Preterm Labor

Dr.H.M.Hatta Ansyori SpOG(K) Sriwijaya University Faculty of Medicine

Definition
Preterm labor is the presence of contractions of sufficient strength and frequency to effect progressive effacement and dilation of the cervix between 20 and 37 weeks' gestation
WHO

Preterm Labor
Incidence : 6- 10%
Spontaneous PROM : 40-50% : 25-40%

Obstetrically indicated : 20-25%

Preterm Labor
Most mortality and
morbidity is experienced by babies born before 34 weeks.

Major Risks Of Preterm Delivery

Death Respiratory distress syndrome Hypothermia Hypoglycaemia Necrotising enterocolitis Jaundice Infection Retinopathy of prematurity
Goldenberg , Obstetrics &Gynecology 11-2002

Can preterm labor be predicted?

Prediction
1. Assessment of risk factors 2. Vaginal examination to assess the cervical status 3. Ultrasound visualization of cervical length and dilatation 4. Detection of foetal fibronectin in cervicovaginal secretions

1-Risk Factors
While the exact cause of preterm labor is often unknown, there is strong evidence that intrauterine infection may play a role in very early preterm labor.
ACOG NEWS RELEASE November 2002

1-Risk Factors
Bacterial Vaginosis
Bacterial vaginosis increased the risk of preterm delivery >2-fold . Risks were higher for those screened at <16 weeks (odds ratio, 7.55; 95% CI, 1.80-31.65) than those at <20 weeks of gestation (odds ratio, 4.20; 95% CI, 2.11-8.39).
Leitich et al Am J Obstet Gynecol. 2003 Jul;189(1):139 ( Meta-Analysis)

1-Risk Factors
Other Risk Factors
Multiple pregnancy: risk >50% Previous preterm delivery: risk 20- 40% Cigarette smoking: risk 20-30% Cervical incompetence Uterine abnormalities
MOH Sing. Guideline Grade C Recommendation 2001

1-Risk Factors
Other Risk Factors
Young age of mother - less than 16 years of age. Lower socioeconomic class. Reduced body mass index (BMI) - BMI less than 19.0. Antiphosphlipid syndrome. Obstetric complications, including hypertension in pregnancy,antepartum haemorrhage, infection, polyhydramnios, foetalabnormalities.
MOH Sing. Guideline Grade C Recommendation 2001

2-Vaginal examination

Digital examination is the traditional method used to detect cervical maturation, but quantifying these changes is often difficult.

3-Vaginal U/S
Vaginal ultrasonography allows a more objective

approach to examination of the cervix.

Goldenberg , Obstetrics &Gynecology 11-2002

4-Fibronectin Test
Outcome
Delivery <37 Sensitivity specificity 52% 53% 71% 67% 59% 85% 89% 89%

Delivery <34
Delivery within 1 Week Delivery within 2 Week Delivery within 3 Week

89%
92%

Leitich & Kaider ,BJOG. 2003 Apr;110 , 20:66-70. Meta-Analysis 40 studies

Prevention

Prevention of Preterm Labor

Women at increased risk of preterm delivery may be identified by various risk factors in the obstetric history and treated.
American Academy of Pediatrician & ACOG 1997

17 Hydroxy -Progesterone Caproate

Prophylactic use of 17 hydroxy progesterone caproate to prevent preterm labor revealed a significant decrease in preterm birth . However, it has not successfully inhibited active preterm labor.
Keirse. Br J Obstet Gynaecol 1990;97:149-54. Meta-anlysis of 6RCTs. Meis et al. N Engl J Med. 2003 Jun 12;348(24):2379-85.RCT (19 centers )

Treatment Of Vaginosis
Treatment of asymptomatic abnormal vaginal flora and bacterial vaginosis with oral clindamycin early in the 2nd trimester significantly reduces the rate of late miscarriage and spontaneous preterm birth.
Ugwumadu et al. Lancet. 2003 Mar 22;361:983-8. ) RCT

Diagnosis

Diagnosis
3 criteria to document PTL(20-37w)
1-Regular uterine contractions occur at 4/20 min. or 8/60 min. Plus: progressive change in the cervix.

2- Cervical dilatation > 1 cm 3- Effacement > _ 80%.

American Academy of Pediatrician & ACOG 1997

Vaginal U/S+ Fibronectin Test

Suspected preterm labor with no cervical changes :
Negative fetal fibronectin + Cervical length > 30 mm the likelihood of delivering in the next week is less than 1%. Thus most women with a negative test can safely be sent home without treatment.
Goldenberg , Obstetrics &Gynecology 11-2002

 Inhibition of labor Corticosteroid Antibiotics Others.

