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Learning Outcome
• Discuss Preterm labor
• Discuss the Etiology
• Discuss the management

PRETERM BIRTH
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Preterm infants- those delivered before 37 Preterm birth is defined as a birth between
completed weeks 20 0/7 weeks to 36 6/7 weeks gestation
APEC GUIDELINES, Preterm Labor, 2013

Early preterm those before 33 6/7 weeks

70 % of neonatal deaths
Late Preterm those occurring between
34-36 completed weeks 36 % of infant deaths
Early Term those births 37-38 6/7 weeks 25-50% long term neurologic impairment
ACOG, 2012 a
Term those births 39-40 6/7 weeks

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Approximately 50% of all preterm births are

the result of preterm labor (PTL) Preterm Labor
Advanced Preterm Labor
Preterm Labor
- When cervix is dilated 3 cm or more , 80% effaced
- regular contractions before 37 weeks that
are associated with cervical change Early Preterm Labor
- American Academy of Pediatrics - greater than 1 but less than 3 cm , 80% effaced
- American College of Obstetrics and Gynecologists (2012) Practical Guide to High Risk Pregnancy and Delivery
Section II: Obstetrical Complications
Fernando Arias

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Advanced Preterm Labor Causes of Preterm Delivery

Implications:
- Most women with advanced preterm labor are
4 main direct reasons for preterm births
destined to have a preterm birth, while this is not
the case for women with early preterm labor 1. Spontaneous Unexplained Preterm Labor
- 60-65% of women in early preterm labor will with Intact Membranes
respond to tocolysis and will deliver at term or 2. Idiopathic PPROM
closer to term.
- The incidence of cultured bacteria during
3. Delivery for Maternal or Fetal Indications
amniocentesis in women with advanced labor 4. Twins and higher order multi-fetal births
Williams Obstetrics 25th ed
doubles or triples compared to those women in Chapter 42
early labor Practical Guide to High Risk Pregnancy and Delivery
Section II: Obstetrical Complications
Fernando Arias

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Spontaneous Preterm labor Spontaneous Preterm Labor

and Infection
• Multifetal pregnancy
• Intrauterine infectionof Spontaneous • Preterm labor is a protective mechanism and fetal
Four major causes defense against a hostile intrauterine environment and
• Bleeding
Preterm Labor:
• Placental Infarction
should not be interrupted. Arias 2008
1.) Uterine distention
2.) Maternal-Fetal
• Premature Stress
Cervical Dilatation • The earlier the onset of preterm labor, the greater the
3.) Premature
• Cervical Cervical Changes
Insufficiency likelihood of documented infection.
Goldenber,2000; Watts,1992
4.) Infection
• Hydramnios
• Uterine fundal and fetal anomalies
• Maternal illness – autoimmune, DM, gest HPN

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Spontaneous Preterm Labor Spontaneous Preterm Labor

and Infection and Infection
• Gonclaves and associates (2002) • Microbes associated with Preterm Birth
Stage 1 – Bacterial Vaginosis Gardnerella Vaginalis, Fusobacterium, Mycoplasma
Stage 2 – Decidual Infection Hominis, and Ureaplasma Urealyticum were detected more
Stage 3 – Amnionic Infection frequently than others in amniotic fluid of women with
preterm labor and intact membranes (Gerber, 2003; Hiller, 1998l Yoon 1998)
Stage 4 – Fetal Systemic Infection

