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Overview of preterm labor and delivery Author Charles J Lockwood, MD Section Editor Susan M Ramin, MD Deputy Editor Vanessa

A Barss, MD

Last literature review version 19.3: Janeiro 2012 | This topic last updated: Dezembro 16, 2011

INTRODUCTION Preterm birth (PTB) refers to a birth that occurs before 37 weeks of gestation. Subclassifications of PTB are variably and inconsistently defined as: y Late preterm = 34 to 36 and 0/7ths weeks y Moderately preterm = 32 to 34 weeks y Very preterm = <32 weeks y Extremely preterm = <28 weeks PTB can also be defined by birth weight (BW): y Low birth weight (LBW) BW less than 2500 g y Very low birth weight (VLBW) BW less than 1500 g y Extremely low birth weight (ELBW) BW less than 1000 g By comparison, a term birth is defined as a birth occurring between 37 and 0/7ths and 42 weeks, and a post-term birth is defined as a birth occurring after 42 weeks. SIGNIFICANCE Taken together with its sequelae, PTB is by far the leading cause of infant mortality in the United States. The relationship between neonatal mortality and gestational age is nonlinear (figure 1). (See "Perinatal mortality", section on 'Causes of infant death'.) PTB is also a major determinant of short- and long-term morbidity in infants and children. (See "Incidence and mortality of the premature infant".) INCIDENCE In the United States, 12.18 percent of births in 2009 occurred preterm and 3.51 percent were less than 34 weeks of gestation [1]. PATHOGENESIS Approximately 70 to 80 percent of PTBs occur spontaneously: preterm labor (PTL) accounts for 40 to 50 percent of all PTBs and preterm premature rupture of membranes (PPROM) accounts for 20 to 30 percent. The remaining 20 to 30 percent of PTBs are due to intervention for maternal or fetal problems (table 1). Clinical and laboratory evidence suggest that a number of pathogenic processes can lead to a final common pathway that results in preterm labor and delivery. The four primary processes are: y Activation of the maternal or fetal hypothalamic-pituitary-adrenal axis y Infection y Decidual hemorrhage y Pathological uterine distention These processes are discussed in detail separately. (See "Pathogenesis of spontaneous preterm birth".) RISK FACTORS Numerous risk factors for PTB have been reported (table 2). A causal association between these risk factors and PTB has been difficult to prove because (1) many PTBs occur among women with no risk factors at all (eg, nulliparas), (2) some obstetrical