Treatment

Inhibition Of Labor
Bed rest :DVT Hydration &sedation Tocolytics

Most Efforts to Prevent Preterm Labor Not Effective

Until effective strategies are found, efforts should be aimed at preventing newborn complications by : Corticosteroids Antibiotics against group B strep Avoiding traumatic deliveries. Delivery in a center with experienced resuscitation teams and neonatal intensive care
ACOG NEWS RELEASE: November 2002

Hydration
Intravenous hydration does not seem to be beneficial, even during the period of evaluation soon after admission, Women with evidence of dehydration may, however, benefit from the intervention.
Stan et al (Cochrane Review 2000). In: The Cochrane Library, Issue 1 2003. Oxford

Is Tocolysis Better Than No Tocolysis For Preterm Labour?

It is reasonable not to use tocolytic drugs, as there is no clear evidence that they improve outcome. However, tocolysis should be considered if the few days gained would be put to good use, such as completing a course of corticosteroids, or in utero transfer
RCOG Guideline Grade A recommendation 2002 (Valid:2005)

Tocolytics
Most authorities do not recommend use of tocolytics at or after 34 weeks' . There is no consensus on a lower gestational age limit for the use of tocolytic agents.
Goldenberg , Obstetrics &Gynecology 11-2002

Choice Of Tocolytic Drug

B Sympathomimetic (Ritodrine) Magnesium sulphate Indomethacin

Nifedipine = Epilate Atosiban= Tractocile

B -Sympathomimetic Agents.
Use of beta-agonists should be restricted to the management of preterm labour between 20 and 35 completed weeks, including women with ruptured membranes. (Grade A)
RCOG Guideline Grade A recommendation 1997

Maintenance Tocolysis Is Not Recommended For Routine Practice. There is insufficient evidence for any firm conclusions about whether or not maintenance tocolytic therapy following threatened preterm labor is worthwhile. Therefore maintenance therapy cannot be recommended for routine practice.
RCOG Guideline Grade A recommendation 2002 (Valid:2005)

Corticosteroids
Antenatal corticosteroids are associated with a significant reduction in rates of RDS, neonatal death and intraventricular haemorrhage, although the numbers needed to treat increase

significantly after 34 weeks' gestation.

RCOG Guidelines : Grade A Recommendation

Corticosteroids
The optimal treatment-delivery interval for administration of

antenatal corticosteroids is
after 24 hours but < 7 days after

the start of treatment.

RCOG Guidelines : Grade A Recommendation

Corticosteroids
Two 12 mg doses of betamethasone given IM 24 hours apart, Or Four 6 mg doses of dexamethasone given IM 12 hours apart (I-A). There is no proof of efficacy for any other regimen.

SOGC Recommendation Jan. 2003

Antibiotics
There is no evidence of clear overall benefit from prophylactic antibiotics for preterm labour with intact membranes on neonatal outcomes.
King & Flenady (Cochrane Review August 2002). In: The Cochrane Library, Issue 1 2003. Oxford: Update Software.

Screening for GB Strep.

ACOG Advises Screening All Pregnant Women for Group B Strep.

ACOG NEWS RELEASE November 2002

Group B Streptococci (GBS) Prophylaxis

All patients in preterm labor are considered at high risk for neonatal GBS sepsis and should receive prophylactic antibiotics regardless of culture status.
Goldenberg , Obstetrics &Gynecology 11-2002

Group B Streptococci (GBS) Prophylaxis

The goal of this strategy is to prevent neonatal sepsis, and not to prevent preterm birth.
Goldenberg , Obstetrics &Gynecology 11-2002

Prophylactic Vitamin K Or Phenobarbital

Have not been shown to significantly prevent periventricular haemorrhages in preterm infants.
Crowther & Henderson-Smart (Cochrane Review Novemb. 2000 ) In:The Cochrane Library, Issue 1 2003. Oxford: Update Software Crowther & Henderson-Smart (Cochrane Review May 2003 ) In:The Cochrane Library, Issue 1 2003. Oxford: Update Software

Goldenberg , May 2003

Conclusions
Various strategies that have been used to prevent or treat preterm labor, haven't proven effective.
Tocolysis should be considered only for 2 days- if needed - for corticosteroids thereby , or in utero transfer to a tertiary center .

Conclusions
If a tocolytic drug is used, ritodrine no longer seems the
best choice.

Conclusions
Other drugs with fewer adverse effects and
comparable effectiveness are now

recommended
Atosiban or nifedipine have been

recommended by RCOG
endomethacin may be used as a 2nd line tocolytic or if there is polyhydramnous

Conclusions
Maintenance tocolytic therapy has no proven effect. It cannot be recommended for routine practice.

Thank You