributed to the
both cervical epithelial and stromal elevated rates of multifetal pregnancies
cells.  Effect of uterine stretch.
 Amniotic fluid – secreted by mononuclear
phagocytes or neutrophils activated and Myriad genetic and environment factors affect the
recruited into amniotic fluid. frequency of preterm labor.
o Amount of amnionic fluid IL-1 would
 Threatened Abortor
be determined by the number of o Vaginal bleeding in early pregnancy (6-
leukocytes recruited, their activational 13 weeks) preterm labor, placental
status, or the effect of amnionic fluid abruption, and subsequent pregnancy
constituents on their IL-1 secretion rate. loss before 24 weeks
 Lifestyle Factors
PRETERM PREMATURE RUPTURE OF
o Cigarette smoking, inadequate maternal
MEMBRANES (PPROM)
weight gain and illicit drug use.
Spontaneous rupture of the fetal membranes
o Overweight and obese mothers
before 37 completed weeks and before onset of labor.
o Young or advanced maternal age,
poverty, short stature, and vitamin C
Risk Factor
deficiency.
 Intrauterine infection
o Psychological factors such as
 Low socioeconomic status depression, anxiety and chronic stress.
 Body mass index <19.8
 Nutritional deficiencies
3|O B S T E T R I C S , 2 0 1 4
©ILANO
o Working long hours and hard physical Causes of Preterm birth
labor are probably associated with
increased risk of preterm birth
 Genetic Factors
o Recurrent, familial, and racial nature of
preterm birth
o Immunoregulatory genes in potentiating
chorioamnionitis in cases of preterm
delivery due to infection
 Birth Defects
o First- and Second-Trimester Evaluation
of Risk (FASTER) Trial
 Found that birth defects were
associated with preterm birth
and low birthweight
 Periodontal defects
o Gum inflammation is a chronic
anaerobic inflammation  Infection
 Treatment during pregnancy o Antimicrobial treatment has been given
improved periodontal disease to prevent preterm labor due to
and that it is safe. However, microbial invasion. Based on available
treatment failed to significantly data, these strategies especially targeted
alter preterm birth rates mycoplasma species.
 Interval between pregnancies o Given in the second trimester may
o Short intervals between pregnancies prevent subsequent preterm birth.
have been known for some time to be o Study placebo or metronidazole plus
associated with adverse perinatal erythromycin between 20 and 24 weeks’
outcomes. gestation followed by ampicillin plus
o Intervals < 18 months and > 59 months metronidazole during labor.
were associated with increased risks for  This antimicrobial regimen did
both preterm birth and smallfor- not reduce the rate of preterm
gestational age newborns. birth or that of histological
 Prior Preterm Birth chorioamnionitis.
o Major risk factor  Bacterial Vaginosis
o 1st delivery is preterm-3fold risk o Normal, hydrogen peroxide-producing,
o 1st & 2nd delivery are preterm – 1/3 of lactobacillus-predominant vaginal flora
women will deliver preterm is replaced with anaerobes that include
o 70% occurred within 2weeks of the Gardnerella vaginalis, Mobiluncus
gestational age of the prior preterm species, and Mycoplasma hominis
delivery o Using Gram staining, relative
o Causes of prior preterm delivery also concentrations of the bacterial
recurred. morphotypes characteristic of bacterial
 Infection vaginosis are determined and graded as
o Intrauterine infections are believed to the Nugent score.
trigger preterm labor by activation of the o Bacterial vaginosis has been associated
innate immune system. with spontaneous abortion, preterm
o Microorganisms elicit release of labor, PPROM, chorioamnionitis, and
inflammatory cytokines such as amnionic fluid infection.
interleukins and TNF-α, which in turn o Environmental factors appear to be
stimulate the production of important in bacterial vaginosis
prostaglandin and/or matrix-degrading development. Exposure to chronic
enzymes. stress, ethnic differences, and frequent
o Prostaglandins stimulate uterine or recent douching have all been
contractions, whereas degradation of associated with increased rates of the
extracellular matrix in the fetal condition
membranes leads to preterm rupture of o Gene-environment interaction
membranes.  Susceptible TNF-α genotype
had a ninefold increased
incidence of preterm birth.

