1. Pretem Labor
Ramzy Nakad, MD

2. Preterm Birth
Definition: Birth that occurs prior to completion of 37 weeks of gestation.
Preterm birth is the leading cause of neonatal mortality and the most common reason for antenatal hospitalization .
In the United States, approximately 12% of all live births occur before term, and preterm labor preceded approximately 50% of these preterm births.

3. Preterm Birth
Account for approximately 70% of neonatal deaths and 36% of infant deaths as well as 25–50% of cases of long-term neurologic impairment in children.
Estimated annual cost of preterm birth in the United States to be $26.2 billion or more than $51,000 per premature infant.

4. Preterm Birth Classified into two main categories.
Spontaneous: Approximately 40-50% are due to spontaneous preterm labor with intact membranes and 25-40% due to preterm premature rupture of the membranes.
Indicated: Deliberate intervention for variety of maternal or obstetric indications 20-30%.

5. Preterm Labor
Definition: Cervical change before 37 weeks of gestation due to regular contractions.
Causes ?!?!?!?!

7. Pretem Labor: Risk Factors Multifetal gestation Prior preterm birth
Preterm uterine contractions
Premature rupture of membranes

8. Pretem Labor: Risk Factors Behavioral
. Low maternal pre-pregnancy weight
. Smoking
. Substance abuse
. Short inter-pregnancy interval

9. Pretem Labor: Risk Factors: Vaginal bleeding Urinary tract infections
Genital tract infections
Periodontal disease

10. Prediction of Preterm Labor
Recognize the signs and symptoms:
. Menstrual-like cramps
. Low, dull backache
. Abdominal/ Pelvic pressure
. Increase or change in vaginal discharge.

11. Prediction of Preterm Labor
Cervical change:
Short cervix detected by ultrasound has the most value with people that are high risk patients (had a previous preterm delivery or have an anatomic defect of the crevix).
Early dilation and effacement of the crevix

12. Prediction of Preterm Labor
Other modalities that showed no benefit in improving outcomes of pregnancy in asymptomatic women:
FFN
Bacterial vaginosis
Home uterine contraction monitoring

13. Prevention of Preterm Labor
Historically nonpharmacologic interventions such as bed rest, abstention from intercourse and hydration were recommended; Evidence for the effectiveness of these interventions is lacking, and adverse effects have been reported.

14. Prevention of Preterm Labor
There are currently no uniformly effective interventions toprevent preterm labor , regardless of risk factors.

15. Prevention of Preterm Labor
Treatments that have been proved to affect outcome
- 17OH caproate progesterone for patients with history of preterm delivery.
- Progesterone for short cervix
- Antenatal corticosteroids
Betamethasone or Dexamethasone
- Targeted use of magnesium sulfate for fetal neuroprotection.

16. Evaluation of a Patient With Suspected Preterm Labor
History & Physical
Place patient on the external monitor
Ultrasound
Cervical evaluation
- if PPROM use sterile speculum exam
Collect cultures including GBS, GC and perform a wet mount to rule out BV.

17. Management of Patients with Preterm Labor
Purpose in treating preterm labor is to delay delivery if possible until fetal maturity is attained.
Corticosteroids up until 34 weeks.
Tocolysis: Stopping contractions.
Magnesuim Sulfate for neuroprotection up until 32 weeks.
Possible amniocentesis if infection is suspected.

19. Contraindications to Tocolysis
Intrauterine fetal demise
Lethal fetal anomaly
Nonreassuring fetal status
Severe preeclampsia or eclampsia
Maternal bleeding with hemodynamic instability
Chorioamnionitis
Preterm premature rupture of membranes*
Maternal contraindications to tocolysis (agent specific)

20. Premature Rupture of Membranes
PROM is the rupture of the chorioamniotic membrane before the onset of labor; happens with about 8% of term pregnancies.

21. Preterm PROM
PPROM, defined as PROM that occurs before 37 weeks of gestation, associated with 30% of preterm deliveries.
Major complication is intrauterine infection.
Consequences of PPROM depend on gestational age.
<22 weeks associated with incomplete alveolar development.

22. PROM; Etiology Infections Smoking; two fold increase Short cervix
Previous preterm labor
Polyhydramnios
Multiple gestations
Threatened abortion

23. Chorioamnionitis Fever > or = 100.5 Fundal tenderness
Tachycardia ( maternal and fetal)
Treatment is antibiotics and prompt delivery

24. ROM diagnosis
Nitrazine test, amniotic fluid PH is above 7.1 turns blue
Fern test
Pooling
Ultrasound?role
Carmine dye

27. Evaluation and management
History and Physical exam
Sterile speculum exam, collect vaginal cultures. GC-C, GBS.
Ultrasound