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Biophysical Predictors
Risk Factors:
Maternal Age
6.5% risk for maternal age <21 or > 36 yo
Birth Defects were associated with preterm birth
1. ) Maternal Perception of contraction
•20-40%
(CPG
Prior
Birthon Preterm
Preterm
outcomeLabor 2010)
of preterm birth Second
births result fromBirth
intrauterine - Has little value in predicting preterm labor
and low birthweight
•INFECTION
African American race <34 weeks (%) and spontaneous delivery Cooper et al 1990
Overweight
First birth >= 35 w and Obese mothers 5 have an
Interval
• Age between
<21 orof pregnancies: <18 mos and >59
34>35
elevated risk preterm birth (Cnattingius,2013) - Self percieved symptoms are poor predictors
First birth
Bacterial <=
Vaginosis w (Gardnerella, 16 Mobilincus, and
mos were associated
•Mycoplasma
Low withstatus
increased risk for of preterm birth CPG on Preterm labor 2010
Fist andsocio Second economic
birth 41
both
Cigarette
<34
preterm
weeks
Hominis)
Smokingbirth and ofhas SGA
more been associated
newborns
than 20 sticks/day with 2.) Home Uterine Ambulatory Monitoring
•spontaneous
Low
Metaanalysis
(CPG prepregnancy
by
on Preterm Labor 2010)abortion,
Conde-Agudelo weight
and colleaguespreterm
(2006) (BMIlabor,, 18.6)
PPROM,
(HUAM)
•chorioamnionitis,
Smoking, Alcohol, andIllicit
amniotic drug fluid
use infection
Periodontal Disease – odds ratio
(Hiller, 1995;2.83 (safe
Kurki,1992; Leitichto
2003a,b) - Has not been found to be beneficial and does
• Multiple gestation
treat but did not alter preterm birth rates) not recommend it ACOG 2012a
• Uterine anomaly

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Cervical Exam
Biological Predictors
- Approximately 25% of women whose cervix was
dilated 2-3 cm between 26 and 30 weeks delivered 1. Serum biomarkers – No serum biomarkers
before 30 weeks. (Parkland Hospital) have been described
- Other investigators have verified that cervical 2. Lower genital tract markers
dilatation as a predictor of increased preterm delivery
A. Bacterial Vaginosis
risk (Copper, 1995; Pereira, 2007)
- However, preterm birth rates are not modified by
- little evidence that screening and treating
cervical exam and detection does not improve
will prevent preterm birth (McDonald and colleagues 2005)
pregnancy outcome (Grading of evidence +1) Buekens B. Fetal Fibronectin
1994

- Cervical exam + Bishop score – low sensitivity Iams et al

-
1996, Newman et al 1997

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Biological Predictors
Biological Predictors B. Fetal Fibronectin
B. Fetal Fibronectin ACOG Recommendation for use of Fibronectin:
- Is detected in cervicovaginal secretions in 1. Not later than 34 weeks and not before 24
women who have normal pregnancies with weeks
intact membranes at term. It reflects stromal 2. Must be less than 3 cm dilated
remodelling of the cervix before labor . 3. Should not be ruptured
- Fibronectin detection in CV secretions before
membrane rupture was a possible marker for - Not used for routine screening in low risk
impending preterm labor asymptomatic women (ACOG 2012a)

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Biological Predictors Cervical Ultrasound

B. Fetal Fibronectin
POSITIVE if 50 ng/ml
-Women with negative FFN test have a 97%
probability that they will not deliver within 2-3 weeks
-If test is POSITIVE, the likelihood of preterm
delivery in the following 2 weeks is approximately
35%.
Sonographic cervical length measurement is
the single most powerful predictor of preterm
birth, far more informative than a history of
prior preterm birth. R Romero, G Guzman, P Rozenburg, Y Villie, S
Hassan, K Nicolaides

- In summary: A negative FFN indicates that

delivery will not occur in the next 2-3 weeks,
while a positive result will increase the
possibilities of preterm delivery Arias 2010 et al

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Ultrasound Diagnosis Ultrasound Diagnosis

• Why is a shortened cervix NOT
• Shortening of the cervix DIAGNOSTIC for CERVICAL
• Funneling INCOMPETENCE?
• Dynamic Changes - it does not differentiate between
primary cervical disease and early
• Cervical Length
preterm labor
- Short cervix is not exclusive to
incompetent cervices, but is also found
in women with preterm labor and
PROM

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Ultrasound Diagnosis Ultrasound Diagnosis

• Funneling • Dynamic Changes
• Increases adverse perinatal outcome -Is an evidence of myometrial activity and
( had more incidence of preterm labor, early preterm labor
chorioamnionitis, abruption, PROM and - This tells the clinician that the patient is
cerclage placement) having painless uterine contractions and
that the cervix is opening because of
those contractions.

