Preterm Birth

Present by:
Dr.Worapa Asavaritikrai
Health Promotion Center Region 4
Objective

• Definition

• Risk factors

• Diagnosis

• Treatment
Definition of Preterm Birth

• A birth that occurs before 37 completed

weeks of gestation (<259 days)

• Late preterm births, defined as 34-36+6

weeks of gestation (~ 75% of all
preterm birth)
36-2
36-3
SURVIVAL RATE OF INFANTS
RAMATHIBODI HOSPITAL (2000-2008)
36-8
 Reasons for preterm delivery

• 4 main direct reasons:

– Maternal or fetal indications
– Spontaneous unexplained preterm labor with
intact membranes
– Idiopathic preterm premature rupture of
membranes (PPROM)
– Twins

Cunningham et al, 23rd Ed Williams Obstetrics

Definition of PPROM

• Defined as rupture of the membranes

before labor and prior to 37 weeks of
gestation
 Antecedents & Contributing
Factors

• Threatened Abortion
• Lifestyle Factors
• Racial & Ethnic Disparity
• Work During Pregnancy
• Genetic Factors
• Periodontal Disease
 Antecedents & Contributing
Factors

• Birth Defects
• Interval between Pregnancies & Preterm Birth
• Prior Preterm Birth
• Infection
• Bacterial Vaginosis
Table 36-6
36-10
Prevention of preterm birth

รร่ างแผนการดดูแลการเจจ็บครรภภ์คลอดกร่อนกกาหนด
Clinical Practice Guidelinen of Preterm labor
 Preventions of Preterm
Birth

• Primary Prevention
• Secondary Prevention
• Tertiary Prevention
Primary Prevention
 Preconceptional

• Public educational interventions:

– Increased awareness
– Uterine curettage or endometrial biopsy
– Reduce prevalence of smoking
– Reduce risk of higher-order multiple gestation
– Socioeconomic approach
 During Pregnancy

 Smoking cessation in pregnancy

 Prenatal care
 Periodontal care ??
 Screening of low-risk women
Smoking cessation

A Cochrane review reported that

smoking cessation programmes in
pregnancy successfully reduce the
incidence of preterm birth
(RR 0·84, CI 0·72–0·98)

Lumley J.Cochrane Database Syst Rev 2004

Prenatal Care

High rate of preterm birth in women

who receive no prenatal care than from
the content of care for those who
receive it
Periodontal care

Treatment during pregnency improved

periodontal disease and it is safe, but it
did not significantly alter rate of
preterm birth

Michalowicz BS. N Engl J Med 2006; 355: 1885–94

Screening of low-risk
women

-Screening and treatment of

asymptomatic bacteriuria prevent
pyelonephritis

-Given antibiotic in low-risk does not

reduce this risk of preterm birth

Cunningham et al, 23rd Ed Williams Obstetrics

Secondary Prevention
 Fetal fibronectin testing

• Glycoprotein
• Marker of choriodecidual disruption
• Levels > 50 ng/mL ( >22 weeks) associated
with an increased risk of spontaneous preterm
birth

The Cochrane Library 2009, Issue 2

 Cervical length

• Cervical shortening is a risk factor for preterm

delivery

• Especially useful in asymptomatic women : at 24

wks, a cervical length < 25 mm
Table 36-7
Tertiary Prevention
 Tertiary Prevention

• Early diagnosis of preterm labour

• Treatment of women with acute risk of preterm
birth
 to arrest preterm labour : tocolysis
 antenatal corticosteroid use
 antibiotic for group B streptococcal prophylaxis
Diagnosis of preterm labor

• Regular contractions accompanied by

cervical change at less than 37 weeks

• ACOG 1997 criteria preterm labor:

– Contractions of four in 20 min. or eight in
60 min. + progressive change in the cervix
– Cervical dilatation > 1 cm
– Effacement > 80%.
Threatened preterm labor

Regular contractions without cervical

change
Management of Preterm Labor

• PPROM
• Preterm labor with intact membranes
Table 36-8
 Tocolytic agents

• ACOG 2007 has concluded that tocolytic agents

do not markedly prolong gestation, but may
delay delivery in some women for at least 48
hours
 Tocolytic agents

• Β-Adrenergic receptor agonists

– Ritodrine, Terbutaline
• Magnesium sulfate
• Prostaglandin inhibitors
• Calcium-channel blockers
• Atosiban
• Nitric oxide donors
 Terbutaline
Dose CI Maternal SE Fetal SE

0.25 mg SC every Cardiac Cardiac arrhythmia, Tachycardia,

20 min to 3 h arrhythmia, pulmonary edema, hyperinsulinemia,
(hold for P>120 poorly control MI, hypotension, hyperglycemia,
bpm) thyrotoxicosis or hyperinsulinemia, neonatal
DM antidiuresis, hypoglycemia,
hypokelemia, hypocalcemia,
hypotesion,
myocardial and
septal hypertrophy,
MI

Hearne AE, Nagey DA. Therapeutic agents in preterm labor: tocolytic agents.
Clin Obstet Gynecol 2000;43:787-801
 Magnesium sulfate
Dose CI Maternal SE Fetal SE

4-6 gm bolus Myasthenia Flushing, lethargy, Lethargy,

then 2-3 gm/hr gravis headache, muscle hypotonia, resp.
weakness, diplopia, dry depression,
mouth, pulm edema, demineralization
cardiac arrhythmia with prolong use

Hearne AE, Nagey DA. Therapeutic agents in preterm labor: tocolytic agents.
Clin Obstet Gynecol 2000;43:787-801
 Nifedipine
Dose CI Maternal SE Fetal and
neonatal SE

30 mg Loading Cardiac dis, use Flushing, None note as

Then 10-20 mg caution with headache, yet
q 4-6 hr renal dizziness,
dis,BP<90/50m Nausea ,
mHg, transient
Avoid use with hypotension
MgSo4

Hearne AE, Nagey DA. Therapeutic agents in preterm labor: tocolytic agents.
Clin Obstet Gynecol 2000;43:787-801
 Corticosteroid Therapy

• Enhance fetal lung maturation

• Rescue therapy?
• Betamethasone is superior to Dexamethasone
• Regimens:
– Two doses of Betamethasone 12 mg IM q 24 hrs
– Four doses of Dexamethasone 6 mg IM q 12 hrs
 Group B streptococcus
prophylaxis

• Goal is neonatal sepsis prevention

• Not to prevent preterm birth
Group B streptococcus
prophylaxis

Centers for Disease Control and Prevention, 2002d

Cunningham et al, 23rd Ed Williams Obstetrics
 Recommended Management of
Preterm Labor

• Confirmation of preterm labor

• GA <34 weeks: corticosteroids are given for
enhancement of fetal lung maturation
• GA <34 weeks: reasonable to attempt inhibition of
contractions to delay delivery while given
corticosteroid & group B streptococcal prophylaxis
• GA >34 weeks: monitor for labor progression &
fetal well-being
Thank You