Pre and Post term pregnancy

(Diagnosis &Management)
DEPARTMENT OF OBSTETRICS & GYNECOLOGY
MARRY JOHNSTON HOSPITAL

CHAUDHARY,JITENDRA (PGI)
OBJECTIVES : PRETERM LABOR

• DEFINITION OF PRETERM LABOR

• ETIOLOGY OF PRETERM LABOR
• ETIOPATHOGENESIS OF PRETERM LABOR
• PREDICTORS OF PRETERM LABOR
• DIAGNOSIS
• MANAGEMENT OF PRETERM LABOR
 DEFINITION OF PRETERM LABOR

Preterm labor (PTL) is defined as one where the labor starts before the
37th completed week (< 259 days), counting from the first day of the
last menstrual period. Mortality characteristic of premature infants,
pre-term births were subdivided. Those before 336/7 weeks are
labeled as early preterm, and those occurring between 34 and 36
completed weeks are labeled as late preterm.
 ETIOLOGY OF PRETERM LABOR

• In about 50%, the cause of preterm labor is not known. Often it is multifactorial.
The following are, however, related with increased incidence of preterm labor,
A.History :
There is an increased incidence of preterm labor in cases such as:
(1)Previous history of induced or spontaneous abortion or preterm delivery;
(2) Pregnancy following assisted reproductive techniques (ART);
(3) Asymptomatic bacteriuria or recurrent urinary tract infection;
(4) Smoking habits
(5) Low socioeconomic and nutritional status and
(6) Maternal stress.
(B) Complications in present pregnancy: May be due to maternal, fetal or
placental.
Maternal:
(1) Pregnancy complications: Preeclampsia, antepartum hemorrhage, premature
rupture of the membranes, polyhydramnios;
(2) Uterine anomalies: Cervical incompetence, malformation of uterus;
(3) Medical and surgical illness: Acute fever, acute pyelonephritis, diarrhea, acute
appendicitis, toxoplasmosis and abdominal operation. Chronic diseases:
Hypertension, nephritis, diabetes, decompensated heart lesion, severe anemia, low
body mass index (LBMI);
(4) Genital tract infection: Bacterial vaginosis, beta-hemolytic Streptococcus,
bacteroides, chlamydia and mycoplasma.
Fetal: Multiple pregnancy, congenital malformations and intrauterine death.
Placental: Infarction, thrombosis, placenta previa or abruption.
(C) Iatrogenic:
Indicated preterm delivery due to medical or obstetric
complications.

(D)Idiopathic: (Majority)
Premature effacement of the cervix with irritable uterus and
early engagement of the head are often associated. In the absence of
any complicating factors, it is presumed that there is premature
activation of the same systems involved in initiating labor at term.
ETIOPATHOGENESIS OF PRETERM LABOR

Source :- DC-Dutta’s-Textbook of obstetrics 8th edition

 PREDICTORS OF PRETERM LABOR
A. Clinical predictors:
(i) History of prior preterm birth;
(ii) Multiple pregnancy;
(iii) Presence of genital tract infection.
B. Biophysical predictors:
(i) Uterine contractions (UC) > 4/hr ;
(ii) Bishop score > 4;
(iii) Cervical length (TVS) < 25 mm.
C. Biochemical predictors: (i) Fetal fibronectin (fFN) in cervicovaginal
discharge ;
(ii) Others IL-6, IL-8, TNF-α.
• Fibronectin is a glycoprotein that binds the fetal membranes to the
decidua. Normally it is found in the cervicovaginal discharge before 22
weeks and again after 37 weeks of pregnancy. Presence of fibronectin
in the cervicovaginal discharge between 24 weeks and 34 weeks is a
predictor of preterm labor.

DIAGNOSIS
(1)Regular uterine contractions with or without pain (at least one in
every 10 minutes);
(2) Dilatation (> 2 cm) and effacement (80%) of the cervix;
(3) Length of the cervix (measured by TVS) < 2.5 cm and funneling of
the internal os and
(4) Pelvic pressure, backache and/or vaginal discharge or bleeding.
 MANAGEMENT OF PRETERM LABOR

The management includes:

(1)To prevent preterm onset of labor, if possible;
(2) To arrest preterm labor, if not contraindicated;
(3) Appropriate management of labor;
(4) Effective neonatal care.
 (1)Prevention of preterm on set of labor
In about 50%, the cause remains unknown. The risk of delivery of a low birth
weight baby has to be weighed against the risks involved to the fetus and/or to the
mother in continued pregnancy.
However, the following prevention can be done .
Primarycare is aimed to reduce the incidence of preterm labor by reducing the
high-riskfactors (e.g. infection, etc.).
Secondary care includes screening tests for early detection and prophylactic
treatment (e.g. tocolytics).
Tertiary care is aimed to reduce the perinatal morbidity and mortality after the
diagnosis (e.g. use of corticosteroids).
Following investigation will be helpfull in prevention of preterm onset
of labor.
Investigations: (1) Full blood count; (2) Urine for routine analysis,
culture and sensitivity; (3) Cervicovaginal swab for culture and
fibronectin; (4) Ultrasonography for fetal well being, cervical length and
placental localization and (5) Serum electrolytes and glucose levels
when tocolytic agents are to be used .
 MEASURES TO ARREST PRETERM LABOR
The following regime may be instituted in an attempt to arrest
premature labor.
• Bed rest—The patient is to lie preferably in left lateral position though the
benefits are doubtful.
• Adequate hydration is maintained. Prophylactic antibiotic is not routinely
given. It is recommended when infection is evident or culture report suggests.
• Prophylactic cervical cerclage for women with prior preterm birth and short
cervix in the present pregnancy may be beneficial.
• Tocolyticagents: Various drugs nifedipine, atosiban, progesterone(micronized)
have been used to inhibit uterine contractions. The tocolytic agents can be
used as short-term (1–3 days) or long-term therapy.
• Dose schedule of MgSO and monitoring are same as used for seizure
4

prophylaxis of preeclampsia (4 g IV over 3–5 minutes followed by an infusion

of 1 g/hr).
Glucocorticoid therapy:
Maternal administration of glucocorticoids is advocated where the
pregnancy is less than 34 weeks. This helps in fetal lung maturation so that
the incidence of RDS, IVH and NEC are minimized. This is beneficial when the
delivery is delayed beyond 48 hours of the first dose. Benefit persists as long
as 18 days. Either betamethasone (Betnesol) 12 mg IM 24 hours apart for
two doses or dexamethasone 6 mg IM every 12 hours for 4 doses is given.
Betamethasone is the steroid of choice.
Risks of antenatal corticosteroid use:
(a) Premature rupture of the membranes especially with evidence of
infection as the infection may flare-up; (b) Insulin-dependent diabetes
mellitus where patients need insulin dose readjustment; (c) Transient
reduction of fetal breathing and body movements.
 MANAGEMENT IN LABOR
• The principles in management of preterm labor are: (1) To prevent birth
asphyxia and development of RDS; (2) To prevent birth trauma.
 Immediate management of the preterm baby
following birth
PROGNOSIS:
Preterm labor and delivery of a low birth weight baby results in high
perinatal mortality and morbidity. However, with NICU, the survival rate of
the baby weighing between 1,000 g and 1,500 g is more than 90%. With the
use of surfactant survival rate of infants born at 26 weeks is about 80%.

Late preterm labor:

Birth of infants between 34 weeks and 36 weeks gestation. These
infants do better than those infants born before 34 weeks.
 KEY POINTS
•A preterm labor is one when labor starts at less than 259 days (< 37 completed
weeks) of pregnancy .
• High risk factors for preterm labor are many Etiopathology of preterm labor is
complex. Infection, uterine enlargement and/or fetal stress can initiate the
pathology.
•Risk of preterm labor increases as the length of the cervix decreases (< 2.5 cm).
•Presence of fetal fibronectin in the cervicovaginal discharge between 22 weeks
and 34 weeks of pregnancy is a good predictor of preterm labor.
• To arrest preterm labor, tocolytics may be used for a short-term basis There are
several contraindications for the use of tocolytics.
•Complications of a preterm infant are many and are inversely related
to the gestational age and birth weight.
• Management of PTL is aimed to reduce perinatal morbidity and
mortality. Th e principles of management are:
– To transfer the mother with the fetus in utero to a hospital where
special care baby unit is available.
– To give glucocorticoid to the woman to reduce neonatal RDS and IVH .
– To start antibiotic to the woman if infection is present .
– To start tocolytic medications to delay delivery at least for 48 hours.
 PoST-TERM PREGNANCY
DEFINITION:
Uniform criteria are lacking as to the precise definition of postmaturity.
Literally, any pregnancy which has passed beyond the expected date of
delivery, is called a prolonged or postdated pregnancy.
But for clinical purposes, a pregnancy continuing beyond 2 weeks
of the expected date of delivery (> 294 days) is called postmaturity or
post-term pregnancy.
•INCIDENCE:
The incidence of pregnancies continuing beyond 42 completed weeks
(> 294 days) ranges between 4% and 14%. The average is about 10%.
Many suspected post-term pregnancies are actually wrongly dated.
Incidence varies as different criteria are used for gestational age
dating (clinical and sonography).
ETIOLOGY:
So long as the complex mechanism in initiation of labor remains
unknown, the cause of the prolongation of pregnancy will remain
obscure.
But certain factors are related with postmaturity.
(1) Wrong dates—due to inaccurate LMP (most common)
(2) Biological variability (Hereditary) may be seen in the family
(3) Maternal factors: Primiparity, previous prolonged pregnancy,
sedentary habit, elderly multiparae
(4) Fetal factors: Congenital anomalies: Anencephaly → abnormal
fetal HPA axis and adrenal hypoplasia → diminished fetal cortisol
response
(5) Placental factors: Sulfatase defi ciency → low estrogen.