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Cervical Ultrasound
In normal pregnancies- effacement starts at 32
weeks
In women with preterm labor- may begin 16-24
weeks
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Cervical Ultrasound
CPG: Preterm Labor 2nd ed (2010)
POINTS
- The length of the cervix is directly correlated with
the duration of the pregnancy – the shorter the
cervix, the higher the risk of preterm birth
Goldenberg et al, 1998; Iams et al, 1996
-TVS is the preferred route (II-2B)
- The optimal time frame for cervical measurement
is between 14 and 30 weeks; before or after that
time period, measurement of CL as a preterm birth
predictor is not accurate or useful
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Cervical Ultrasound
CPG: Preterm Labor 2nd ed (2010)
POINTS:
• In a HIGH RISK PATIENT
Ø If the cervix is abnormally short, weekly follow
up CL measurements may be prudent
Ø If the patient remains asymptomatic, and the
initial CL is normal, follow up of every 2 weeks
until 24-28 weeks could be considered
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Cervical Ultrasound
CPG: Preterm Labor 2nd ed (2010)
POINTS
*Cervical length of less than 2.5 cm has been
found to have the best predictive accuracy for
increased risk for preterm birth Berghella 2007
• A short CL,measured by TVS in the
midtrimester of pregnancy, has proved to be the
best predictor of preterm birth.
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Cervical Ultrasound
CPG: Preterm Labor 2nd ed (2010)
POINTS:
* In women with historical risk factors for
preterm birth (prior preterm birth, PPROM,
previous cervical surgery or uterine
anomaly,multiple pregnancies) planned CL
measurements could be initiated at approximately
16 weeks, with routine follow up thereafter
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Cervical Ultrasound
CPG: Preterm Labor 2nd ed (2010)
POINTS:
For a low risk patient for whom screening with a
single measure of CL may be desirable, a
reasonable approach would be to assess the
cervix at the time of the midtrimester
comprehensive fetal anatomic survey (at 18-22
weeks)
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Cervical Ultrasound Cervical Ultrasound

WHO should be screened? WHO should be screened?

1. Those patient with identified risk factors
Cervical length of less than 25 mm in the
second trimester -> predicted risk of recurrence
is 69% (sensitivity) 80% (specificity) J Obstet Gynaecol
Can 2011 May; 33(5):486-99
2.) Symptomatic patient with preterm labor
- May be used (II-2B)
- J Obstet Gynaecol Can 2011 May; 33(5):486-99 Pubmed Guidelines Status
- Useful in predicting delivery within 7 days if CL is
less than <15 mm
- Better predictor of delivery than fetal fibronectin

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Cervical Ultrasound Cervical Ultrasound

WHEN
WHO should be screened? Cervical length measurement can be used at
2.) Asymptomatic Low Risk < 24 weeks who have other risk factors for preterm
- NOT RECOMMENDED birth
SOGC Ultrasonographic Cervical Length Assessment in Predicting
- Low sensitivity and predictive value of a short Preterm Birth in Singleton Pregnancies, May 2011

cervix before 35 weeks CPG: Optimal time is at 14-30 weeks, preferably at

- ACOG 2011
16 weeks
S.S Hassan and R.Romero: 22-24 weeks has a
NPV= 96.7%, and PPV 97.6%

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Cervical Ultrasound

TWINS
Cervical Length of <20 mm in twin pregnancies at
27 weeks gestation predicts delivery before 34
weeks.
(sensitivity 77%, specificity of 86%, PPV 34%)
Guzman, Andrews, and Berghella

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Best Practice Recommendation Best Practice Recommendation

There are 2 KINDS OF PATIENTS:

1.Asymptomatic LOW/HIGH risk woman – PREVENTION
2.Symptomatic preterm labor – to prevent preterm birth –
TREATMENT

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Best Practice Recommendation Prevention

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Prevention Prevention

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Prevention Prevention

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Best Practice Recommendation

Prevention

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TOCOLYTICS TOCOLYTICS

ACOG (2012a)
Tocolytic agents do not markedly prolong
gestation but may delay delivery in some
women up to 48 H ( for ACS administration or
transport)

Maintenance therapy with tocolytics is

INEFFECTIVE for preventing preterm birth and
improving neonatal outcome and is not
recommended for this purpose

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TOCOLYTICS TOCOLYTICS

ACOG (2012a)
… and women with preterm contractions
without cervical change, especially those with
cervical dilatation of less than 2 cm, generally
should not be treated with tocolytics.

