Preterm Labour: Pembimbing: Dr. Andriana Kumala Dewi, SP - OG

Preterm Labour
Pembimbing:
dr. Andriana Kumala Dewi, Sp.OG
DEFINITION OF PRETERM
• Preterm birth, defined as delivery before 37 completed weeks

• Those before 36/7 weeks are labeled—early preterm
• between 34 and 36 completed weeks—late preterm
CAUSES OF PRETERM DELIVERY
• There are four main direct reasons for preterm births:
(1) Spontaneous unexplained preterm labor with intact membranes
(2) Idiopathic preterm premature rupture of membranes (PPROM)
(3) Delivery for maternal or fetal indications
(4) Twins and higher-order multifetal births.
Uterine Distention
• Multifetal pregnancy and hydramnios lead to an increased risk

of preterm birth
• Early uterine distention acts to initiate expression of
contraction-associated proteins (caps) in the myometrium.
• Gastrin-releasing peptides (grps) are increased with stretch to
promote myometrial contractility
• Excessive uterine stretch also leads to early activation of the
placental–fetal endocrine cascade
Maternal–Fetal Stress
• Last trimester is marked by rising maternal serum levels of

placental-derived corticotropin-releasing hormone (CRH) 
works with adrenocorticotropic hormone (ACTH)  increase
adult and fetal adrenal steroid hormone production
• CRH  stimulate fetal adrenal dehydro-epiandrosterone
sulfate (DHEA-S) biosynthesis  increase estriol
Maternal–Fetal Stress
• Premature rise in cortisol and estrogens results in an early loss

of uterine quiescence
• Spontaneous preterm labor is associated with an early rise in
maternal CRH levels  predictor of preterm birth
• Placental CRH enters the fetal circulation
• Maternal estrogen is prematurely elevated  alter
myometrial quiescence and accelerate cervical ripening
Infection
• Infection  primary cause of preterm labor in pregnancies with intact

membranes
• Bacteria can gain access to intrauterine tissues through:
(1) transplacental transfer of maternal systemic infection
(2) retrograde flow of infection into the peritoneal cavity via the fallopian
tubes
(3) ascending infection with bacteria from the vagina and cervix.
• Ascending infection is considered to be the most common
• 4 stages of microbial invasion:
– Stage I: bacterial vaginosis
– Stage II: decidual infection
– Stage III: amnionic infection
– Stage IV: fetal systemic infection
• Gardnerella vaginalis, Fusobacterium, Mycoplasma hominis,
and Ureaplasma urealyticum  more frequently than
others in amnionic fluid of women with preterm labor
Multifetal Gestation
• Twins and higher-order multifetal births account for

approximately 3 percent of infants born
• Preterm delivery continues to be the major cause of
the excessive perinatal morbidity and mortality with
multifetal pregnancies.
Preterm Premature Rupture of Membranes
• Spontaneous rupture of the fetal membranes before 37

completed weeks and before labor onset
• Intrauterine infection is  major predisposing event
• Associated risk factors:
– Low socioeconomic status
– Body mass index ≤ 19.8
– Nutritional deficiencies
– Cigarette smoking
• Increased apoptosis of membrane cellular components and
to increased levels of specific proteases in membranes and
amnionic fluid
Symptoms
• Painful or painless uterine contractions,

• Pelvic pressure
• Menstrual-like cramps,
• Watery vaginal discharge
• Lower back pain
• Uterine contractions, appeared only within 24 hours of
preterm labor
• Those whose cervix remained < 2 cm for 2 hours  false
preterm labor
• The mean cervical length at 24 weeks was
approximately 35 mm, and those women with
progressively shorter cervices experienced increased
rates of preterm birth
PRETERM BIRTH PREVENTION
Management Of Preterm Prematurely
Ruptured Membranes
MANAGEMENT OF PRETERM LABOR WITH
INTACT MEMBRANES
If possible, delivery before 34 weeks

is delayed.
Amniocentesis to Detect Infection
• Evaluated the diagnostic value of amnionic fluid containing an

elevated leukocyte count, a low glucose level, a high IL-6
concentration, or a positive gram stain result in 120 women
with preterm labor and intact membranes. Women with
positive amnionic fluid culture results were considered
infected.
Corticosteroids for Fetal Lung Maturation
• Because glucocorticosteroids were found to accelerate lung

maturation in preterm sheep fetuses
• Corticosteroid therapy was effective in lowering the incidence
of respiratory distress syndrome and neonatal mortality rates
if birth was delayed for at least 24 hours after initiation of
betamethasone
• With each round, a nonsignificant rise in cerebral palsy rates
was identified in infants exposed to repeated courses.
“Rescue Therapy”
• Administration of a repeated corticosteroid dose when

delivery becomes imminent and more than 7 days have
elapsed since the initial dose
• Significantly decreased rates of respiratory complications and
neonatal composite morbidity with rescue corticosteroids.
• There were no differences in mortality and other morbidities
attributable to prematurity
Antimicrobials
• Fetal exposure to antimicrobials in this clinical setting was

