Frequency Of Preterm Labor And Its Factors In Patients Presenting To

Secondary Care Hospital

Introduction:
Definition: It is the birth of the baby after 24+0 weeks & before 37+0 completed weeks of
pregnancy.2 Preterm birth is one of the biggest and important reason of neonatal mortality and
morbidity and a notable burden on health of public. 3 Globally, there are about 15 million preterm
births each year.1 In a Study done in 2012 revealed that there is 7.3% of live births from preterm
labor in England,2 while In the USA the rate is between 9 and 12%. 1

Pakistan, Zimbabwe, Gabon, Malawi, Botswana have Incidence of Preterm labor more than 15%.
Therefore developing countries such as India, Pakistan, Indonesia, Nigeria have greatest numbers of
preterm birth.1Preterm births rate has increased in developed countries due to assisted
reproduction, elective deliveries for the management of different conditions as in Pre-eclampsia,
Fetal Growth Restriction.1 Neonatal mortality risk increases if the gestational age at delivery
reduces. However, those newborns who live through preterm birth have more risk of impairment
and handicap.1

Recently, Two studies have been compared of extreme preterm births in 1995 and 2006 which
showed that cohorts born during these years had improved survival rate, (from 40% to 53%). 2
Studies show that there is an increased risk of preterm labor in teenagers and females above 30.
Also, other risks are Primigravidas, Marital status, Poor nutrition, cigarette smoking , street drugs
especially cocaine, environmental factors, ethnicity and history of any cervical surgery. 1,4 Nadir
level of education to females has also known to be a risk factor for preterm labor in many
reasearchs.5

The most important and severe consequence of preterm birth is a neurodevelopmental disability.
Babies born due to preterm labor have a 7-fold risk of cerebral palsy when compared with babies
born at term.1 About 75% of women give birth after spontaneous preterm labor that is may or may
not be preceded by preterm prelabour rupture of membranes. 2

In a study by Halimi Asl AA, et al. has shown that frequency of preterm labor was 48.7%.6

In another study by Roozbeh N, et al. has shown that frequency of smoking was 3%, Infection
during pregnancy 35.8%, history of miscarriage 19.9%, history of prematurity 11.6%, Preterm
Prelabor Rupture Of Membrane 30.3% and history of multiple pregnancies was 10.2% as factors for
preterm labor.7

Suspected preterm labor: It is defined as when a patient complains of symptoms of preterm

labor and on clinical examination, it is confirmed that there might be a possibility of preterm labor
but still it rules out established labor.2

Diagnosed preterm labor: It is defined as patient who is in suspected preterm labor and her
diagnostic test came out to be positive for preterm labor. 2
Established preterm labor: It is defined as when the woman presents with regular uterine
contractions alongwith progressive cervical dilation and effacement from 4 cm. 2

As there is an association between premature babies and infantile mortality, it is very important to
know the causes and its frequency in our community.There is a very limited data regarding preterm
labor in our area. So, The Rationale of my study is to observe the frequency of Preterm labor and
most common etiological factors associated with Preterm Labor in a secondary care hospital. We
cannot always prevent preterm labor, but we can try to find methods to reduce it.Therefore,This
vital study will help us in developing preventive measures against preterm labor. This study will
provide data for researchers and will also help in creating awareness to the families and caregivers.
Objective:
● To determine the frequency of Preterm Labor in a secondary care hospital

● To determine the most common etiological factors associated with Preterm Labor.

Operational Definitions:

Preterm labor: It is defined as the presence of uterine contractions between 24 +0 to 36+6 weeks
with the frequency of 4-5 in 10 minutes with the time of 30 seconds and intensity to effect
progressive effacement and dilation of the cervix >4cm, assessed by vaginal examination.8

Symptoms of preterm labor

Symptoms that may indicate preterm labor are abdominal pain, PPROM but no clinical examination
of the women has taken place. 2

Preterm Pre labor Rupture Of Membrane: Offer women speculum examination to the women
presenting with the symptoms of PPROM:

● A speculum examination reveals the appearance of a pool of clear fluid in the vagina and is
greatly suggestive of rupture of membrane and when this is noted there is no further need for
diagnostic tests to confirm the diagnosis.9

● If a pool of amniotic fluid is not clearly noted on examination, testing for IGFBP1 or PAMG-1
should be considered.9

Cervical trauma: It is defined as Any damage to the cervix and that may include surgery; for
example, previous cone biopsy , large loop excision of the transformation zone (LLETZ – any
number), or radical diathermy.

Material and Methods:

Study design: Cross-Sectional Study.

Setting: Department of Obstetrics and Gynaecology, Kulsum Bai Valika Hospital, Karachi.

Duration of study: Six months after approval of synopsis

Sample size:

196 sample size is calculated with WHO sample size software using 95% confidence interval,7%
margin of error and expected frequency of preterm labor by 48.7%. 6

Sampling technique: Non-probability consecutive sampling.

