I.

INTRODUCTION

Premature labor (or pre-term labor) is when you start having contractions and true labor after your 20th week of pregnancy and more than 3 weeks before your due date. Contractions (tightening of the uterus muscles) cause the cervix (lower end of the uterus) to open earlier than normal. Pre-term labor may result in the birth of a premature baby. However, labor often can be stopped to allow the baby more time to grow and develop in the uterus. Premature labor treatments include bed rest, fluids given intravenously (in your vein), and medications to relax the uterus. If born prematurely after the seventh month, a baby would likely survive, but may need to stay in the hospitals neonatal intensive care unit (NICU). If the baby is born earlier than the seventh month, he or she may be able to survive with specialized care in the NICU. Recognizing the signs and knowing what to do about them increase the chance that you can get help quickly to stop pre-term labor.

II.

ANATOMY AND PHYSIOLOGY A. B O O K C E N T E R E D :

Functions: Fallopian Tube are one of the main components of the female reproductive system, and they must work properly to ensure fertility. Each side of the uterus has a fallopian tube extending from it that reaches to the ovary on the corresponding side. The main function of the fallopian tubes is to catch eggs released from the ovaries each month during ovulation, and guide them into the uterus. Uterus consists of the following 3 tissue layers the inner layer, called the Endometrium, is the most active layer and responds to cyclic ovarian hormone changes; the endometrium is highly specialized and is essential to menstrual and reproductive function, the middle layer, or Myometrium, makes up most of the uterine volume and is the muscular layer, composed primarily of smooth muscle cells, the outer layer of the uterus, the serosa or Perimetrium, is a thin layer of tissue made of epithelial cells that envelop the uterus.The uterus is a dynamic female reproductive organ that is responsible for several reproductive functions, including menses, implantation, gestation, labor, and delivery. It is responsive to the hormonal milieu within the body, which allows adaptation to the different stages of a womans reproductive life. Ovary are small, lumpy, almondshaped organs near the lateral walls of the pelvic cavity. The ovaries perform three main functions: (1) produce immature female gametes, or oocytes, (2) secrete female sex hormones, including estrogens and progestins, and (3) secrete inhibin, involved in the feedback control of pituitaryFSH production. Cervix is the lower third portion of the uterus which forms the neck of the uterus and opens into the vagina which is also called the endocervical canal. The narrow opening of the cervix is called the os. The cervical os allows menstrual blood to flow out from the vagina during menstruation. During pregnancy the cervical os closes to help keep the fetus in the uterus until birth. Another important function of the cervix occurs during labor when the cervix dilates, or widens, to allow the passage of the fetus from the uterus to the vagina. Vagina is an elastic, muscular canal with a soft, flexible lining that provides lubrication and sensation. The vagina connects the uterus to the outside world. The vulva and labia form the entrance, and the cervix of the uterus protrudes into the vagina, forming the interior end.The vagina receives the penis during sexual intercourse and also serves as a conduit for menstrual flow from the uterus. During childbirth, the baby passes through the vagina (birth canal).

PATHOPHYSIOLOGY

SYNTHESIS OF THE DISEASES

Risk factors: There are a number of risk factors, but keep in mind that more than half of spontaneous preterm births occur in pregnancies where there's no identifiable risk factor. Although it's impossible to say whether you'll give birth prematurely, it may be more likely if you:

Previously had a preterm delivery (the earlier in gestation your baby was born and the more spontaneous preterm births you've had, the higher your risk) Are pregnant with twins or other multiples Are younger than 17 or older than 35 Are African American Were underweight before you got pregnant or don't gain enough weight during your pregnancy Have had vaginal bleeding in the first or second trimester. Vaginal bleeding in more than one trimester means the risk is even higher. Had moderate to severe anemia early in your pregnancy Smoke, abuse alcohol, or use drugs (especially cocaine) during pregnancy Gave birth in the last 18 months (particularly if you became pregnant within six months of giving birth) Were born to a mother who took the drug DES. (Note: DES was taken off the market in the United States in 1971 but remained available in some other countries. If you're in your late thirties or older or your mother lived in another country when she carried you, ask her whether or not she took DES.) Have had no prenatal care or got a late start on prenatal care Are pregnant with a single baby that's the result of fertility treatments Have low socioeconomic status There also appears to be an association between high levels of stress, particularly chronic stress, and preterm birth. The theory is that severe stress can lead to the release of hormones that can trigger uterine contractions and preterm labor. This may explain why women who are victims of domestic abuse have a higher risk for spontaneous preterm labor. Those who endure physical violence have an even higher risk, of course, particularly if there's trauma to the abdomen. Some research suggests that night shift workers are at higher risk of preterm birth compared to women who work during the day. There's also evidence that pregnant women who stand for more than 40 hours a week or who have extremely tiring jobs are at higher risk than women with less physically demanding jobs. Other studies have not confirmed these findings, though.