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TOCOLYTICS TOCOLYTICS

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TOCOLYTICS TOCOLYTICS
CPG: Nifedipine
1. Most current data seem to favor NIFEDIPINE
as the tocolytic agent of choice
EVIDENCE as a TOCOLYTIC
- Reduced the number of women giving birth
within 7 days
EVIDENCE as a MAINTENANCE THERAPY
- No difference in incidence of Preterm Birth with
maintenance tx compared with no treatment

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TOCOLYTICS
TOCOLYTICS
CPG: PROGESTERONE
EVIDENCE as a TOCOLYTIC
The potential benefit of progesterone for
preventing preterm birth < 34 weeks was
statistically significant in the following subgroups
1. Women with hx of spontaneous preterm birth
2. Women with short cervix identified on
ultrasound
3. Women with multiple pregnancy
4. For women following presentation with
threatened preterm labor
- Cochrane Database Sys Rev 2006

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TOCOLYTICS TOCOLYTICS

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TOCOLYTICS TOCOLYTIC MAINTENANCE

CPG: PROGESTERONE
EVIDENCE as a TOCOLYTIC
- Insufficient evidence to advocate
progestational agents as tocolytic agents
for women presenting with preterm labor
- Cochrane Database Sys Rev 2010

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ANTIBIOTICS
ANTIBIOTICS
No difference the rates of newborn RDS or sepsis
between placebo and antimicrobial treated
groups.
Cochrane metaanalysis by King (2000)

In women with spontaneous preterm labor, intact

membranes, but without evidence of infection,
fetal exposure to antimicrobials was associated
with increased risk of cerebral palsy at 7 years of
age.
ORACLE II trial, Kenyon and associates (2008b)

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“ Rescue Therapy”

• A single rescue course of of antental corticosteroid should

be considered in women before 34 weeks whose prior
course was administered at least 7 days previously (ACOG
2012a)

• Decreased rates of respiratory complications and

neonatal composite morbidity with rescue corticosteroids
–Kurtzmann and associates (2009)

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Choice of Corticosteroid Cerclage

• Betamethasone and Recommendations:
Dexamethasone were comparable in
reducing rates of major neonatal 1. The practice of performing cerclage
morbidities in preterm infants Elimian and exclusively based on historical diagnosis
associates (2007)
of cervical incompetence should be
ABANDONED.

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Historical Diagnosis of Incompetent Cervix
• History of painless cervical dilatation
treated with cerclage in the second
trimester of a previous pregnancy
• History of ruptured membranes
without contractions in the second
trimester
• A history of cervical manipulation,
trauma, or a diagnosis of anatomical
abnormality in the uterus or the cervix
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• DISADVANTAGE
1. Follow up studies in women
diagnosed with incompetent
cervix indicate that a majority of
them will not show evidence of
incompetence in a subsequent
pregnancy
2. Cervical incompetence has a
spontaneous cure rate of 50%.
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Cerclage
Recommendations:
2. It is erroneous to recommend prophylactic
cerclage for women identified only with risk
factors.
3. Women with identified risk factors should be
followed with SERIAL VAGINAL
ULTRASOUND between 16 to 24 weeks and
perform CERCLAGE only IF ultrasound
reveals CERVICAL SHORTENING.
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Women at HIGH RISK for Cervical
Incompetence
Cervical Incompetence diagnosed in a previous
Pregnancy
Cervical Treatment ( Cone, LEEP, freezing)
History of voluntary pregnancy termination
Congenital abnormality of the connective tissue
Anatomical abnormalities of the uterus
History of ruptured membranes in the second
trimester
Short cervix (<1 cm in the intravaginal portion)
Short Labors
History of two or more second trimester losses
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DISADVANTAGE
3. Studies indicate that approximately
60% with a history of incompetent
cervix will have a normal outcome
without treatment in the next
pregnancy, and that ULTRASOUND is
a useful adjunct to DIFFERENTIATE
those women who need cerclage from
those who do not
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B. Ceclage
Identification of Risk Factors
+
Serial Ultrasound Measurement
-----------------------------------------
DECREASED CERCLAGE in 70-75% of
patients with known risk factors for
cervical incompetence
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Cerclage Cerclage
• Randomized clinical trials suggest that
cerclage may be valuable in women with
short cervix on ultrasound during the second
trimester IF they have a history of second
trimester delivery with characteristics
suggestive of cervical incompetence, or have
gynecological accepted factors for
primary cervical disease.

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Pessary In summary …..

• Supports the cervix in women with a

sonographically short cervix.
• Studies conducted show conflicting results

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Thank you………

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