Inclusion Criteria:

1. Booked and Unbooked

2. Singleton or multiple pregnancies
3. Gestational age between 24+0 and 36+6 weeks
4. Parity: Any Parity
5. Ethnicity: all ethnicity
6. Socio economical group: Any socioeconomic group
7. Current or Past history: PE, Diabetes, UTI.
8. History of domestic abuse, abdominal trauma.

Exclusion Criteria:

▪ Gestational age less than 24 weeks & Equal or more than 37 weeks.

Data Collection Procedure:

Patients fulfilling the inclusion criteria from the Department of Obstetrics and Gynaecology,
Kulsoom Bai Valika Hospital, Karachi will be included in the study after permission from the ethical
committee. Basic demographics like age, gestational age, parity will be noted and detailed history of
patient will be taken. Informed consent will be taken from each patient. Preterm labor will be noted
as per operational definition and factors (Primigravida, domestic violence, smoking, Infection
during pregnancy, history of miscarriage, history of cervical trauma/LLETZ, any significant medical
history such as hypertension, diabetes and UTI, history of prematurity, Preterm Premature Rupture
Of Membrane and history of multiple pregnancies) will be noted as per operational definition. I will
perform an abdominal examination for the measurement of Symphysis-Fundal Height, if there is
palpable uterine activity and fetal heart rate by sonicaide. After that, I will perform her speculum
examination for cervical assessment and check if there is leaking. If I shall find any difficulty in
cervical assessment then I will perform a digital cervical assessment to confirm the diagnosis of
preterm labor. All this data will be recorded on especially designed Proforma.

(Annexure-I).

Data Analysis:
Data will be analyzed with a statistical analysis program (SPSS-version 22). Mean ±SD will be
presented for quantitative variables like age, parity, and gestational age. Frequencies and
percentages will be computed for qualitative variables like preterm labor, Primigravida, domestic
violence, smoking, Infection during pregnancy, history of miscarriage, history of prematurity,
Premature Rupture Of Membrane, history of cervical surgery, any significant medical history such
as hypertension, diabetes and UTI, and history of multiple pregnancies. Preterm labor and its
factors will be stratified to age, parity and gestational age. Post-stratification chi square test will be
applied p ≤0.05 will be considered statistically significant.

References:
1- Dewhurst’s Textbook of Obstetrics & Gynaecology, Ninth Edition. Edited by D. Keith Edmonds,
Christoph Lees and Tom Bourne.

© 2018 John Wiley & Sons Ltd. Published 2018 by John Wiley & Sons Ltd.

2- Preterm labour and birth NICE guideline Published: 20 November 2015

www.nice.org.uk/guidance/ng25

3. Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, et al. Global, regional, and national causes of

under-5 mortality in 2000–15: an updated systematic analysis with implications for the

sustainable development goals. Lancet. 2016;388(10063):3027–35.

4. Kildea SV, Gao Y, Rolfe M, Boyle J, Tracy S, Barclay LM. Risk factors for preterm, low

birthweight and small for gestational age births among Aboriginal women from remote

communities in northern Australia. Women Birth. 2017;30(5):398–405.

5. Oftedal AM, Busterud K, Irgens LM, Haug K, Rasmussen S. Socio-economic risk factors for

preterm birth in Norway 1999-2009. Scand J Public Health. 2016;44(6):587–92.

6. Halimi Asl AA, Safari S, Parvareshi Hamrah M. Epidemiology and related risk factors of preterm
labor as an obstetrics emergency. Emergency. 2017;5(1):e3.

7. Roozbeh N, Moradi S, Soltani S, Zolfizadeh F, Hasani MT, Yabandeh AP. Factors associated with
preterm labor in Hormozgan province in 2013. Electron Physician. 2016;8(9):2918-23.

8. Sarri G, Davies M, Gholitabar M, Norman JE. Guideline Development Group. Preterm labour:
summary of NICE guidance. BMJ. 2015;351:h6283.

9-Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0
Weeks of Gestation. AJ Thomson, on behalf of the Royal College of Obstetricians and Gynaecologists
 ANNEXURE- I

Frequency Of Preterm Labor And Its Factors In Patients Presenting To

Secondary Care Hospital

• Patient SS no: ___________________________________

• Husband name
• Booking status: Booked /unbooked
• Presenting complaint
1. Age:
▪ Less than 18 YRS
▪ More than 18 YRS
2. BMI:
▪ <18.5kg/m2
▪ Equal or more than 35 K/m2
3. Socioeconomic group:
▪ Financially stable
▪ Financially unstable
4. 4Parity
▪ Nulliparous
▪ Multiparous
5. Gestational age
▪ B/w 24+0 & 27+6weeks
▪ B/w 28+0 & 31+6weeks
▪ B/w 32+0 & 36+6 weeks
6. Past h/o PTL/PPROM
▪ YES
▪ NO
7. H/O Smoking/recreational drugs
▪ Yes
▪ No
8. H/o domestic violence
▪ Yes ( which type ? physical/ mental. Sexual )
▪ No
9. History of any infection
▪ vaginal
▪ urinary tract
10. h/o vaginal bleeding
11. Past h/o cervical trauma
▪ Yes
▪ No