Preterm labor

Definition
preterm labor
 defined as labor that occurs after 20/28 weeks’ gestation and before the completion of 37
menstrual weeks of gestation regardless of birthweight.
 Presence of regular painful uterine contractions sufficient enough to cause cervical dilation
and/or effacement (after viability and before 37 completed weeks)
 Cervical softening is the most common initial evidence that parturition has begun.
Preterm birth
 Live birth between 28 0/7 weeks' and 36 6/7 weeks' gestation
 WHO subcategories
o Extremely preterm (< 28 weeks)
o Very preterm (28 to < 32 weeks)
o Moderate preterm (32 to < 34 weeks)
o preterm (34 to < 37 weeks)

Low birthweight
 birthweight below 2500 g regardless of gestational age
 very low birthweight (VLBW) is birthweight below 1500 g,
 extremely low birthweight (ELBW) is birthweight below 1000 g

Epidemiology
 leading cause of neonatal mortality and the most common reason for antenatal
hospitalization
o preterm births account for approximately 70% of neonatal deaths and 36% of infant
deaths as well as 25–50% of cases of long-term neurologic impairment in children
 Complications of preterm birth are the leading cause of death in children < 5 years of age
worldwide
 In the United States, approximately 12% of all live births occur before term
 preterm labor preceded approximately 50% of these preterm births
o About half of patients who deliver prematurely are diagnosed with preterm labor.
o World Health Organization has estimated nearly 10% of all births in 2010 were
preterm
 almost 15 million worldwide. Africa and Asia accounted for almost 11 million
 Black women have rates of PTB that are almost twofold higher than those of other
racial/ethnic groups
Risk factors
 approximately half of women who deliver preterm have no obvious risk factors
 High risk factors
 History of preterm birth
 Cervical insufficiency
 Multiple gestation
 Low-risk factors
 Infections (e.g., urinary tract infections, STIs, vaginal infections )
 Polyhydramnios
 Malaria
 Hypertensive pregnancy disorders (e.g., preeclampsia, HELLP syndrome)
 Diabetes mellitus, gestational diabetes
 Uterine anomalies (e.g., anomalies of Mullerian duct fusion, uterine fibroids)
 Placenta previa
 Placental abruption
 Congenital abnormalities of the fetus
 Smoking Substance use (e.g., alcohol or drugs)
 Maternal or fetal stress
 Maternal age (≤ 18 years, > 35 years)
 Low maternal prepregnancy weight, obesity

Clinical features
 Regular uterine contractions and associated symptoms of labor (e.g., lower back pain,
increased vaginal mucus production or blood-tinged vaginal mucus, pressing sensation in the
vagina)
 Cervical dilation, effacement, or both
 Preterm premature rupture of membranes

Diagnosis
 preterm labor must be considered whenever a pregnant woman reports recurrent
abdominal or pelvic symptoms that persist for several hours in the second half of pregnancy
 Contractions may be painful or painless, depending on the resistance offered by the cervix
o Contractions against a closed, uneffaced cervix are likely to be painful, but
persistence of recurrent pressure or tightening may be the only symptoms when
cervical effacement precedes the onset of contractions
 Approximately 30% of preterm labor spontaneously resolves and 50% of patients
hospitalized for preterm labor actually give birth at term
Management
Corticosteroids

 Dexamethasone 6 mg IM BID for 48 hours or betamethasone 12 mg every 24 hours for 48

hours.
 A single repeat course of antenatal corticosteroid is recommended if preterm birth does not
occur within 7 days after the initial dose, and a subsequent clinical assessment demonstrates
that there is a high risk of preterm birth in the next 7 days.
 This rescue dose is reserved
 for patients with intact membranes
 antecedent treatment had been given at least 2 weeks before the rescue course
 gestational age was less than 33 weeks
 the women were judged by the clinician to be likely to give birth within the next
week.
 Recommendations
 A single course of corticosteroids is recommended for pregnant women between 24
weeks and 34 weeks of gestation who are at risk of delivery within 7 days.
 A single course of corticosteroids is recommended for pregnant women between 24
weeks and 34 weeks of gestation who are at risk of delivery within 7 days.
 administration of antenatal corticosteroids to the woman who is at risk of imminent
preterm birth is strongly associated with decreased neonatal morbidity and
mortality
 Because treatment with corticosteroids for less than 24 hours is still associated with
significant reductions in neonatal morbidity and mortality, a first dose of antenatal
corticosteroids should be administered even if the ability to give the second dose is
unlikely, based on the clinical scenario
 Antenatal corticosteroids reduces
 respiratory distress syndrome
 intracranial hemorrhage
 necrotizing enterocolitis
 Death

fetal neuroprotection