IV. DIAGNOSIS

Symptoms
 Early differentiation between true and false
labor is difficult

4|O B S T E T R I C S , 2 0 1 4
©ILANO
 Braxton hicks contraction – irregular, Fetal fibronectin
nonrhythmical and either, and either painful or  Glycoprotein is produced in 20 different
painless molecular forms by various cell types, including
 ACOG 2012, define preterm labor to be regular hepatocytes, fibroblasts, endothelial cells, and
contractions before 37 weeks that are associated fetal amnion.
with cervical change.  High concentrations in maternal blood and in
 Pelvic pressure, menstrual-like cramps, watery amnionic fluid, it is thought to function in
vaginal discharge, and lower back pain have intercellular adhesion during implantation and in
been empirically associated with impending maintenance of placental adherence to uterine
preterm birth. deciduas.
 Detected in cervicovaginal secretions in women
Cervical Change who have normal pregnancies with intact
 Dilation membranes at term.
o Asymptomatic cervical dilatation after  It appears to reflect stromal remodeling of the
midpregnancy is suspected to be a risk cervix before labor.
factor for preterm delivery.  Detection in cervicovaginal secretions before
o Cervical examination were not related to membrane rupture was a possible marker for
preterm membrane rupture impending preterm labor.
o Prenatal cervical examination are  (+) > 50ng/ml (ELISA)
neither beneficial nor harmful.  ACOG does not recommend screening with fetal
 Length fibronectin tests.
o Vaginal-probe sonographic cervical o fetal fibronectin screening in
assessment asymptomatic women have not
 Not affected by maternal demonstrated improved perinatal
obesity, cervix position, or outcomes.
shadowing from the fetal
presenting part. V. PRETERM BIRTH PREVENTION
o Safe, highly reproducible, and more Prevention of preterm birth has been an elusive goal.
predictive than transabdominal Recent reports, however, suggest that prevention in
sonographic screening selected populations may be achievable.
o Mean cervical length at 24 weeks was
approximately 35mm and those women  Cervical cerclage
with progressively shorter cervices There are at least three circumstances when
experienced increase rates of preterm cerclage
birth. o Prophylactic cerclage is used in women
o The risk of spontaneous preterm birth who have a history of recurrent
increase as the length of the cervix midtrimester losses and who are
decrease across the entire range if diagnosed with cervical insufficiency
cervical length. o Prophylactic cerclage is for women
o Cervical Length and Funnelling identified during sonographic
examination to have a short cervix.
o ―rescue‖ cerclage, done emergently
when cervical incompetence is
recognized in women with threatened
preterm labor.
o Owen (2009) - Women with a cervical
length < 15 mm delivered before 35
weeks significantly less often following
 T shaped cervix - best cerclage compared with women with no
 Y shaped cervix cerclage—30 versus 65 percent.
 V shaped cervix  Recurrent preterm birth can be
 U shaped cervix – poor, prevented in a subset of women
associated with cervical who have a history of prior
dilatation preterm births.
o To and associates (2004) - 253 women
Ambulatory Uterine Monitoring with cervices < 15 mm to cerclage or no
 An external tocodynamometer belted around the cerclage.
abdomen and connected to an electronic waist  The frequency of preterm
recorder allows a woman to ambulate while delivery < 33 weeks was not
uterine activity is recorded. significantly different between
the treatment groups.
 Women are educated concerning signs and
 Cerclage for sonographically
symptoms of preterm labor, and clinicians are
detected short cervix alone has
kept apprised of their progress.
not been found to be beneficial.
 ACOG does not recommend home uterine
 Women with a very short
activity monitoring.
cervix, that is, < 15 mm, and a

