Preterm labor

Department of Gynecology and Obstetrics

Lecturer: Ou Wenjun
The Second Clinical College of Chongqing Medical University
Definition
n Preterm birth: occurring after 28 weeks and before 37
completed weeks of gestation

n Preterm labor: labor occurs between these gestational

age
General Considerations
n Major causes of perinatal morbidity and mortality

n Preterm births in China: 10%

n Preterm infants’ contribution to neonatal morbidity

and mortality: 50%-70%

n Prevention of prematurity become a high priority

Etiology & risk factors
n Spontaneous preterm birth (idiopathic)
Ø Undiagnosed conditions and/or problems of placental origin
Ø Silent infection
Ø Immunologic etiology
Ø Uterine and/or cervical origin
n Preterm premature rupture of the membranes
n Induction of labor of medical indications

Ø Genetic thrombophilias → intrauterine growth restriction,

preeclampsia
Medical & obstetric factors
n History of preterm birth

ØOne preterm birth → relative risk of preterm delivery in

the next pregnancy is 3.9

ØTwo preterm birth → relative risk of preterm delivery in

the next pregnancy is 6.5

n Second-trimester abortions

n Repeated spontaneous 1st-trimester abortions

Other medical & obstetric factors
n Bleeding in the 1st trimester

n Urinary tract infections

n Multiple gestation

n Uterine anomalies

n Polyhydramnios

n Incompetent cervix

n Maternal employment, physical activity, nutritional status,

genital tract infections, stress, and anxiety
Prevention
n First identify the patient at risk! 30%

n Potential pathways leading to preterm delivery:

ØInfection-cervical

ØPlacental-vascular

ØStress-strain
Infection-cervical pathway
n Treatment of bacterial vaginosis (BV) reduced
incidence of preterm delivery
n Antibiotics prolongs time from onset of treatment to
delivery → relatively asymptomatic infections
n A link between vaginal-cervical infections and
progressive changes in cervical length (CL)
ØCL 3.5cm (50th percentile)→ relative risk 2.4

ØCL 2.5cm (10th percentile)→ relative risk 6.2

Infection-cervical pathway
n Fetal fibronectin (fFN)

ØfFN (+) at 22-24 weeks → >50% preterm births occur

before 28 weeks

ØfFN (+) associated with a short cervix, vaginal

infections, and uterine activity

ØfFN (-) → best predictor of a low risk of preterm

delivery
Placental-vascular pathway (PVP-1)
n PVP-1 begins at the time of implantation
n Immunologic changes: a switch from a Th-1 to Th-2
antibody profile
n Trophoblasts invade the spiral arteries of the decidua
and myometrium, assuring that a low resistance
vascular connection is established
Stress-strain pathway
n Mental & work-related stress and strain → initiate a
stress response → increases release of cortisol and
catecholamines
ØCortisol initiates placental corticotrophin-releasing
hormone (CRH) → initiate labor at term

ØCRH increases in the weeks prior to the onset of

preterm labor

ØCatecholamines affect blood flow to the

uteroplacental unit and cause uterine contractions
Clinical findings
n Symptoms & signs
Ø Uterine contractions
Ø Effacement and dilatation of cervix
Ø Vaginal bleeding
n Evaluation
Ø Estimated gestational age (EGA)
Ø Fetal weight
Ø Presenting part
Ø Fetal monitoring
Clinical findings
n Laboratory tests
Ø Complete blood cell count
Ø Random blood glucose level
Ø Serum electrolytes level
Ø Urinalysis
Ø Urine culture and sensitivity
n Ultrasonic examination
Ø Assess fetal weight, CL
Ø Document presentation, placental location
Ø Rule out presence of congenital malformation
Ø Detect etiologic factors, e.g. twins or a uterine anomaly
Clinical findings
n Speculum examination
Ø Cervical cultures for gonorrhea, chlamydia, Ureaplasma, and
Mycoplasma
Ø A wet mount for signs of bacterial vaginosis such as
Gardnerella vaginalis
Ø Group B Streptococcus cultures taken from vaginal and rectal
mucosa
Ø A cervical swab for fFN
Diagnosis
n Occurring between 28 and 37 weeks
n Documented uterine contractions
Ø4 per 20 min
Ø8 per 60 min
n Documented cervical change
ØCervical effacement 80%
ØCervical dilatation ≥ 2cm
Management
n Observed for 30-60 min
n Management decisions based on:
Ø EGA
Ø Estimated fetal weight (EFW)
Ø Whether contraindications exist to suppressing preterm labor,
e.g. advanced cervical dilation (>4 cm), fetal distress or death,
maternal hemorrhage, etc.
n Expectant management (observation)
n Intervention
Ø 24-34 weeks’ EGA
Ø EFW 1000-2500g
Management
n An initial assessment must be done to ascertain
Ø CL and dilatation
Ø Station and nature of the presenting part
n Evaluate patient for presence of any underlying correctable
problem
Ø A urinary tract infection
Ø A vaginal infection
n Monitoring for presence and frequency of uterine activity
n Reexamining for evidence of cervical change after an
appropriate interval
A protocol for intervention
n Bed rest in lateral decubitus position
n Hydration
→Adequate hydration + bed rest → 20% uterine contractions
cease
n Corticosteroids
Ø Accelerate fetal lung maturity
Ø For women at risk of preterm delivery between 24 and 34
weeks’ EGA
Ø Dexamethasone 6 mg IM every 12h for a total of 4 doses
n Tocolysis
n Antibiotics
Uterine tocolytic therapy
n Shortterm goal: continue the pregnancy for 48h after steroid
administration
n Long-term goal: continue the pregnancy beyond 34-37 weeks
n Cervical dilation <4 cm
n Successful tocolysis: fewer than 4-6 uterine contractions per
hour without further cervical change
n Common tocolytics
Ø Beta-mimetic adrenergic agents
Ø Magnesium sulfate
Ø Calcium channel blockers
Ø Prostaglandin synthetase inhibitors
Ø Oxytocin receptor antagonists - atosiban
Uterine tocolytic therapy
n Beta-mimetic adrenergic agents - ritodrine
Ø Side effects & complications: pulmonary edema, hypotension,
tachycardia, hyperglycemia
Ø Contraindications: cardiac disease, hyperthyroidism,
uncontrolled hypertension or pulmonary hypertension, asthma,
uncontrolled diabetes, and chronic hepatic or renal disease
n Oxytocin receptor antagonists - atosiban
Ø Expensive!
Uterine tocolytic therapy
n Magnesium sulfate
Ø Side effects & complications: flushing, nausea/vomiting,
headache, generalized muscle weakness, shortness of breath
Ø Monitored for signs of toxicity: check of deep tendon reflexes,
pulmonary exams, and calculations of fluid balance
Ø Prepare calcium gluconate
n Calcium channel blockers - nifedipine
Ø Monitor BP
A protocol for intervention
n Antibiotics
Ø A 7-day course of ampicillin and/or erythromycin
Ø If allergic to penicillin → clindamycin
Labor and delivery of the preterm
infant
n Continuous fetal heart monitoring and prompt attention to
abnormal fetal heart rate patterns
n With a vertex presentation, vaginal delivery is preferred,
provided that fetal acidosis and delivery trauma are avoided
n An episiotomy to shorten the second stage are advocated
n For the breech fetus estimated at less than 1500g, neonatal
outcome is improved by cesarean section