PRETERM BIRTH

- Defined as birth before 259 days (37 weeks) from the first day of the
first day of the last normal menstrual period or 245 days after
concepcion.
- Chronological categorization of preterm birth is needed for practical
purposes regarding management as follows;
1. previable: < 24 weeks
2. remote from term: 24-32 completed weeks
3. near term: 33-36 weeks
-accurate estimation of preterm birth rate is however difficult due to
variation of reporting.
-Prematurity is still the most common underlying cause of perinatal and
infant mortality
- Ten years data on survival rates (%) based on age gestation (AOG) and
birth weight at delivery are: at least 60% between 28-31 weeks AOG and
> 85% between 32-36 weeks AOG; and at least 50% between 10001499g and> 70% at 1500-1999g at birth
- Approximate health care cost for a preterm newborn in the intensive
care unit (ICU) is P 7,000-15,000/ day.

Definition:
Preterm labor-is defined as regular contractions associated with
cervical change before the completion of 37 weeks of gestation.

Preterm birth is before 259 days (37 weeks) from the first day of
the last normal menstrual period or 245 days after conception
Premature- refers to neonate that has the function expected of a
newborn with age of gestation less than 37 weeks. This includes the
problem of underdeveloped organ functions including pulmonary
function.
Spontaneous Preterm Birth- includes preterm labor with intact
membranes, preterm prelabor rupture of membranes (PPROM), preterm
cervical effacement or insufficiency, and some instances of uterine
bleeding of uncertain origin.
Indicated preterm birth- comprises preterm births that are
medically initiated because of maternal compromise.

REASONS FOR PRETERM DELIVERY

4 MAIN DIRECT REASONS
1. Delivery for maternal or fetal indications in which labor is induced or
the infant is delivered by prelabor cesarean delivery.
2. Spontaneous unexplained preterm labor with intact membranes.
3. Idiopathic preterm premature rupture of membranes (PPROM)
4. Twins and higher-order multifetal births.

ANTECEDENTS AND CONTRIBUTING FACTORS

-Threatened Abortion
Vaginal bleeding in early pregnancy is associated with increased adverse
outcomes later.
-Lifestyle factors
Cigarette smoking, inadequate maternal weight gain, and illicit drug use
have important roles in both the incidence and outcome of lowbirthweight neonates.
-Racial and Ethnic Disparity
Black, African American, and Afro-caribbean are consistently reported
to be at higher risk of preterm birth.
-Work during pregnancy
Working long hours and hard physical labor are probably associated with
increased risk of preterm birth.
-Genetic factors
Recurrent, familial, and racial nature of preterm birth have produced
conflicting results, however some studies implicated immunoregulatory
genes in potentiating chorioamnionitis in cases of preterm delivery due
to infection.
-Periodontal disease
Gum inflammation is a chronic anaerobic inflammation that affects
many pregnant women.
-Birth Defects
Associated with preterm birth and low birthweight

-Interval between pregnancies and preterm birth

Short intervals between pregnancies have been known for some time to
be associated with adverse perinatal outcomes.
-Prior preterm birth
A woman whose first delivery was preterm was increased threefold
compared to mother whose first delivery was term.
-Infection
Infection trigger preterm labor by activation of the innate immune
system. 2 common microorganisms, ureaplasma urealyticum and
mycoplasma hominis.
-Bacterial vaginosis
In this condition , normal, hydrogen peroxide-producing, lactobacilluspredominant vaginal flora is replaced with anaerobes that include
Gardnerella vaginalis, Mobiluncus species and mycoplasma hominis.

Recommended Screening Strategies to Prevent Preterm Birth

1. no current data support use of home uterine- activity monitoring or
bacterial vaginosis screening.
2. Screening for risk of preterm labor, other than historical risk factors ,
is not beneficial in the general obstetrical population
3. Sonography to determine cervical length and /or fetal fibronectin level
measurement may be useful in determining women at risk for preterm
labor. However , their value may rest primarily with their negative
predictive value given the lack of proven treatment options.