complications resulting in PTB require cofactors to exert their effect, making the chain of causality difficult to document, and (3) an adequate animal model for study of PTB does not exist. Risk factors for PTB are discussed in detail separately. (See "Risk factors for preterm labor and delivery".) CLINICAL MANIFESTATIONS AND DIAGNOSIS PTL is one of the most common reasons for hospitalization of pregnant women, but identifying women with preterm contractions who will deliver preterm is an inexact process. In one systematic review, approximately 30 percent of preterm labors spontaneously resolved [2]. Others have reported 50 percent of patients hospitalized for PTL deliver at term [3-5]. Signs and symptoms of early PTL include menstrual-like cramping, constant low back ache, mild uterine contractions at infrequent and/or irregular intervals, and vaginal discharge and pressure sensation. Mucus that has accumulated in the cervix may be discharged as clear, pink, or slightly bloody secretions (ie, mucus plug, bloody show), sometimes several days before labor begins. However, these signs and symptoms are non-specific and often noted in women whose pregnancies go to term. Uterine contractions, the sine qua non of labor, are a normal finding at all stages of pregnancy, thereby adding to the challenge of distinguishing true from false labor. The frequency of contractions increases with gestational age, the number of fetuses, and at night. Although many investigators have tried, no one has been able to identify a threshold contraction frequency that effectively identifies women who will go on to deliver preterm. The diagnosis of PTL is generally based upon clinical criteria of regular painful uterine contractions accompanied by cervical dilation and/or effacement. Specific criteria, which were initially developed to select subjects in research settings, include persistent uterine contractions (four every 20 minutes or eight every 60 minutes) with documented cervical change or cervical effacement of at least 80 percent, or cervical dilatation greater than 2 cm. Women who do not meet these criteria are diagnosed with false labor; these women typically go on to have a term or late preterm birth [6]. Digital cervical examination has limited reproducibility between examiners, especially when changes are not pronounced; therefore, some centers evaluate the cervix via transvaginal ultrasound to confirm the diagnosis [7,8]. Sonographic measurement of cervical length is a more sensitive indicator of a patient's risk for PTB than cervical dilatation. Cervical length is predictive of PTB in all populations studied, including asymptomatic women with prior cone biopsy, mllerian anomalies, or multiple dilation and evacuations [9]. A short cervix has been variously defined as a cervical length less than 2.0 cm, 2.5 cm, or 3.0 cm. Using a higher cut-off increases sensitivity, but lowers specificity, for prediction of PTB. The correlation between cervical findings in ultrasound examination and risk of PTB is discussed in detail separately. (See "Prediction of prematurity by transvaginal ultrasound assessment of the cervix".) INITIAL EVALUATION In addition to reviewing the patient's obstetrical and medical history, the initial evaluation of women with suspected PTL should determine: y The presence and frequency of uterine contractions y Whether there is uterine bleeding (see "Clinical manifestations and diagnosis of placenta previa" and "Clinical features and diagnosis of placental abruption") y Whether the fetal membranes have ruptured (see "Preterm premature rupture of membranes") y Gestational age (see "Prenatal assessment of gestational age") y Fetal well-being (see "Intrapartum fetal heart rate assessment") Uterine contractions and fetal well-being are evaluated continuously using an electronic fetal heart rate and contraction monitor.

Physical examination The uterus is examined to assess firmness, tenderness, fetal size, and fetal position. A sterile speculum examination is performed to rule out ruptured membranes, to visually examine the vagina and cervix, and to obtain specimens for laboratory testing (see below). A digital examination to assess cervical dilatation and effacement is performed after placenta previa and PPROM have been excluded (by history and physical, laboratory, and ultrasound examinations, as indicated). When assessing cervical dilation and effacement in the second trimester, it is important to distinguish between patients whose membranes have hour-glassed (prolapsed) through a mildly dilated and effaced cervix (suggestive of cervical insufficiency) from those who are fully dilated and effaced as a result of advanced labor. Ultrasound imaging can distinguish between these two diagnoses. (See "Cervical insufficiency", section on 'Physical examination reveals a dilated cervix and visible membranes' and "Transvaginal cervical cerclage", section on 'Replacement of prolapsed membranes'.) Laboratory tests y Urine culture, since bacteriuria and pyelonephritis are associated with PTB. (See "Urinary tract infections and asymptomatic bacteriuria in pregnancy".) y Rectovaginal group B streptococcal culture, to determine need for antibiotic prophylaxis. (See "Chemoprophylaxis for the prevention of neonatal group B streptococcal disease".) y Tests for gonorrhea and chlamydia. Testing for gonorrhea and chlamydia may be omitted if previously performed, the results were negative, and the patient is not at high risk of acquiring sexually transmitted infections. y Fetal fibronectin (fFN). We obtain a swab for fFN on all symptomatic patients considered at high risk for PTB, and then perform transvaginal sonographic measurement of cervical length. We only send the swab to the laboratory for FFN determination if the cervical length is 20 to 30 mm (see 'Triage based upon cervical length' below) y Given the link between cocaine use and placental abruption, we perform drug testing in patients with risk factors for drug abuse. Imaging Lastly, we perform an ultrasound examination. During this examination, we measure cervical length (see 'Triage based upon cervical length' below), look for anatomic abnormalities, confirm the fetal presentation, and estimate fetal weight to counsel about mode of delivery and anticipated neonatal outcome [10]. Assessment of amniotic fluid volume is useful as oligohydramnios should prompt evaluation for premature rupture of membranes as the cause of premature labor while uterine distention from polyhydramnios (or multiple gestation) could lead to preterm contractions. (See "Prediction of prematurity by transvaginal ultrasound assessment of the cervix".) TRIAGE BASED UPON CERVICAL LENGTH There are no data from large randomized trials to help determine the optimal approach to management of women with suspected PTL (eg contractions with cervical dilation <2 cm) and intact membranes. The approach described below reflects our paradigm based upon our experience and data from observational studies, which are described separately. (See "Fetal fibronectin for prediction of preterm labor and delivery" and "Prediction of prematurity by transvaginal ultrasound assessment of the cervix".) Cervical length >30 mm These women are at low risk of PTB [11,12], regardless of fFN result, so we do not send their swabs for fFN testing to the laboratory. We discharge the patients home after an observational period of four to six hours during which we confirm fetal well-being (eg, reactive nonstress test), exclude the presence of an acute precipitating event (eg, an abruption or overt infection), and assure ourselves that the cervix is not dilating or effacing. Follow-up in one to two weeks is arranged and the patient is given instructions to call if she experiences additional signs or symptoms of PTL, or has other pregnancy concerns (eg, bleeding, PROM, decreased fetal activity). (See "Patient information: Preterm labor".)

