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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[4]

Synonyms and Keywords: Preterm delivery, Premature labour, Early delivery, Premature birth, Premature labor, Pre term birth

Overview

Preterm birth is any birth that happens between 20 weeks of gestation and 36 6/7 weeks of gestation. In Europe, it is defined after 22 weeks and before 37 weeks of gestation. The gestation can be dated using first-trimester ultrasound. In the US, approximately 12% of the births are preterm, while in Europe it varies between 5-18%.The diagnosis is made based on clinical criteria which include: cervical dilation of at least 2cm and/or cervical effacement, which happens with regular uterine contractions. It may happen with or without rupture of membrane. Preterm labor and delivery is associated to many risks for the babies such as: respiratory distress syndrome, periventricular leukomalacia, intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, late-onset infection, retinopathy of prematurity, cerebral palsy and other adverse neurological outcomes.

Historical Perspective

  • In the 1930s, George Corner was the first to suggest the association between progesterone and the development of preterm labor.[1]
  • James Elgin Gill (born on 20 May 1987 in Ottawa, Canada) was the earliest premature baby in the world. He was 128 days premature (21 weeks and 5 days gestation) and weighed 1 lb. 6 oz. (624 g). He survived and is quite healthy.[2][3]

Classification

  • Preterm labor may be classified according to the WHO into 3 groups: extremely preterm (<28 weeks), very preterm (28 to 32 weeks), moderate to late preterm (32-37 weeks).[4]

Pathophysiology

Causes

Differentiating preterm labor from other Diseases

Epidemiology and Demographics

  • The incidence of preterm labor is approximately 12% of the births in the United States.[7]
  • In Europe the incidence varies between 5-18% of the births.[8]
  • Approximately 17% of preterm births occur in the Americas (North, Central and South America, and the Caribbean), Europe and Australia.[9]

Risk Factors

Screening

  • There is insufficient evidence to recommend routine screening for preterm labor.

Natural History, Complications, and Prognosis

  • If left untreated, women in preterm labor will progress to delivery. Tocolysis can postpone the delivery in up to 48 hours.
  • Prognosis is generally dependent on gestational age.
    • Survival rate is about:
      • 40% for newborns at 24 weeks' gestation,
      • 50% for newborns at 25 weeks,
      • 60% for newborns at 26 weeks,
      • 70% for newborns at 27 weeks,
      • 80% newborns born at 28 weeks.[20]

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

  • There are no ECG findings associated with preterm labor.

X-ray

  • There are no x-ray findings associated with preterm labor.

Echocardiography or Ultrasound

CT scan

  • There are no CT scan findings associated with preterm labor.

MRI

  • There are no MRI findings associated with preterm labor.

Other Imaging Findings

  • There are no other imaging findings associated with preterm labor.

Other Diagnostic Studies

Treatment

Medical Therapy

According to the American College of Obstetricians and Gynecologists guidelines[7]:

  • Pharmacologic medical therapy is recommended among patients with preterm labor in which a delay in delivery will be beneficial to the newborn. Such cases include patients presenting a gestational age no higher than 34 weeks.
  • The medical therapy of delaying delivery is called tocolysis, and it is effective for up to 48 hours.
  • It is generally not indicated if there's no neonatal viability.
  • Its use must be used only on women with preterm labor at high risk of spontaneous preterm birth.
  • Administering corticosteroids (single course) is recommended for pregnant women between 24 weeks and 34 weeks of gestation who are at risk of delivery within 7 days.
  • Antibiotics should not be used to prolong gestation or improve neonatal outcomes if membranes are intact.
Tocolytic agents according to the American College of Obstetricians and Gynecologists[7]
Agent or Class Maternal Side Effects Fetal or Newborn Adverse Effects Contraindications
Calcium channel blockers Dizziness, flushing, and hypotension; suppression of heart rate, contractility, and left ventricular systolic pressure when used with magnesium sulfate; and elevation of hepatic transaminases No known adverse effects Hypotension and preload-dependent cardiac lesions, such as aortic insufficiency
Nonsteroidal anti-inflammatory drugs Nausea, esophageal reflux, gastritis, and emesis; platelet dysfunction is rarely of clinical significance in patients without underlying bleeding disorder In utero constriction of ductus arteriosus, oligohydramnios, necrotizing enterocolitis in preterm newborns, and patent ductus arteriosus in newborn Platelet dysfunction or bleeding disorder, hepatic dysfunction, gastric ulcers, renal injury, and asthma (in women with hypersensitivity to aspirin)
Beta-adrenergic receptor agonists Tachycardia, hypotension, tremor, palpitations, shortness of breath, chest discomfort, pulmonary edema, hypokalemia, and hyperglycemia Fetal tachycardia Tachycardia-sensitive maternal cardiac disease and poorly controlled diabetes mellitus
Magnesium sulfate Causes flushing, diaphoresis, nausea, loss of deep tendon reflexes, respiratory depression, and cardiac arrest; suppresses heart rate, contractility and left ventricular systolic pressure when used with calcium channel blockers; and produces neuromuscular blockade when used with calcium channel blockers Neonatal depression Myasthenia gravis

Surgery

Primary Prevention

Secondary Prevention

  • Cerclage is a surgical procedure made in a certain group of patients to avoid the recurrence of preterm labor.
  • Administration of progesterone is being investigated for high-risk patients, especially those who had an episode of preterm labor previously.[22]