Signs and Symptoms of Pre-term Labor:

Contractions in your uterus every 10 minutes or more often Tightening or low, dull backache that may be constant or come and go, but changing positions and other comfort measures don't ease it Menstrual-like cramps or lower abdominal cramping that may feel like gas pains, with or without diarrhea Increased pressure in your pelvis or vagina Increased vaginal discharge Leaking of fluid from the vagina Vaginal bleeding Flu-like symptoms such as nausea, vomiting, or diarrhea Less movement or kicking by your baby

Complications Many women treated for preterm labor deliver at or near term. Sometimes, however, preterm labor can't be stopped or an infection or other complications make an early delivery safer for mother or baby. If preterm labor can't be stopped, your baby will be born prematurely. This could pose various health concerns, such as low birth weight, breathing difficulties, underdeveloped organs and vision problems. Children who are born prematurely also have a higher risk of learning disabilities and behavioral problems. The risks are greatest for babies born before 32 weeks of pregnancy. Babies born before the 37th week of gestation are considered premature. Premature newborns are sometimes referred to as preemies. Mothers who have their baby prematurely are often frightened and nervous. Premature newborns face increased risk of one or more complications. The risk of complications increases the earlier the baby is born. Any complication that a premature newborn experiences will be treated in the neonatal intensive care unit (NICU). Below is a list of the most common complications that a premature newborn may experience. Immature Lungs Most babies have mature lungs by 36 weeks of gestation. However, since babies develop at different rates there are exceptions to this. If a mother and her health care provider know that the baby might be coming early, amniocentesis may be performed to check the maturity level of the lungs. In some cases, an injection of steroids will be given to the baby before the delivery in order to speed the development

of the lungs. The major concern in cases of premature labor is the development of the newborns lungs. Immature lungs are associated with the following complications:

Respiratory Distress Syndrome (RDS) causes harsh, irregular breathing and difficulties due to the lack of a specific agent (surfactant) in the lungs that helps prevent the lungs from collapsing. Treatment involves one or more of the following: supplemental oxygen (through an oxygen hood), use of a respirator (ventilator), continuous positive airway pressure, endotracheal intubation and in severe cases, doses of surfactant.

Transient tachypnea is rapid shallow breathing. This can occur in both premature babies as well as full term babies. Recovery usually takes three days or less. Until the newborn has recovered, feedings may be altered and in some cases intravenous feedings may be done. There is usually no other treatment necessary.

Bronchopulmonary Dysplasia (BPD) occurs when a babys lungs have shown evidence of deterioration. Unfortunately, when preemies are put on a ventilator (also known as respirators) their lungs are still immature and sometimes can not withstand the constant pressure from the respirator. Preemies that have been on a respirator for more than twenty-eight days are at risk of developing BPD. Preemies can recover from this condition but some take longer to recover than others.

Pneumonia Complications with premature-related respiratory problems can lead to pneumonia. Pneumonia is an infection in the area of the lung involved in the exchange of carbon dioxide and oxygen causing inflammation which reduces the amount of space available for the exchange of air. This can result in inadequate amounts of oxygen for the baby. Treatment can include antibiotics and supplemental oxygen and intubation. If left untreated, it condition can develop into a deadly infection or lead to sepsis or meningitis. Apnea and Bradycardia Apnea is the absence of breathing. In the NICU an alarm will sound if a newborn develops an irregular breathing pattern of intervals of pauses longer than 10-15 seconds. Bradycardia is the reduction of heart rate. An alarm will also sound if the newborns heart rate falls below 100 beats per minute. Usually a little tap or simple rub on the back helps remind the preemie to breath and also increases the heart rate.

