Preterm Labor and Delivery

Dr. Yonas G
 Preterm Birth

Preterm birth (PTB) is delivery prior to the

completion of 37 weeks (259 days) of gestation.

It is the most common cause of perinatal morbidity

and mortality the united states,

Incidence

11% to 12% of babies born prematurely

Account for 75% of all perinatal mortality and 50%

of long-term neurologic impairment in children

Preterm Birth

Preterm births may be spontaneous or indicated.

Approximately 40% to 50% of PTBs result from

spontaneous preterm labor with intact membranes;

25% to 40% result from preterm premature rupture of

membranes (PROM)
The remaining 20% to 30% occur following deliberate

intervention for a variety of maternal or obstetric

complications (e.g. Pre eclampsia, eclampsia, IUGR,
APH).
 Complications of preterm delivery
Common neonatal complications in premature infants
include
Respiratory distress syndrome (RDS),
Intraventricular hemorrhage (IVH),
Bronchopulmonary dysplasia (BPD),
Patent ductus arteriosus (PDA),
Necrotizing enterocolitis (NEC),
Sepsis,
Apnea, and
Retinopathy of prematurity.
Complications of preterm delivery

Long-term outcomes
Follow up studies of infants born preterm and LBW
infants reveal increased rates of
Chronic lung disease,
Cerebral palsy,
Neurosensory impairment-vision and hearing impairment
Reduced cognition and motor performance
Academic difficulties, and attention deficit disorders
The incidence of long-term morbidity in survivors is
especially increased for those born before 26 weeks
 Preterm Labor (PTL)
Preterm labor (PTL) is defined as the presence of regular
uterine contractions associated with cervical changes before
37 weeks of gestation
PTL may represent a final common pathway for a number of
pathogenic processes.
The four main processes include
1. Activation of the maternal or fetal hypothalamic pituitary-
adrenal axis due to maternal or fetal stress,
2. Decidual-chorioamniotic or systemic inflammation caused
by infection,
3. Decidual hemorrhage, or
4. Pathologic uterine distention
 PRETERM LABOR- Dx
Labor at GA>20wks & < 37wks
 Frequent + Regular ux contractions
May manifest as abdominal pain /tightening, back pain
or pelvic pressure
 Cervical change (E&D) along with the contractions
 NB. At least 4cont/hr is required to cause Cx change
Late Preterm 34-36 wks
Moderately PT 32-34
Very PT 28 - 32
Extremely PT <28 wks
 PTL Risk Factors
 Obstetric complications (in previous or current pregnancy)
Previous premature or low-birth-weight infant (2x increase
in subsequent pregnancy)
Severe hypertensive state of pregnancy
Anatomic disorders of the placenta
E.g. abruptio placentae, placenta previa, circumvallate
placenta
Placental insufficiency
PROM
AFV disorders-Poly/ oligo
Low socioeconomic status
Maternal age < 18 years or > 40 years
Low pre pregnancy weight
 PTL Risk Factors
 Medical complications
    Pulmonary or systemic hypertension
    Renal disease
    Heart disease
 Infection systemic or FGT:(mainly at earlier GA, <32wk)
Acute systemic infection, (eg, pneumonia, influenza, malaria,
periodontal infection ),
UTI, pyelonephritis,
GT infection ( gonorrhea, H. Simplex, mycoplasmosis )
Bacterial vaginosis
Fettoxic infection (CMV, toxoplasmosis, listeriosis
Maternal intra-abdominal sepsis (eg, appendicitis, cholecystitis,
diverticulitis)
PTL Risk Factors
Surgical complications
    Any intra-abdominal procedure
    Conization of cervix
    Previous incision in uterus or cervix (e.g., cesarean
delivery)
 PTL- Prediction
A number of factors are used to predict the potential to
develop preterm labor.
Fetal fibronectin ( f FN) in cervicovaginal secretions
A preterm rise in the concentration of fFN may be associated
with an increased likelihood of birth between 22 and 34 weeks
of gestation and birth within 7–14 days of the test.
However, data combined from several studies reveal that the
positive predictive value for delivery within a week is only
18%.
Cervical length
Shortened cervical length < 2.5cm in midpregnancy is
associated with the risk of preterm labor and delivery.
PTL- Management
The purpose in treating preterm labor is to delay
delivery, if possible, until fetal maturity is attained
More than 50% of patients with preterm contractions
have spontaneous resolution of abnormal uterine
activity.
Non-pharmacologic methods of Uncertain efficacy
include
Bed rest
Abstinence from intercourse and orgasm
Hydration ( oral / parenteral)
 PTL Mgt-Interventions
ሀ: TOCOLYSIS
 Pharmacologic inhibition of uterine activity to suppress labor
At least for 48 hrs. after administration of corticosteroids or
If possible to take pregnancy to >34wks in those with high
risk of preterm birth, i.e.
 Hx of preterm birth,
Contraction sustained,
 Cervical dilatation change
Short Cx
 Fibronectin positive