DIAGNOSIS
-Pt. symptoms
Criteria
1. contractions of four in 20 minutes or eight in 60 minutes plus
progressive change in cervix
2. Cervical dilatation greater than 1 cm
3. Cervical effacement of 80% or greater.
-Cervical Changes
Cervical dilatationPrenatal cervical examinations are neither beneficial nor harmful
Cervical Length=
The mean cervical length at 24 weeks was approximately 35mm, and
those women with progressively shorter cervices experienced increased
rates of preterm birth.
Incompetent CervixCervical incompetence is a clinical diagnosis characterized by recurrent,
painless cervical dilatation and spontaneous midtrimester birth in the
absence of spontaneous membrane rupture, bleeding, or infection.
-Ambulatory Uterine Monitoring
An external tocodynamometer belted around the abdomen and
connected to an electronic waist recorder allows a woman to ambulate
while uterine activity is recorded.

-Fetal Fibronectin
this glycoprotein is produced in 20 different molecular forms by a
variety of cell types, including hepatocytes, fibroblast, endothelial cells
and fetal amnion.
A positive value for cervical or vaginal fetal fibronectin assay even as
early as 8-22 weeks, has been found to be powerful predictor of
subsequent preterm birth.

PREVENTION OF PRETERM BIRTH

-Progesterone use
-cervical cerclage
Management of preterm rupture of membranes and preterm labor
--despite the numerous management methods proposed , the incidence of
preterm birth has changed little over the past 40 years.

Recommended Management of Preterm Labor

1. Confirmation of preterm labor
2. For pregnancies less than 34 weeks in women with no fetal or
maternal indications for delivery, close observation with
monitoring of uterine contractions and fetal heart rate is
appropriate. Serial examinations are done to assess cervical
changes
3. For pregnancies less than 34 weeks, costecosteriods are given foe
enhancement of fetal lung maturation

4. Consideration is given for maternal magnesium sulfate infusion for

12 to 24 hours to afford fetal neuroprotection
5. For pregnancies less than 3 weeks in women who are not in
advance labor, some practitioners believe it is reasonable to
attempt inhibition of contractions to delay delivery while the
women are given corticosteroid therapy and group B streptococcal
prophylaxis.
6. . For pregnancies at 34 weeks or beyond, women with preterm
labor are monitored for labor progression and fetal well-being
7. For active labor, an antimicrobial is given for prevention of
neonatal group B streptococcal infection.

POSTERM PREGNANCY
-post term, prolonged, postdate and post maturity are often used
interchangeably to pregnancies that exceed a duration considered to be the the
upper limit of normal ( that is EDD) .
-postmaturity -is used to described an infant with reconizable clinical
features indicating a pathologically prolonged pregnancy.
-postdate refers to the age of pregnancy that has gone beyond the EDD ( 40
weeks) but less than 42 weeks.
MATERNAL, FETAL AND NEONATAL RISKS AND COMPLICATION
Maternal risk associated with prolonged pregnancies :
-operative delivery (inc CS rates because of macrosomia, failure of
induction of fetal distress.

infection and hemorrhage due to prolonged labor.

Considrable psychological morbidity passed EDC maternal anxiety.

Fetal and Neonatal risks and complications:
-macrosomia and possible fetal trauma due to shoulder distocia.
-fetal hypoxia (distress and death)
-oligohydramnios and associated cord accidents during labor /

delivery.
-meconium aspiration syndrome and and neonatal pneumothorax.
-intrauterine growth restriction (IUGR)
-postmaturity syndrome.
PATHOPHYSIOLOGY
-postmaturity syndrome is a specific syndrome of IUGR
associated with prolonged gestation. Fetuses are characterized by decreased
amount of subcutaneous fats and wrinkled skin.
-they also have long hair and nails
-skin may have greenish/yellowish staining
-they are generally fragile
-poorly tolerant of labor (intolerant to labor )
-frequently acidotic at birth.
-advanced maturity because the infant is open-eyed, unusually alert,
and appears old and worried looking.
PLACENTAL DYSFUNCTION-(clifford-1994) attributed postmaturity syndrome to placental
senescence.
-(smith and baker-1999) that placental apoptosis-programmed
celldeath- was significantly inc. at 41 to 42 weeks.
FETAL DISTRESS AND OLIGOHYDRAMNIOS
-(leveno and associates -1984)-reported that both fetal jeopardy and fetal
distress were the consequence of cord compression associated with
oligohydramnios.
-abnormalities electronic fetal monitoring were also due to oligohydramnios,
utero
placental insuffeciency, cord occlusion.
MANAGEMENT PRINCIPLES
Patient counseling-management option should be discussed thoroughly with the pt
and her relatives.
Antepartum Evaluation and Management
-establishment of accurate AOG
-modes of antenatal Monitoring
-pelvic examination
-antenatal fetal surveillance

