Preterm labour

• Preterm labour (PTL) is the onset of labour before 37 weeks’ gestation

• Worldwide, 15 million babies are born preterm every year and of these 1.1 million die.

• PTL now the most important cause of perinatal morbidity and mortality worldwide.

• 25% of PTDs are for maternal or fetal indications • 12% of births before 37 weeks and preterm.
• 20% of preterm are iatrogenic :IUGR -preeclampsia, placenta
• 50% follow spontaneous PTL previa,
• 80 % spontaneous, related to preterm labor or PROM
• 25% follow PPROM.

Risk factors

1. Teenagers women.

2. Advanced maternal age.

3. First pregnancies.

4. Low Socioeconomic status.

5. Cigarette smoking

6. Illegal substance (cocaine, alcohol) .

7. poor nutrition.

8. Previous preterm delivery

9. African or Afro-Caribbean women

• Causes of preterm birth

1. Cervical weakness

2. Infection :(e.g bacterial vaginosis)

✓ Chorioamnionitis associated with fetal brain damage.

3. Multiple pregnancy and uterine distension:

✓ The risk of PTD rises with fetal number.

✓ Polyhydramnios also increases the risk of PTL and PPROM.

4. Uterine müllerian anomalies :

✓ They occur as a consequence of abnormal embryologic fusion and canalization of the müllerian ducts.
 5. Hemorrhage:

✓ APH and placental abruption may lead to spontaneous PTL.

6. Stress:

✓ In the mother as in stressful sociodemographic conditions and in fetus in form of FGR.

✓ They are associated with 2ed tri. miscarriage, PPROM, preterm birth , FGR, breech presentation and C/S

Management Of Preterm Labour

• Up to 70% of women who present with threatened PTL will not deliver during the current admission, and up to
50% will not deliver until term.

• Deciding who is and who is not in PTL has been helped by testing the cervicovaginal fluid levels of fetal
fibronectin (fFN).

• Patients with a positive fFN test can be admitted for tocolysis and steroids for fetal lung maturation.

1- Tocolytics 2-Corticosteroid Therapy

• Tocolytics are used to delay delivery long enough for corticosteroid impact administration of corticosteroid:
administration to improve neonatal lung function 1. Decrease incidence of RDS.
• and, if necessary, for in utero transfer to a Neonatal Intensive 2. Decrease intra-ventricular hemorrhage.
Care Unit (NICU). 3. Improve fetal brain development.
• The first choice should be Oxytocin Receptor Antagonists (atosiban) or 4. Improve fetal hypothalamic–pituitary–
acalcium channel blocker (nifedipine) . adrenocortical axis.

• Other types of tocolytic:

1. Beta-sympathomimetics : e.g salbutamol and terbutaline
• They are effective in delaying delivery, but they have significant
maternal side-effects. 3- Antibiotics
•
2. Magnesium sulphate: • In singleton pregnancies with PPROM,
• in addition of tocolytic effect magnesium sulphate reduces the erythromycin improved neonatal
risk of cerebral palsy in surviving infants. outcomes.
• • 10 days of erythromycin has been
3. Non-steroidal anti-inflammatory drugs: adopted as the treatment of choice for
✓ The first NSAID to be widely used in the management of PTL was PPROM.
indomethacin.

✓ Although prostaglandin inhibitors are effective in delaying PTD,

they have several adverse fetal effects like premature closure of
ductus arteriosus, necrotizing enterocolitis and neonatal renal
dysfunction.
 PPROM
• Preterm premature rupture of the membranes (PPROM) is a pregnancy complication characterize by rupture of
amniotic membrane after 24 week and before 37 week of pregnancy.

• PPROM occurs in approximately 2% of all pregnancies .

• PPROM is diagnosed through clinical history and the demonstration of a pool of liquor in the vagina on speculum
examination.

Management Of PPROM
• Management balances the risk of prematurity versus the risk of maternal and fetal infection.

• In general, conservative management is followed in PPROM before 34 weeks’ gestation unless there is evidence of
Chorioamnionitis and immediate induction of labour is advised in women after 37 weeks’ gestation.

• Conservative management includes intensive clinical surveillance for signs of Chorioamnionitis including:

1. Maternal temperature.

2. Heart rate.

3. Cardiotocography.

4. Rising white cell count.

5. Rising C-reactive protein.

6.

➢ Tocolysis in patients with PPROM is NOT recommended, it does not significantly improve perinatal outcome
and might be associated with an increased risk of chorioamnionitis.
➢ In PPROM, amnio-infusion is NOT recommended as part of routine clinical practice

❖Prediction Of Preterm Delivery

• Research has focused on detecting those women who are at high risk of PTL and intervening to reduce their risk.

• Having had a previous PTD increases the risk of PTL in a subsequent pregnancy 4 times in comparison to a woman
who had a previous delivery at term.

• There is a direct relationship between cervical length and the risk of PTD.

• Cervical length surveillance by transvaginal ultrasound with serial measurement of cervical length throughout
the second and early third trimester is now used to monitor women at high risk of PTD.
 ❖ Prevention Of Preterm Delivery
• In those found to be at high risk of PTD, two interventions are currently available:

A. Progesterone:

• In women with a previous preterm birth, there is some evidence that intramuscular hydroxy-progesterone
caproate is effective in reducing the risk of recurrence.

B. Cervical cerclage:

• cerclage provides structural support to a weakened cervix, and :

A. enhances the cervical immunological barrier by improving retention of the mucous plug

B. preventing ascending infection by maintaining cervical length.

C. New Developments

• Recent data suggest that the arabin pessary may reduce the risk of PTD in women with a singleton or
multiple pregnancy