References

  1. 1.0 1.1 1.2 Talati AN, Hackney DN, Mesiano S (2017). "Pathophysiology of preterm labor with intact membranes". Semin Perinatol. 41 (7): 420–426. doi:10.1053/j.semperi.2017.07.013. PMID 28889957.
  2. "Powell's Books - Guinness World Records 2004 (Guinness Book of Records) by". Retrieved 2007-11-28.
  3. "Miracle child". Retrieved 2007-11-28.
  4. "Preterm birth". Retrieved 2020-09-13.
  5. 5.0 5.1 5.2 5.3 5.4 Romero R, Dey SK, Fisher SJ (2014). "Preterm labor: one syndrome, many causes". Science. 345 (6198): 760–5. doi:10.1126/science.1251816. PMC 4191866. PMID 25124429.
  6. 6.0 6.1 Meller CH, Carducci ME, Ceriani Cernadas JM, Otaño L (2018). "Preterm premature rupture of membranes". Arch Argent Pediatr. 116 (4): e575–e581. doi:10.5546/aap.2018.eng.e575. PMID 30016035.
  7. 7.0 7.1 7.2 7.3 7.4 American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics (2016). "Practice Bulletin No. 171: Management of Preterm Labor". Obstet Gynecol. 128 (4): e155–64. doi:10.1097/AOG.0000000000001711. PMID 27661654.
  8. 8.0 8.1 Di Renzo GC, Cabero Roura L, Facchinetti F, Helmer H, Hubinont C, Jacobsson B; et al. (2017). "Preterm Labor and Birth Management: Recommendations from the European Association of Perinatal Medicine". J Matern Fetal Neonatal Med. 30 (17): 2011–2030. doi:10.1080/14767058.2017.1323860. PMID 28482713.
  9. 9.0 9.1 9.2 Souza RT, Cecatti JG (2020). "A Comprehensive Integrative Review of the Factors Associated with Spontaneous Preterm Birth, Its Prevention and Prediction, Including Metabolomic Markers". Rev Bras Ginecol Obstet. 42 (1): 51–60. doi:10.1055/s-0040-1701462. PMID 32107766 Check |pmid= value (help).
  10. Rosenberg TJ, Garbers S, Lipkind H, Chiasson MA (2005). "Maternal obesity and diabetes as risk factors for adverse pregnancy outcomes: differences among 4 racial/ethnic groups". Am J Public Health. 95 (9): 1545–51. doi:10.2105/AJPH.2005.065680. PMID 16118366.
  11. Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC (2006). "Birth spacing and risk of adverse perinatal outcomes: a meta-analysis". JAMA. 295 (15): 1809–23. doi:10.1001/jama.295.15.1809. PMID 16622143.
  12. Koullali B, Kamphuis EI, Hof MH, Robertson SA, Pajkrt E, de Groot CJ; et al. (2016). "The Effect of Interpregnancy Interval on the Recurrence Rate of Spontaneous Preterm Birth: A Retrospective Cohort Study". Am J Perinatol. doi:10.1055/s-0036-1584896. PMID 27367283.
  13. Ball SJ, Pereira G, Jacoby P, de Klerk N, Stanley FJ (2014). "Re-evaluation of link between interpregnancy interval and adverse birth outcomes: retrospective cohort study matching two intervals per mother". BMJ. 349: g4333. doi:10.1136/bmj.g4333. PMC 4137882. PMID 25056260.
  14. To MS, Skentou CA, Royston P, Yu CKH, Nicolaides KH. Prediction of patient-specific risk of early preterm delivery using maternal history and sonographic measurement of cervical length: a population-based prospective study. Ultra Obstet Gynecol 2006; 27: 362–367.
  15. Fonseca et al. Progesterone and the risk of preterm birth among women with a short cervix. NEJM 2007; vol 357, no 5, pg 462-469.
  16. Romero R. Prevention of spontaneous preterm birth: the role of sonographic cervical length in identifying patients who may benefit from progesterone treatment. Ultrasound Obstet Gynecol 2007; 30: 675-686. http://www3.interscience.wiley.com/journal/99020267/home free download
  17. 17.0 17.1 Koullali B, Oudijk MA, Nijman TA, Mol BW, Pajkrt E (2016). "Risk assessment and management to prevent preterm birth". Semin Fetal Neonatal Med. 21 (2): 80–8. doi:10.1016/j.siny.2016.01.005. PMID 26906339.
  18. Shiono, Patricia H., Mark A. Klebanoff, Robert P. Nugent, Mary F. Cotch, Diana G. Wilkins, Douglas E. Rollins, Christopher J. Carey, and Richard E. Behrman. "Fetus-Placenta-Newborn: the Impact of Cocaine and Marijuana Use on Low Birth Weight and Preterm Birth: a Multicenter Study." American Journal of Obsetrics and Gynecology 172 (1995): 19-27. 1 May 2007 [1].
  19. Parazzini, F, L. Chatenoud, M. Surace, L. Tozzi, B. Salerio, G. Bettoni, and G. Benzi. "Moderate Alcohol Drinking and Risk of Preterm Birth." European Journal of Clinical Nutrition 57 (2003): 1345. 1 May 2007 [2].
  20. Koh T (1996). "Simplified way of counselling parents about outcome of extremely premature babies". Lancet. 348 (9032): 963. doi:10.1016/S0140-6736(05)65379-2. PMID 8843835.
  21. 21.0 21.1 21.2 Von Der Pool BA (1998). "Preterm labor: diagnosis and treatment". Am Fam Physician. 57 (10): 2457–64. PMID 9614414.
  22. 22.0 22.1 Honest H, Hyde CJ, Khan KS (2012). "Prediction of spontaneous preterm birth: no good test for predicting a spontaneous preterm birth". Curr Opin Obstet Gynecol. 24 (6): 422–33. doi:10.1097/GCO.0b013e328359823a. PMID 23099810.

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