OBSTETRICS AND GYNECOLOGY

Preterm Labor
and birth

CSU JI HANNA B. BALIGOD

DEFINITION OF TERMS

CAUSES

DIAGNOSIS

PREVENTION

MANAGEMENT
● PRETERM PREMATURE RUPTURE OF
MEMBRANES
● PRETERM LABOR WITH INTACT MEMBRANES
 DEFINITION OF TERMS
WITH RESPECT TO GESTATIONAL AGE
Preterm Threshold of Viability
● Neonate <37 weeks but ● bet 20 and 26 weeks aog
● lower limit of fetal maturation
>20weeks compatible with extrauterine
survival

Early Term Late Term

Early Preterm ● born at 37 to 38 6/7 weeks age ● 41 0/7 weeks through 41 6/7
● neonate born before 33 6/7 of gestation weeks
weeks

Late Preterm Term

● born 39 to 40 6/7 weeks age of
● neonate born between 34 to gestation
36 weeks age of gestation
DEFINITION OF TERMS
WITH RESPECT TO SIZE

Small for gestational age / Fetal growth restriction

/ Intrauterine growth restriction
● birthweight is <10th percentile for gestational age

Large for gestational age

● birthweight is >90th percentile for gestational age

Appropriate for gestational age

● birthweight between 10th and 90th percentile
DEFINITION OF TERMS
WITH RESPECT TO WEIGHT

Low birth weight

● weighs 1500g to 2500g

Very Low Birth Weight

● bet 1000g to 1500g

Extremely Low Birth Weight

● Between 500 and 1000 g
 CAUSES OF PRETERM BIRTH

SPONTANEOUS IDIOPATHIC DELIVERY FOR TWINS AND

UNEXPLAINED PRETERM MATERNAL OR . HIGHER-ORDER
PRETERM LABOR PREMATURE FETAL INDICATIONS MULTIFETAL BIRTH
WITH INTACT RUPTURE OF
MEMBRANES MEMBRANES
 CAUSES OF PRETERM BIRTH
Uterine Distention
● Multifetal distention, hydramnios
● Contraction-associated proteins
○ influenced by stretch
● Gastrin-releasing peptides
○ promote myometrial contractility
● Stretch-induce K channel (TREK-1)
○ up regulated during gestation
○ downregulated in labor
SPONTANEOUS ○ Potential role in uterine relaxation during pregnancy
UNEXPLAINED ● Excessive uterine stretch
PRETERM LABOR ○ early activation of the placental-fetal endocrine cascade
WITH INTACT ○ resultant early rise in maternal corticotropin releasing
MEMBRANES hormone and estrogen levels can further enhance the
expression of myometrial CAP genes
 CAUSES OF PRETERM BIRTH
Maternal-Fetal stress
● Stressors:
○ nutrient restriction
○ diabetes
○ obesity
○ infection
○ hypertension
○ Psychological duress

SPONTANEOUS
UNEXPLAINED
PRETERM LABOR
WITH INTACT
MEMBRANES
 CAUSES OF PRETERM BIRTH
Cervical Dysfunction
● cervical dysfunction of either the epithelia or stromal
extracellular matrix
● Defect at the stroma or cervical epithelium
○ allows ascending infections that may lead to PPROM
● Group B streptococcus
○ secrete hyaluronidase
■ degrades hyaluronic acid in the cervicovaginal
epithelia to aid bacterial ascension
SPONTANEOUS
UNEXPLAINED
PRETERM LABOR
WITH INTACT
MEMBRANES
 CAUSES OF PRETERM BIRTH
Infection
● Intraamniotic infection
○ primary cause of preterm labor
○ accounts for 25 to 40 percent of preterm births
● Bacteria can gain access to intrauterine tissues through:
○ Transplacental transfer of maternal systemic infection
○ Retrograde flow of infection into the peritoneal cavity
(fallopian tubes)
○ Ascending infection with bacteria from the vagina and
SPONTANEOUS the cervix (Most common)
UNEXPLAINED ● G. vaginalis, Fusobacterium spp, Mycoplasma hominis, and
PRETERM LABOR U. urealyticum
WITH INTACT
MEMBRANES
 CAUSES OF PRETERM BIRTH
Infection

SPONTANEOUS
UNEXPLAINED
PRETERM LABOR
WITH INTACT
MEMBRANES
 CAUSES OF PRETERM BIRTH
Preterm Premature Rupture of Membranes
● Major predisposing events:
○ intrauterine infection
○ oxidative stress-induced DNA damage
○ premature cellular senescence