associated with an increased cerebral palsy rate at age 7 years
compared with that of children without fetal exposure.
• The primary outcomes of neonatal death, chronic lung
disease, and major cerebral abnormality were similar
Bed Rest
• Bed rest in the hospital compared with bed rest at home had
no effect on pregnancy duration in women with threatened
preterm labor before 34 weeks.
• Bed rest for 3 days or more increased thromboembolic
complications to 16 per 1000 women compared with only 1
per 1000 with normal ambulation.
Tocolysis to Treat Preterm Labor
• tocolytic agents do not markedly prolong gestation but may

delay delivery in some women for up to 48 hours.
• β-Adrenergic Receptor Agonists  reduce intracellular ionized
calcium levels and prevent activation of myometrial
contractile proteins
β-Adrenergic Receptor Agonists
• Ritodrine  The drugs have been implicated in increased

capillary permeability, cardiac rhythm disturbances, and
myocardial ischemia
• Terbutaline  randomized trials have reported no benefit for
terbutaline pump therapy
Magnesium Sulfate
• Can alter myometrial contractility.
• Intravenous magnesium sulfate—a 4-g loading dose followed
by a continuous infusion of 2 g/hr—usually arrests labor
• Prolonged use of magnesium sulfate given to arrest preterm
labor due to bone thinning and fractures in fetuses exposed
for more than 5 to 7 days. This was attributed to low calcium
levels in the fetus.
• magnesium sulfate provided for threatened preterm deliveryfrom 240/7
to 276/7 weeks
• 6-g loading dose is followed by an infusion of 2 g per hour for at least 12
hours
Prostaglandin Inhibitors
• Indomethacin was first used as a tocolytic

• Antagonists act by inhibiting prostaglandin synthesis or by
blocking their action on target organs. A group of enzymes
collectively termed prostaglandin synthase is responsible for
the conversion of free arachidonic acid to prostaglandins
• Indomethacin is administered orally or rectally. A dose of 50
to 100 mg is followed at 8-hour intervals not to exceed a
total 24-hour dose of 200 mg.
• Neonates born before 30 weeks identified necrotizing
enterocolitis in 30%, higher incidences of intraventricular
hemorrhage and patent ductus arteriosus were also
documented
• Indomethacin therapy for 7 or more days before 33 weeks
does not increase the risk of neonatal or childhood medical
problems.
Calcium-Channel Blockers
• Myometrial activity is directly related to cytoplasmic free

calcium, and a reduction in its concentration inhibits
contractions
• Nifedipine treatment reduced births of neonates weighing <
2500 g, significantly nifedipine, are safer and more effective
tocolytic agents than are β-agonists
• The combination of nifedipine with magnesium for tocolysis is
potentially dangerous
• Nifedipine enhances the neuromuscular blocking effects of
magnesium that can interfere with pulmonary and cardiac
function
Atosiban
• A competitive antagonist of oxytocin-induced contractions

• In randomized clinical trials, atosiban failed to improve
relevant neonatal outcomes and was linked with significant
neonatal morbidity
Labor
• Whether labor is induced or spontaneous, abnormalities of

fetal heart rate and uterine contractions should be sought
• Fetal tachycardia, especially with ruptured membranes, is
suggestive of sepsis.
• Increasing umbilical artery blood acidemia was related to
more severe respiratory disease in preterm neonates.
• Group b streptococcal infections are common and
dangerous in the preterm neonate
Prevention of Neonatal
Intracranial Hemorrhage
• Preterm newborns frequently have intracranial

germinal matrix bleeding that can extend to more
serious intraventricular hemorrhage
• Newborns with birthweights less than 1500 g and
found that cesarean delivery did not lower the risk of
mortality or intracranial hemorrhage

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Preterm Labour

• Preterm birth, defined as delivery before 37 completed weeks

• Multifetal pregnancy and hydramnios lead to an increased risk

• Last trimester is marked by rising maternal serum levels of

• Premature rise in cortisol and estrogens results in an early loss

• Infection  primary cause of preterm labor in pregnancies with intact

• Twins and higher-order multifetal births account for

• Spontaneous rupture of the fetal membranes before 37

• Painful or painless uterine contractions,

If possible, delivery before 34 weeks

• Evaluated the diagnostic value of amnionic fluid containing an

• Because glucocorticosteroids were found to accelerate lung

• Administration of a repeated corticosteroid dose when

• Fetal exposure to antimicrobials in this clinical setting was

• tocolytic agents do not markedly prolong gestation but may

• Ritodrine  The drugs have been implicated in increased

• Indomethacin was first used as a tocolytic

• Myometrial activity is directly related to cytoplasmic free

• A competitive antagonist of oxytocin-induced contractions

• Whether labor is induced or spontaneous, abnormalities of

• Preterm newborns frequently have intracranial

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