5|O B S T E T R I C S , 2 0 1 4
©ILANO
history of prior preterm birth Risks of Expectant Management
may benefit.  Maternal and fetal risks vary with the gestational
age at membrane rupture.
Prophylaxis with progestin Compounds  Neurologic abnormality, oligohydramnios,
 Progesterone levels in most mammals fall pulmonary hypoplasia, limb compression
rapidly before the onset of labor. deformities, infectious morbidity, umbilical cord
 Parturition-triggering event – progesterone prolapsed.
withdrawal.  23 weeks or less is the threshold for
 Human parturition involves functional development of lung hypoplasia
progesterone withdrawal mediated by decreased
progesterone activity of progesterone receptors. Clinical Chorioamnionitis
 Administration of progesterone to maintain  Prolonged membrane rupture: increased fetal
uterine quiescence may block preterm labor. and maternal sepsis
 Chorioamnionitis is diagnosed, prompt efforts to
VI. MANAGEMENT OF PPROM effect delivery, preferably vaginally.
 History of vaginal leakage of fluid, either as  Fever is the only reliable indicator for this
continous stream or as a gush. diagnosis, and temperature of 38°C (100.4°F) or
 Speculum exam to visualize gross vaginal higher accompanying ruptured membranes
pooling of amniotic fluid, clear fluid from the implies infection.
cervical canal  Maternal leukocytosis alone has not been found
 Sonographic exam to assess amniotic fluid to be reliable
volume, to identify the presenting part, and if not  WOF- maternal or fetal tachycardia, for uterine
previously determined, to estimate gestational tenderness, and for a malodorous vaginal
age discharge.
 Amniotic fluid is slightly alkaline (pH 7.1-7.3)  Increase incidence of sepsis, RDS, early onset
compared with vagina (pH 4.5-6.9) seizures, intraventricular hemorrhage and
preventricular leukomalacia
Hospitalization  Neurological injury, cerebral palsy.
 Most clinicians hospitalize women with
PPROM. Accelerated Pulmonary Maturation
 Carlan & co-workers (1993)-No benefits were  Various clinical events—some well defined—
found for hospitalization. were once proposed to accelerate fetal surfactant
 Concern regarding the cost of lengthy production
hospitalization.  Chronic renal or cardiovascular disease,
hypertensive disorders, heroin addiction, fetal-
Intentional Delivery growth restriction, placental infarction,
 1970s, labor was usually induced in women with chorioamnionitis, and preterm ruptured
preterm ruptured membranes because of fear of membranes.
sepsis.
 Reduced the length of maternal hospitalization Antimicrobial Therapy
and also reduced infection rates in both mothers Mercer & associates (1995) reviewed 13 randomized
and neonates. trials performed before 35 weeks.
 3 out of 10 outcomes were possibly benefited.
Expectant Management o Fewer women developed
 Despite extensive literature concerning chorioamnionitis
expectant management of PPROM, tocolysis has o Fewer newborns developed sepsis,
been used in few studies. o more often prolonged 7 days in women
o Investigators concluded that active given antimicrobials.
interventions did not improve perinatal  Neonatal survival, however, was
outcomes unaffected, as was the incidence
 Use of digital cervical examination and cerclage. of necrotizing enterocolitis,
o Women who were examined had a respiratory distress, or
rupture-to-delivery interval of 3 days intracranial hemorrhage.
compared with 5 days in those who were  7-day treatment with ampicillin, amoxicillin plus
not examined. This difference did not erythromycin, or placebo. The women had
worsen maternal or neonatal outcomes. membrane rupture between 24 and 32 weeks.
 114 women with cerclage in place who later had  Efficacy of shorter treatment lengths and other
ruptured membranes before 34 weeks. They antimicrobial combinations.
were compared with 288 controls who had not  Amoxicillin-clavulanate regimen was NOT
received a cerclage. recommended,
o Pregnancy outcomes were equivalent in  Increase risk of resistant bacteria
both groups.
 Management is controversial Corticosteriods to accelerate fetal lung maturity
National Institute of Health (NIH) (200)
 Single course of antenatal corticosteroids for
women with preterm membrane rupture before
6|O B S T E T R I C S , 2 0 1 4
©ILANO
32 weeks and in whom there was no evidence of o That fetal exposure to antimicrobials in
chorioamnionitis. this clinical setting was associated with
ACOG (2013d) an increased cerebral palsy rate at age 7
 Single-dose therapy is recommended from 24 to years compared with that of children
32 weeks. without fetal exposure.
 No consensus regarding treatment between 32
and 34 weeks. Bed Rest
 Corticosteroid therapy is not recommended  Most often prescribed interventions during
before 24 weeks. pregnancy, yet one of the least studied.
 Insufficient evidence to support the use of bed
VII. MANAGEMENT OF PRETERM rest and found several studies showing harm
LABOR WITH INTACT MEMBRANE with its use