IDIOPATHIC
PRETERM
PREMATURE
RUPTURE OF
MEMBRANES
 CAUSES OF PRETERM BIRTH

○ Increased apoptosis or necroptosis of membrane

cellular components
○ greater levels of specific proteases in membranes and
amniotic fluid
Infection
○ The inflammatory response
■ lead to membrane weakening

IDIOPATHIC
PRETERM
PREMATURE
RUPTURE OF
MEMBRANES
 CAUSES OF PRETERM BIRTH
Pathologic Uterine distention or stretching
Average length of gestation
● Twins=36 weeks
● Triplets =33 weeks
● Quadruplets =31 weeks

MULTIFETAL
PREGNANCY
 Contributing Factors
Pregnancy factors Genetic Factors
● Threatened abortion ● immunoregulatory genes potentiates
● Placenta previa/ abruptio placenta chorioamnionitis
● birth defects

Periodontal Disease
Lifestyle factors
● bacteria that cause inflammation in the
● cigarette smoking
gums can actually get into the bloodstream
● inadequate material weight gain
and target the fetus, potentially leading to
● illicit drug use
premature labor and low-birth-weight
● Underweight and Obese mothers
(PLBW) babies.
● Young or advanced maternal age
● Poverty
● Short Stature
● Vitamin C deficiency Coitus
● release of PG
 Contributing Factors
Interval between pregnancies Bacterial vaginosis
● <18 months and >59 months ○ causes vaginitis or cervicitis and then
progresses to inflammation of all
fetal membranes, it can in turn cause
premature rupture of membranes
and labor
○ Foul-smelling “fishy” vaginal odor
Prior preterm birth
● most important risk factor
● >3x for women whose first neonate was born
preterm
● influenced by:
○ frequency
○ severity
○ order
Diagnosis
SYMPTOMS
● Differentiate false and true labor contractions
● Braxton hicks contractions
○ irregular, non-rhythmic uterine contraction which does not effect
a change in the cervix
● True Preterm Labor
○ >6 contractions/ hr and cervical dilatation is 3cm or greater
and/or effacement is >80%
● Pelvic pressure
● menstrual-like cramps
● watery vaginal discharge
● lower back pain
Diagnosis
Preterm Premature Rupture of Membranes
● Presence of pooling at the posterior fornix, free flowing fluid (clear or
meconium stained) from the cervical canal
● pH determination (vaginal pH=4.5 to 5.5) versus amnionic fluid (7.0 to
7.5)
● Presence of arborization or ferning
● Nitrazine test for presence of amniotic fluid changes the color of the
test paper
● Detection of alpha-feto protein in the vaginal vault
● Identification of carmine indigo dye
Diagnosis
CERVICAL CHANGE
● Asymptomatic cervical dilation after midpregnancy
○ risk factor for preterm delivery
● 2-3cm cervical dilation before 34 weeks
○ predictor of increased preterm delivery risk
● prenatal cervical examination in asymptomatic women are neither
beneficial not harmful

AMBULATORY UTERINE MONITORING

● external tocodynamometer
○ allows women to ambulate while uterine activity is recorded
● use is discouraged
○ expensive
○ time consuming
○ does not reduce preterm birth rates
Diagnosis
FETAL FIBRONECTIN
● Function: intercellular adhesion during implantation and in
maintenance of placental adherence to uterine decidua
● fFn detection in cervicovaginal secretions before membrane rupture
○ marker for impending preterm labor
○ >50ng/ml
● ACOG does not recommend screening with fFn tests
● It’s use in conjunction with cervical length measurement
Diagnosis
CERVICAL LENGTH MEASUREMENT
● Progressively shorter cervical canals assessed sonographically are
associated with increased rates of preterm birth
● Safe, highly reproducible, and more sensitive than transabdominal
● Transvaginal cervical sonography
○ not affected by maternal obesity, cervix position, or shadowing
from fetal presenting part
○ performed after 16 weeks AOG
○ limited to singleton gestations
● Indications:
○ history of prior spontaneous preterm birth
Diagnosis
CERVICAL LENGTH MEASUREMENT
• Cervical length screening for women with or without prior preterm
birth
• (+) history- assessed every 1-2 weeks from 16 to 24 weeks of
gestation
• High risk- initial exam at 15-16 weeks
• Lower risk- exam at 18-20 weeks
• With uterine anomalies
• 24 weeks AOG or mid trimester
• Cut-off length
• Asymptomatic singleton CL at 24wks
■ 25mm
• Symptomatic singleton beyond 30 wks
■ <15mm
• Routine measurement for multiple pregnancy is not recommended
 Prevention
Cervical Cerclage
Prevent preterm birth
● history of recurrent midtrimester losses;
diagnosed with cervical insufficiency
● short cervix identified sonographically
● “rescue” cerclage in women with threatened
preterm labor
ACOG recommendation
● women with singleton pregnancy, prior
spontaneous preterm birth before 34 weeks,
cervical length <25mm, and < 24 weeks AOG
 Prevention
Cervical Cerclage
Rationale for use of cerclage:
● to provide mechanical support to the cervix
● To prevent shortening and dilatation
● to prevent or postpone preterm delivery
Contraindications:
● Fetal anomaly incompatible with life
● Intrauterine infection
● Active bleeding
● Active preterm labor
● Ruptured membranes
● Fetal demise
 Prevention
Cervical Cerclage
History-indicated cerclage
• history of 3 or more previous preterm deliveries
and/or 2nd trimester losses.

