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Preterm Labour: Introduction and Causes by Humna Anis

Preterm labour is defined as onset of labour before 37 weeks of gestation. It can be spontaneous or indicated. Risk factors include infections, previous preterm births, cervical insufficiency, demographic factors like age and socioeconomic status. Prediction of preterm labour involves testing for fetal fibronectin and ultrasound assessment of cervical length. Repeat vaginal exams are important to monitor progression of preterm labour in the absence of specialized tests.

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Manjunath Vankadari
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192 views19 pages

Preterm Labour: Introduction and Causes by Humna Anis

Preterm labour is defined as onset of labour before 37 weeks of gestation. It can be spontaneous or indicated. Risk factors include infections, previous preterm births, cervical insufficiency, demographic factors like age and socioeconomic status. Prediction of preterm labour involves testing for fetal fibronectin and ultrasound assessment of cervical length. Repeat vaginal exams are important to monitor progression of preterm labour in the absence of specialized tests.

Uploaded by

Manjunath Vankadari
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Preterm Labour

Type to enter a caption.

Introduction and Causes


By Humna Anis
Definition
• Preterm labour is defined by WHO as Onset of
Labour prior to the completion of 37 weeks of
gestation, in a pregnancy beyond 20 weeks of
gestation.

• Preterm labour is considered to be established if


regular uterine contractions can be documented
atleast 4 in 20 minutes or 8 in 60 minutes with
progressive change in the cervical score in the
form of effacement of 80% or more and cervical
dilation>1 cm.
• If uterine contractions are perceived in the
absence of cervical change, the condition is
called “Threatened Preterm Labour”.

• Nearly 50-60% of preterm births occur following


spontaneous labour.

• 30% due to preterm premature rupture of


membranes.

• Rest are iatrogenic terminations for maternal or


fetal benefit.
Pathogenesis
• Preterm labour maybe Physiological or Pathological.

• As parturition nears, the fetal adrenal axis becomes more sensitive


to ACTH and there is an increased production of Cortisol.

This stimulates 17-hydroxylase in the trophoblast resulting in


decreased progesterone secretion.

The reversal of estrogen-progesterone ratio

Increase in Prostaglandin Formation

Initiation of Labour
Classification
• For reasons related to aetiology, outcome and
recurrence risk, preterm births should be divided
into 3 gestational periods:

• Mildly preterm births (32+0 to 36+6 weeks)

• Very Preterm births (28+0 to 31+6 weeks)

• Extremely preterm births (24+0 to 27+6


weeks)
Aetiology and Risk Factors
• Obstetric Complications

• Racial Factors

• Demographic Factors

• Psychological Factors

• Past Obstetric History

• Infection

• Genetic Factors
Obstetric Risk Factors
• Conditions that cause over distension of uterus: Multiple
Pregnancies, Hydramnios.

• Preterm Premature Rupture of Membranes (PPROM)

• Idiopathic Preterm Labour

• Pre eclampsia

• Antepartum Hemorrhage

• Second Trimester bleeding not associated with Placental Causes

• Iatrogenic Preterm Termination for pre-eclampsia, fetal distress,


IUGR, Abruptio Placenta and uterine fetal death.
Racial Factors

• Black women have twice the risk compared to


whites.

This maybe explained by multiple factors like


socioeconomic status, medical disorders and
genetic predisposition.
Demographic Factors
• Women with low BMI and poor maternal weight gain in
pregnancy are at increased risk.

• Age-women younger than 17 and older than 35 yrs.

• Poor education

• Women living alone

• Minimal or no prenatal care

• Low socioeconomic status

• Multiple sexual partners


Psychsocial Factors
• Anxiety

• Stress

• Depression

• Negative life events

• Perception of racial discrimination and domestic violence

• Excessive alcohol intake

• Smoking
Past Obstetric History
• Previous h/o preterm birth (17-20% recurrence risk) or
second trimester pregnancy loss.

• 3 or more abortions (may result in cervical


incompetence)

• DES (diethylstilbestrol) exposure

• Conceptions following IVF

• Cervical incompetence (10-20% second trimester


losses)
Infection
• Result in 50% spontaneous preterm births.

• Asymptomatic bacterial vaginosis

• Trichomonas vaginalis

• Chlamydia trachoma’s

• Ureaplasma Urealyticum

• Mycoplasma hominis

• Asymptomatic bacteriuria

• Systemic Infections like pyelonephritis, pneumonia, acute


appendicitis.
Genetic
• Important component of idiopathic group.

• Single gene polymorphisms of cytokines in


both mother and fetus may be responsible.

• Polymorphisms involving TNF alpha-308, IL-


1Beta and IL-6 have been most consistently
associated with spontaneous preterm labour
and preterm birth.
Clinical Features of Preterm
Labour
• HISTORY:

• Always check the dating of pregnancy by


reviewing menstrual history and prior USG
examinations.

• Vague complaints such as increased discharge,


pelvic pressure or low backache.

• Contractions accompanied by advanced dilation


(>3cm), ruptured membranes or significant
vaginal bleeding.
• EXAMINATION:

• Abdominal examination will reveal the


presence of uterine tenderness, suggesting
abruption or chorioamnionitis.

• Speculum examination may reveal: pooling


of amniotic fluid, blood and/or abnormal
discharge.

• A visual assessment of cervical dilation.


Prediction of Preterm Labour
(Investigations)

• The two most promising markers currently


available are:

1.Fetal Fibronectin levels

2.Ultrasound assessment of cervical length


Fetal Fibronectin (fFN)
• It is an extracellular glycoprotein secreted by the chorionic tissue at
maternal-fetal interface.

• It is present in amniotic fluid, placental tissue and decidua basalis.It


acts as a biological glue which binds blastocyst to endometrium.

• It can be normally present upto 20-22 weeks.

• Therefore presence of fFN between 27-34 weeks can provide


important marker of preterm labour.

• Swabs can be taken from ectocervix or post vaginal fornix. ELISA


with FDC-6 monoclonal Ab is used to detect fFN.

• A cut-off of 50ng/ml is considered positive.


Length of Cervix
• Cervical insufficiency is defined as cervical
changes in absence of uterine contractions.

• Cervix can be assessed visually or by USG.

• A reduction in cervical length of >6mm between


2 Ultrasounds have higher risk.

• Funneling (internal os diameter >= 5mm) is also


independent risk factor.
Repeat Vaginal
Examination

• Repeat in 1-4 hours should be considered


essential in the absence of specialised tests. The
interval between assessments should be guided
by the severity of the symptoms.

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