* Tocoytics may prolong gestation for 2-7 days ( time for steroid
administration & transportation to facility having NICU, no other
clear benefits)
 PTL- Management
 Tocolytic agents
Magnesium sulfate
Prostaglandin synthetase inhibitors (indomethacin)
Calcium-channel blockers (nifedipine)
β-adrenergic agents (ritodrine, terbutaline)
Some cases in which preterm labor should not be suppressed.
Maternal factors
Severe hypertensive disease
(e.g., acute exacerbation of
chronic HTN , eclampsia,
severe PE)
 Pulmonary or cardiac
disease (eg, pulmonary edema,
adult respiratory distress
syndrome, Valvular disease,
tachyarrhythmias )
Advanced cervical dilatation
(> 4 cm)
 Maternal hemorrhage (eg,
abruptio placentae, placenta
previa, DIC)
Fetal factors
Fetal death or lethal anomaly
Fetal distress
Intrauterine infection
( chorioamnionitis )
 Therapy adversely affecting
the fetus (e.g. fetal distress due
to attempted suppression of
labor)
Estimated fetal weight 2500 g
Erythroblastosis fetalis
Severe IUGR
 Potential complications of tocolytic agents

 Beta- Adrenergic
Hyperglycemia  Magnesium Sulfate
Hypokalemia Pulmonary edema
Hypotension
Pulmonary edema
Respiratory depression a
Cardiac insufficiency Cardiac arrest a
Arrhythmias Maternal tetany a
Myocardial ischemia
Profound muscular paralysis a
Maternal death
Profound hypotension a
 Indomethacin
Hepatitisb
Renal failureb
GI bleedingb
 Nifedipine a
Effect is rare; seen with toxic levels.
Transient hypotension b
Effect is rare; associated with chronic
use
PTL Mgt-intervention cont’d.
 ለ፡Steroid administration :- for GA 24-34 weeks (24-32 wk for PROM,
efficacy b/n 33-34 not clear, my be given esp if pulmonary immaturity is
documented ACOG 2013)
The most beneficial intervention for pts with true PTL
To facilitate lung maturity and reduce incidence and severity of
neonatal RDS and
Reduce incidence of IVH and NEC
Indication- Risk of PTB (24-34wk GA) in one week
Regimen for two days
 Betamethasone 12mg Im /24hr totally 2 dose or
Dexamethasone 6mg IM BID totally 4 dose
No multiple regular doses
Rescue dose- 01 repeat course may be given if
2 weeks passed after the first dose
GA < 32 weeks
Delivery is anticipated within 01 week (ACOG 2018)
PTL Mgt-intervention cont’d.
ሐ፡ Adjuvant antibiotics
No evidence that Antibiotic administration prolongs
gestation or reduces neonatal complications
May be used for GBS prophylaxis in those delivery is
imminent .
 Thank
you !!!