UTZ-indicated cerclage
• history of 3 or more previous preterm deliveries
and/or 2nd trimester losses who, on TVS
surveillance were found to have CL of 25mm or
less before 24 weeks gestation
 Prevention
PROPHYLAXIS WITH PROGESTOGEN COMPOUNDS
● Indication
○ singleton pregnancy
○ history of prior spontaneous preterm
birth at <37 weeks gestation
○ Short cervix (<1.5 cm) is a secondary
major indication
● Vaginal progesterone (100-200mg/ day,
○ high uterine bioavailabitily
● Intramuscular (17α-hydroxyprogesterone
caproate)
○ Given at 16 weeks until less than 21
weeks gestation, continued until less
than 37 weeks or delivery whichever
comes first
○ Oral Micronized progesterone 200mg ODHS
 Prevention
Cervical Pessary
• Singleton pregnancies
• May be beneficial in certain populations
• Twin Gestation at 16-24weeks
• not recommended because it does not
prevent spontaneous preterm birth or
improve perinatal outcome.
• With supplemental vaginal progesterone
Management of Preterm Labor

Delivery
• Episiotomy in the absence of relaxed vaginal outlet

Corticosteroid
• Single course of corticosteroid for pregnant women between 24-34 weeks who are
at risk for delivery within 7 days
• Betamethasone-12 mg/IM q24h x 2 doses
• Dexamethasone-6mg/IM q12h x 4 doses
• Single RESCUE DOSE for women whose prior course was administered 7 days
previously and who were <34 weeks AOG (ACOG)
Management of Preterm Labor
Antibiotics
● Did not reduce the preterm birth

Bed rest
● rarely indicated and ambulation should be considered in most cases

Cervical Pessaries
● Conflicting published report and lack of FDA approved pressary for the indication of
preterm birth prevention

Rescue cerclage
● Greater delay in deliver in cerclage group compare to those assigned in bed rest
Management of Preterm Labor

MAGNESIUM SULFATE FOR NEUROPROTECTION

● Very-Iow-birthweight neonates
○ reduced incidence of cerebral palsy at 3 years
● 6g bolus over 20-30min followed by maintenance infusion of 2g per hour
● Given to women at risk for imminent delivery from 24-33 weeks AOG
Management of Preterm Labor

BETA-ADRENERGIC AGENTS
● Mechanism of action
○ Attachment of drug to β2-adrenergic receptor
○ Activation of adenyl cyclase
○ Increased cAMP
○ Decreased myosin light chain kinase activity Interference with actin/myosin
interaction
○ Prevents activation of the contractile proteins and uterine muscle cell
contractions
● Caution in patients with
○ Major antenatal hemorrhage
○ Heart disease
○ Gestational or established diabetes mellitus
○ Tricyclic/amine oxidase inhibiting antidepressant drugs.
Management of Preterm Labor

BETA-ADRENERGIC AGENTS
● Maternal side effects
○ Cardiac arrhythmias
○ Pulmonary edema
○ Hyperglycemia
● Fetal side effects
○ Elevation of fetal heart rate
○ Accelerated Lung maturation
○ fetal and neonate hypoglycemia
○ Improvement of uteroplacental blood flow
Management of Preterm Labor

BETA-ADRENERGIC AGENTS
● Ritodrine
○ Intravenous route:
■ Started at 50 µg/min and increased every 20 minutes by 50 µg/min
until contractions are inhibited or serious side effects occur.
■ Once labor is inhibited, the infusion rate may be continued for 60
minutes.
■ infusion rate is decreased by 50 µg/min every 30 minutes to the lowest
rate that sustains labor inhibition and arbitrarily maintained for 12-24
hours.
○ Intramuscular injection:
■ ff intravenous infusion
■ deltoid or gluteus muscle
■ 10 mg/hour
○ Oral :
■ 10 mg tablet
■ maximum dose : 120 mg/day
Management of Preterm Labor