Cervical length 20 to 30 mm PTB is more likely in women with cervices 20 to 30 mm than in women with longer cervices, but most women in this group do not deliver preterm. Therefore, we send the swab for fFN testing in this subgroup of women. If the test is positive (level greater than 50 ng/mL), we actively manage the pregnancy to prevent morbidity associated with PTB. (See "Fetal fibronectin for prediction of preterm labor and delivery".) Cervical length <20 mm These women are at high risk of PTB regardless of fFN result. Therefore, we do not send their swabs for fFN testing to the laboratory and actively manage them to prevent morbidity associated with PTB. MANAGEMENT OF WOMEN WITH PRETERM LABOR We hospitalize women diagnosed with PTL at less than 34 weeks of gestation and initiate the following treatments: y Antenatal glucocorticoids to reduce neonatal morbidity and mortality associated with PTB (see "Antenatal use of corticosteroids in women at risk for preterm delivery"). y Appropriate antibiotics for GBS chemoprophylaxis (see "Chemoprophylaxis for the prevention of neonatal group B streptococcal disease"). y Tocolytic drugs for up to 48 hours to delay delivery so that glucocorticoids given to the mother can achieve their maximum effect. (See "Inhibition of acute preterm labor".) y Appropriate antibiotics to women with positive urine culture results or positive tests for gonorrhea or chlamydia. (See "Prevention of spontaneous preterm birth".) PTL itself is not an indication for antibiotic prophylaxis or treatment in the absence of documented infection or GBS prophylaxis [13]. Management of women after diagnosis and initial treatment of PTL is discussed separately. (See "Management of pregnant women after inhibition of acute preterm labor".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) y Basics topics (see "Patient information: Preterm labor (The Basics)" and "Patient information: How to tell when labor starts (The Basics)") y Beyond the Basics topics (see "Patient information: Preterm labor") SUMMARY AND RECOMMENDATIONS y The diagnosis of preterm labor (PTL) is based on clinical criteria of regular painful uterine contractions accompanied by cervical dilation and/or effacement. Ultrasound measurement of cervical length and laboratory analysis of cervicovaginal fetal fibronectin (fFN) level can help to confirm or exclude the diagnosis of PTL. (See 'Clinical manifestations and diagnosis' above.) y We suggest cervical length measurement be used to identify patients for further evaluation and therapy (Grade 2C). (See 'Initial evaluation' above and 'Triage based upon cervical length' above.) y We suggest treatment of women with suspected PTL (Grade 2C). We administer tocolytic drugs for up to 48 hours; appropriate antibiotics to women with positive urine culture results or positive tests for gonorrhea and chlamydia; appropriate antibiotics

for GBS chemoprophylaxis, and antenatal glucocorticoids to reduce neonatal morbidity and mortality associated with preterm birth. (See 'Management of women with preterm labor' above.)