Infection A premature baby might not be able to resist certain infections. For its own protection the baby is placed in an incubator to provide protection against these infections. Jaundice A yellowish skin color caused by the buildup of substances in the blood called bilirubin. Treatment involves being placed under a bilirubin light called phototherapy. The procedure can take from one week to 10 days. Intraventricular hemorrhage (IVH) Babies born sooner than 34 weeks have increased risk of bleeding in the brain because immature blood vessels might not tolerate the changes in circulation that took place during labor. This can lead to future complications such as cerebral palsy, mental retardation and learning difficulties. Intracranial hemorrhage occurs in about 1/3 of babies born at 24-26 weeks gestation. If preterm labor is identified and is inevitable, there are medications that can be given to the mother to help reduce the risk of severe intracranial hemorrhage in the newborn. Inability to maintain body heat A premature baby is born with little body fat and immature skin which makes it harder to maintain body heat. Treatment involves warmers or incubators to provide warmth. Immature gastrointestinal and digestive system Premature newborns are born with gastrointestinal systems that are too immature to absorb nutrients safely. In such cases, they receive their initial nutrients through intravenous (IV) feeding. This is referred to as total parenteral nutrition (TPN). After a few days, newborns may be fed through a tube with breast milk or formula because they might not yet have the ability to swallow or suck on their own. Anemia This is a medical condition caused by abnormally low concentrations of red blood cells. Red blood cells are important because they carry a substance called hemoglobin which carries oxygen. Most newborns should have red blood cell levels higher than 15 grams. However, preemies are at a high risk of having lower levels with subsequent risk of anemia. If the anemia is severe, treatment can involve a transfusion of red blood cells to the newborn. Patent Ductus Arteriosus (PDA) This is a cardiac disorder that results in breathing difficulties after delivery because of an open blood vessel called the ductus arteriosus. During fetal development the ductus arteriosis is open to allow blood to be diverted from the lungs into the aorta. A fetus makes a chemical compound called prostaglandin E which circulates his or her blood thus keeping the ductus arteriosus open. At a full term,

levels of prostaglandin E fall causing the ductus arteriosus to close and allowing a babys lungs to receive the blood needed to function properly after it is born. With preterm labor, the prostaglandin E may stay at the same level causing an open ductus arteriosus. Treatment involves a medication that stops or slows the production of prostaglandin E. Retinopathy of Prematurity (ROP) This is a potentially blinding eye disorder. It affects most preemies between 24-26 weeks gestation but rarely affects them beyond 33-34 weeks gestation. There are many different stages of this condition, and the prescribed treatment will depend on its severity, and can include laser surgery or cryosurgery. Necrotizing Enterocolitis (NEC) This condition occurs when a portion of the newborns intestine develops poor blood flow that can lead to infection in the bowel wall. Treatment includes intravenous feeding and antibiotics. Only in severe cases is an operation considered necessary. Sepsis This is a medical condition where bacteria enter the blood stream. Sepsis often brings infection to the lungs and can result in pneumonia. Treatment involves antibiotics.

Diagnostic test: Fibronectin (fTN) test,If you have signs of preterm labor, your provider may want you to have the fFN test. Its a protein that your body makes during pregnancy.ThefFN test is like a Pap smear. It checks to see how much fFN is in your vagina. If the test shows you dont have any fFN, you probably wont have your baby for at least another 2 weeks. Treatment: Progesterone. This is a hormone thats normally present in the body. Treatment with progesterone during pregnancy may help reduce the risk of giving birth early. Cerclage. This is a stich that your provider puts in your cervix. The stich may help keep your cervix closed so that your baby isnt born too early. Your provider removes the stich at about 37 weeks of pregnancy. A cerclage is only used for certain women. For example, if you have a condition called cervical insufficiency, you may need a cerclage. If you have preterm labor, your provider may give you treatments to try to stop your contractions and help prevent health problems in your baby. These include: Corticosteroids. These medicines speed up your babys lung development. They also greatly reduce the risk ofhealth problems in your baby, like respiratory distress syndrome and intraventricular hemorrhage.

 Tocolytics. These medicines may postpone labor, often for just a few days. This delay may give you time to get treatment with corticosteroids and arrange to have your baby in a hospital with a neonatal intensive care unit (NICU). This is part of a hospital that takes care of sick newborns. Magnesium sulfate. This medicine may help reduce the risk for cerebral palsy in premature babies. However, magnesium sulfate shouldnt be used for more than 5 to 7 days. Using this medicine longer than that may lessen the amount of calcium in your growing baby and lead to bone problems.

Reference: http://americanpregnancy.org/labornbirth/complicationspremature.htm http://www.babycenter.com/0_preterm-labor-and-birth_1055.bc?page=2 http://www.webmd.com/baby/premature-labor http://pathophysiology-tlc.blogspot.com/2011_06_01_archive.html