BETA-ADRENERGIC AGENTS
● Terbutaline
○ Intravenous route:
■ Started at 5-10 µgm/min then increased every 20 minutes by 5-10
µg/min to a peak rate of 25 µg/min
○ Subcutaneous administration:
■ 0.25 mg over 20-60 minutes.
○ Oral :
■ 30 mg/day at 5 mg every 4 hours

● Salbutamol
○ Intravenous route:
■ Given at 10 µg/min, gradually increasing to 45 µg/min
Management of Preterm Labor

BETA-ADRENERGIC AGENTS
● Isoxsuprine
○ Inhibition of acute phase preterm labor
■ IV infusion 0.2-0.5 mg/min until contractions cease
○ Maintenance therapy
■ IM or PO q3-8 hrs/day q3-8hrs
○ Threatened abortion
■ 30mg/pill 1-3 pill/day q3-8 hrs
○ Preterm labor prevention or prophylaxis
■ 1-2pills/day, starting at 2nd mo. of pregnancy and continuing for >/=
mo.
Management of Preterm Labor

Magnesium Sulfate
• Mechanism of action
• Calcium antagonist
• Intravenous magnesium sulfate
• given s a 4-g loading dose
• Continuous inusion of 2 g/hr
• prolonged used:
• one thinning and fractures of the fetus exposed for > 5-7days
Management of Preterm Labor
Recommended
Tocolytic Drug Remarks
Dosage Regimen
I
Not to be used
concurrently with
30mg LD, then 10-20mg PO
magnesium sulfate
Nifedipine q4-6 hrs
most effective at delaying
Max dose: 180mg/day
delivery

initial bolus of 6.75mg

as effective and
administered over 1 min
efficacious as
followed by an infusion of
Atosiban nifedipine, with
300ug/min for 3 hours,
fewer side effects
then 100ug/min for up to
15-45 hours

Administered per orem or

per rectum dose of use is limited to 24-48
Indomethacin 50-100mg q8h hours d/t risk of
(max/24hr-200mg) oligohydramnios
Management for PPROM
Clinical Chorioamnionitis
• Vaginal delivery
• Fever
○ only reliable indicator
○ >38 °C (Parkland)
• ACOG
○ >39 °C only or
○ 38.0 to 38.9°C and one additional clinical risk factor
■ Low parity
■ Multiple digital examinations,
■ Use of internal uterine and fetal monitors
■ Meconium stained amnionic fluid,
■ GBS and STI
• Treatment
○ Penicillin and Gentamycin
○ + Clindamycin (anaerobes)
○ Cefazolin if mild penicillin-allergic
○ Clindamycin or Vancomycin if sever penicillin-allergic
• Chemoprophylaxis against GBS
○ Penicillin orAmpicillin
Management for PPROM
Antimicrobial therapy
• Expectant management
○ institution of broad-spectrum antibiotics
• prolongation of pregnancy and reduction in infant and maternal morbidity
• Incidence of chorioamnionitis and neonatal sepsis, including Group B streptococcal
sepsis was decreased
• IV:
○ Ampicillin 2 g every 6 hours and Erythromycin 250 mg every 6 hours
• Oral:
○ Amoxicillin 250 mg every 8 hours and enteric-coated Erythromycin 333 mg
every 8 hours to complete a 7 day course
• Co-amoxiclav
○ not recommended because of concerns about necrotizing enterocolitis
• PPROM with HSV
• antiviral theray
• cesarean birth
Management for PPROM
ANTENATAL CORTICOSTEROID TREATMENT
• 24-32 weeks AOG
• Lower rates of RDS, NEC, and IVH, and Neonatal death
• Betamethasone 12mg IM twice in a 24 hour interval
• examethasone 6 mg every 12 hours for 4 doses
• <23 weeks
• A single course of CS in those who are at risk for preterm delivery within 7days
may be considered.
• Rescue course at 34 0/7 weeks
• Multifetal gestation at risk for delivery within 7 days
Management for PPROM
Initial Management
• Evaluate for intrauterine infection and abruptio placenate
• Culture for GBS when expectant management is being considered
• Electronic fetal heart rate monitoring and uterine activity
• identify abnormal fetal heart rate tracings and to evaluate for contractions
• Indications for delivery
• abnormal fetal testing
• evidence of intramniotic infection