CONCLUSIONS:
1.
definite/accurate assignment of AOG.
2.
Discussion of risk and benefits of management option.
3.
Conservative management-intensive fetal monitoring
4.
several methods maybe used for active induction of labor.
5.
Knowledge on the pathophysiology of the inherent problems associated with
posterm pregnancy will significantly guide us in planning our management
strategies for optimum outcome in the antenatal, labor, intrapartal and early
neonatal period.
FETAL GROWTH RESTRICTIONS
-fetal growth potential is determined genitically
NORMAL FETAL GROWTH-human fetal growth is characterized by sequential patterns of tissue
and organ growth, differentiation and maturation that are determined by maternal
provision of substrate, placental transfer of these substrate and fetal growth
potential governed by genome.
THE SMALL FETUS
-below 10th percentile (SGA)
-designated as suffering from fetal growth restriction.
Metabolic abnormalities- (neconomides and necolaidaes-1989)- found that
the major cause of hypoglycemia in SGA fetus was reduced supply rather than
increased fetal consumption or diminished fetal glucose production.
Morbidity and mortality-associated with substantive perinatal morbidity and
mortality.
accelerated maturation- fetus responds to a stressed environment by incresing
glucocorticoid production, which leads to earlier or accelerated fetal lung
maturation. eg.HPN.PREECLAMPSIA.
SYMETRICAL V S ASYMETRICAL GROWTH RESTRICTION
-symetrical proportionately small,( early insult, decrease in cell number)

- asymetrical had disproportionately lagging abdominal growth.

--preferentially protected from the full effects of the growth-retarding
stimulus-eg preecclamsia, fetal distress, operative intervention and low apgar
score.
RISK FACTORS
-constitutsionally small mothers
-poor maternal nutrition
-social deprivation
-fetal infection
-congenital malformations
-chromosomal aneuploides
-disorder of cartilage and bone
-teratogens
-vascular disease
-renal disease
-chronic hypoxia
-anemia
-placental and cord abnormalities
-multiple fetuses
-antiphospholipid antibody syndrome
-extrauterine pregnancies
IDENTIFICATION OF FETAL GROWTH RESTRICTION
-definitive diagnosis frequently cannot be made until delivery
uterine fundal height-serial measurement, (bet 18 and 32 weeks
coincide with weeks of gestation.
Ultrasonic measurement-combining head, abdomen, and femur
dimention should in theory enhance the accuracy of predictions of fetal size.
Abdominal circumference -impt. Anatomical marker of growth
restriction.
Doppler velocimetry-absent or reversed end diastolic flow -has been
uniquely associated with growth restriction.
MANAGEMENT
-once suspected, efforts should be made to confirm the diagnosis,
asses fetal condition and evaluate for anomalies.
-near term,, usually fetus cannot tolerate labor.
-remote from term- AFI and fetal surveillance should be done, normal

pregnancy is allowed to continue.

Labor and delivery-fetalgrowth restriction is commonly the result of
placental insuffeciency due to faulty maternal perfusion, ablation of functional
placenta or both.-and these could be aggrevated by labor.
MACROSOMIA- above the 90th percentile
-commonly associated with maternal diabetes
pathophysiology
-maternal hyperglycemia believe to induce fetal hyperglycemia and
hyperinsulinemia.

the incidence of macrosomia is 3-7 fold more frequent in postdates than in

term delivery.
Diagnosis -3 methods
-clinical fundic height in conjunction with leopolds maneuver
-maternal history
-sonographic
MANAGEMENT-manage expectantly, the pts obstetrics history and risk
profile, the clinical pelvimetry findings, the progress of labor and other pertinent
factors should be taken into account when deciding on the mode and timing of
delivery.