Women with signs and symptoms of preterm Cervical Pessaries


labor with intact membranes are managed much the  To support the cervix in women with a
same as described above for those with preterm sonographically short cervix.
ruptured membranes. If possible, delivery before 34
weeks is delayed. Emergency or Rescue Cerclage
 Risk of infection and pregnancy loss
Amniocentesis to detect infection  Althuisius and colleagues (2003)
 Test have been used to diagnose intraamniotic o Delivery delay was significantly greater
infection in the cerclagegroup
o Elevated leukocyte count  Terkildsen and co-workers (2003)
o Low glucose content o Significantly decreased chance of
o High IL-6 concentration pregnancy continuation to 28 weeks or
o Positive gram stain result beyond.
 Amniocentesis to diagnose infection does not
improve pregnancy Tocolysis to treat preterm labor
 ACOG (2012a) has concluded that there is no ACOG(2012) - tocolytic agents do not markedly
evidence to support routine amniocentesis to prolong gestation but may delay delivery in some
identify infection. women for up to 48 hours.
 Allow transport to a regional obstetrical center
Corticosteriods for fetal lung maturity  Permit time for corticosteroid therapy.
 Effective in lowering the incidence of ACOG recommends that women with preterm
respiratory distress syndrome and neonatal contractions without cervical change, especially those
mortality rates if birth was delayed for at least with cervical dilation of less than 2 cm, generally should
24 hours after initiation of betamethasone. not be treated with tocolytics.
o 12mg Betamethasone every 24 hrs for 2  β- adrenergic receptor agonist
doses o Reduce intracellular ionized calcium
o 6mg Dexamethasone every 12 hrs for 4 levels and prevent activation of
doses. myometrial contractile proteins.
o Ritodrine and terbutaline
Corticosteroid Rescue Therapy  SE: maternal tachycardia,
 Administration of a repeated corticosteroid dose hypotension and pulmonary
when delivery becomes imminent and more than edema
7 days have elapsed since the initial dose.  Magnesium SO4
 2000 NIH Concensus o Calcium antagonist
o Should not be routinely used and that it o Dose: 4g IV initially then continous
should be reserved for clinical trials. infusion of 2g/hr
 ACOG (2012a) S o SE: pulmonary edema & respiratory
o Single rescue course of antenatal depression
corticosteroids should be considered in o FDA (2013) - warned against prolonged
women before 34 weeks whose prior use of magnesium sulfate given to arrest
course was administered at least 7 days preterm labor due to bone thinning and
previously. fractures in fetuses exposed for more
than 5 to 7 days.
Antimicrobials  Attributed to low Ca levels
 Given in an attempt to arrest preterm labor.  Prostaglandin inhibitors
 ORACLE Collaborative Group study of 6295 o Act by inhibiting prostaglandin
women with spontaneous preterm labor, intact synthesis or by blocking their action on
membranes, but without evidence of infection. target organs.
o Primary outcomes of neonatal death, o Group of enzymes collectively termed
chronic lung disease, and major cerebral prostaglandin synthase is responsible for
abnormality were similar in both groups. the conversion offree arachidonic acid to
o Not recommended. prostaglandins
 ORACLE II trial o Acetylsalicylate and indomethacin
7|O B S T E T R I C S , 2 0 1 4
©ILANO
o SE: oligohydramnios, intraventricular
hemorrhage, PDA, sepsis, necrotizing
enterocolitis or neonatal death.
 Calcium channel blockers
o Myometrial activity is directly related to
cytoplasmic free calcium, and a
reduction in its concentration inhibits
contractions
o Nifedipine
o No clear superiority of either to delay
delivery was identified, and otherwise,
neonatal morbidity was equivalent.
o Combination of nifedipine with
magnesium for tocolysis is potentially
dangerous.
 Atosiban
o Nonapeptide oxytocin analogue is a
competitive antagonist of oxytocin-
induced contractions.
o fFailed to improve relevant neonatal
outcomes and was linked with
significant neonatal morbidity.
o FDA- denied approval - because of
concerns regarding efficacy and fetal–
newborn safety.
 Nitric Oxide Donors
o Potent smooth-muscle relaxants affect
the vasculature, gut, and uterus.
o Nitroglycerin administered orally,
transdermally, or intravenously was not
effective or showed no superiority to
other tocolytics.
o SE: maternal hypotension

VIII. LABOR
 Monitor FHR and uterine contraction
 Continuous electronic monitoring
 Fetal tachycardia, intrapatum acidosis (
umbilical artery pH less than 7.0 )
 Group B strep infections – prophylaxisshould be
provided.

IX. DELIVERY
 Vaginal delivery and episiotomy
 NO to routine forceps delivery to protect the
―fragile‖ fetal head
 Importance if specialized personnel and facilities
for preterm newborn care.

X. PREVENTION OF NEONATAL
INTRACRANIAL HEMORRHAGE
 Preterm newborn frequently have intracranial
germinal matrix bleeding that can extend to
more serious intraventricular hemorrhage
 Vaginal delivery vs C section
 MgSO4 for fetal neuroprotection
o Maternal MgSO4 therapy had a fetal
neuroprotective effect
o Parkland Hospital
 Provide MgSO4 for threatened
preterm delivery from 24 6/7 to
27 6/7 weeks
 6g loading dose is followed by
an infusion of 2g/hr for at least
12 hr
-------------------------------END------------------------------
8|O B S T E T R I C S , 2 0 1 4
©ILANO