Delivery
• Induction of labor with oxytocin
• sufficient period of adequate contractions should be allowed for the latent
phase of labor to progress before diagnosing failed induction and moving to
cesarean birth

• Before 34 0/7 weeks AOG

• managed expectantly if no maternal or fetal contra indications exist
 OBSTETRICS AND GYNECOLOGY

Postterm
pregnancy

CSU JI HANNA B. BALIGOD

DEFINITION OF TERMS

PATHOPHYSIOLOGY
● POSTMATURITY SYNDROME
● PLACENTAL DYSFUNCTION
● FETAL DISTRESS AND OLIGOHYDRAMNIOS
● FETAL GROWTH RESTRICTION

COMPLICATIONS
● OLIGOHYDRAMNIOS
● MACROSOMIA

MANAGEMENT
● Induction Factors
● Management Strategies
● Intrapartum Management
 DEFINITION OF TERMS
Prolonged/ Postterm Estimated Gestational Age
Pregnancy ● first-trimester sonography to be the most
● 42 completed weeks or 294 accurate method to establish or confirm
days or more from LMP gestational age.

Postmaturity
● decribes the infant with clinical features of pathologically
prolonged pregnancy
PATHOPHYSIOLOGY
POSTMATURITY SYNDROME
● Features:
○ Wrinkled, patchy, peeling skin (prominent on palms and soles)
○ Long, thin body suggesting wasting;
○ Advanced maturity in that the infant is open-eyed, unusually alert, and
appears old and worried
○ long nails
● Not technically growth restricted
● Complicates 10 to 20 percent of pregnancy
● Oligohydramnios
○ defined by a sonographic maximal vertical amnionic fluid pocket that
measured ≤1 cm at 42 weeks
PATHOPHYSIOLOGY
POSTMATURITY SYNDROME

Post term Infant Characteristics

○ Newborn emaciated
○ Meconium stained
○ Hair and nails long
○ Dry peeling skin
○ Creases cover soles
○ Limited vernix and lanugo
PATHOPHYSIOLOGY
PLACENTAL DYSFUNCTION
● limited placental capacity due to dysfunctional syncytiotrophoblast
● placental apoptosis
○ significantly greater at 41 to 42 completed weeks compared with that at 36 to
39 weeks

FETAL DISTRESS AND OLIGOHYDRAMNIOS

● cause by cord compression
○ variable decelerations
● Meconium aspiration syndrome.
PATHOPHYSIOLOGY
FETAL GROWTH RESTRICTION
● Stillbirths were more common among growth-restricted newborns who were
delivered after 42 weeks.
COMPLICATIONS
OLIGOHYDRAMNIOS
● Decreased amnionic fluid in any pregnancy signifies increased fetal risk
● The smaller the amnionic fluid pocket, the greater the likelihood that there was
clinically significant oligohydramnios.
● Oligohydramnios cause higher incidence of fetal distress during labor.
● AFI < 5cm
● Single deepest pocket <2cm

MACROSOMIA
● The velocity of fetal weight gain peaks at approximately 37 weeks.
● vaginal delivery
○ non-diabetic
MANAGEMENT STRATEGIES
ANTEPARTUM MANAGEMENT
INDUCTION FACTORS
● Induction Factors:
○ A favorable cervix
○ Cervical length ≤3/2.5cm
○ Station of the fetal head
ANTEPARTUM MANAGEMENT
Cervical ripening
● unfavorable cervix and prolonged pregnancies
● prostaglandin gel can be used safely in postterm pregnancies －
● Buscopan is also effective －
● Low dose oxytocin is also given

Membrane Stripping
● membrane “sweeping”
● lowered the frequency of postterm pregnancy (done at 38- 40 weeks)
● Technique
○ Examining finger inserted into Cervix
○ Finger moved in circular fashion inside endocervix
○ Press against internal cervical os
○ Separates membranes from lower uterine segment
● DRAWBACKS: Pain, vaginal bleeding, irregular contractions
ANTEPARTUM MANAGEMENT
INDUCTION FACTORS
INTRAPARTUM MANAGEMENT
● Fetal heart rate and uterine contractions must be monitored
● Amniotomy
○ Aids in identification of thick meconium
○ problematic because further reduction in fluid volume can enhance the
possibility of cord compression
● Amnioinfusion
○ Does not prevent meconium aspiration
○ reasonable treatment approach for repetitive decelerations
● ACOG does not recommend
● routine intrapartum suctioning
○ not recommended by ACOG
○ depressed newborn has meconium stained fluid, then intubation is carried out
(laryngeal toilette)
THANK
YOU