Preterm Labor in Pregnancy

Preterm labor is defined as a premature labor between 20 - 37 weeks of gestation before full term. According to the statistic, 1 in 8 babies is born premature and 12% of all pregnancies are ended in preterm pregnancy, causing life longed health problem to some and one of the leading cause of infant death.

Signs and symptoms
1. Uterus Contraction
Pregnant women who are experience frequent uterus contraction for 5 minutes or more are at risk of preterm pregnancy.
2. Vagina discharge
It may be result of leaking fluid and bleeding from the womb.
3. Pain during urination
It can be caused by bladder or urinary track infection cause of preterm labor.
4. Intense pelvic pressure and low, dull backache
Symptoms of normal term labor.
5. Abnormal cramps and pain
It is not a usual sign of pregnancy.
6. Etc.
Causes and risk factors
1. Previous history
Women who have a previous incidence of preterm labor are at higher risk of preterm pregnancy again.

2. Pregnancy with multiple babies
According to the article of "Multiple birth" posted in the enote, the article indicated that Babies born from multiple-birth pregnancies are more likely to result in premature birth than those from single pregnancies. 51% of twins and 91% of triplets are born preterm, compared to 9.4% in singletons.

3. Uterine and Cervical structure abnormalities
Certain reproductive structure abnormalities can increase the risk of preterm labor, including
a duplicated or septate cervix, T-shaped uterus, etc.

4. Infection
Certain infections including bacterial vaginosis, bladder, urinary track, kidney infection can increase the risk of preterm labor and give birth early. According to the study of "Periodontal infection and preterm birth, Results of a prospective study by MARJORIE K. JEFFCOAT, D.M.D., NICO C. GEURS, D.M.D., MICHAEL S. REDDY, D.M.D., D.M.SC., SUZANNE P. CLIVER, B.S., ROBERT L. GOLDENBERG, M.D. and JOHN C. HAUTH, M.D., researchers found that Patients with severe or generalized periodontal disease had adjusted odds ratios (95 percent CI) of 4.45 (2.16–9.18) for preterm delivery (that is, before 37 weeks gestational age). The adjusted odds ratio increased with increasing prematurity to 5.28 (2.05–13.60) before 35 weeks’ gestational age and to 7.07 (1.70–27.4) before 32 weeks’ gestational age.

5. Chronic illness
Certain chronic illness such as high blood pressure, kidney disease and diabetes may increase the risk of preterm labor.

6. Maternal α-fetorrprotein levels in second trimester
Abnormally high plasma levels of α-fetoprotein in early pregnancy increases risk of preterm labor. According to the study of "PREDICTING THE RISK OF PRETERM LABOR BY SECOND TRIMESTER MEASUREMENT OF MATERNAL α-FETOPROTEIN LEVELS AND A RISK FACTOR SCORING SYSTEM" by FATEMEH DAVARI TANHA,* M.D., FARIBA SARDARI, M.D.,ZAHRA EFTEKHAR, M.D., MAHBOD KAVEH, M.D., AND NARGESSIZADY MOOD, M.D., researchers found that the combination of measurement of maternal serum AFP in the second trimester associated with a risk factor scoring system provides a more accurate indicator of the risk of preterm delivery and therefore may be of use in targeting prevention strategies.

7. Socio-economical and obstetric effects
Biopsychosocial risk factors for preterm birth and postpartum emotional well-being: a case–control study on Turkish women without chronic illnesses by Ilkay Gungor, Umran Oskay,Nezihe Kizilkaya Beji, researchers found that many of the socio-economical and obstetric causes of preterm births were similar to other countries with higher preterm birth rates. Preterm births were associated with lower social support along with more anxiety and depressive symptoms in early postpartum.

8. Overweight before pregnancy
Women who are overweight or obese are at great risk of giving birth to a preterm baby compared with normal weight women. According to the study of "Overweight and obesity in mothers and risk of preterm birth and low birth weight infants: systematic review and metaanalyses" by Sarah D McDonald, associate professor, Zhen Han, associate professor, Sohail Mulla, student, Joseph
Beyene,researchers found that Overweight or obese women have increased risks of preterm birth before 32 weeks and induced preterm birth before 37 weeks, and, accounting for publication bias, preterm birth before 37 weeks overall.

9. Underweight, smoking, uterine bleeding, blood pressure abnormalities and Inadequate Rate of Weight Gain
In a study of "Maternal Underweight Status and Inadequate Rate of Weight Gain During the Third Trimester of Pregnancy Increases the Risk of Preterm Delivery" by ANNA MARIA SIEGA-RIZ,*3 LINDA S. ADAIR* AND CALVIN J. HOBELf, researchers found that Women who delivered preterm were significantly lower in prepregnancy weight and as a result had a lower mean prepregnant BMI than women who delivered term (Table 2). In addition, mothers of preterm infants were less frequently married, more likely to smoke, to be African-Americans and had more occurrences of uterine bleeding and blood pressure abnormalities (chronic hypertension and/or pregnancy-induced hypertension) than mothers of term infants.
Researchers also found that Women who delivered preterm gained the same
amount of weight in the first trimester and had a similar rate of weight gain in the second trimester as women who delivered term (refer to Table 2). However, differences in rate of weight gain were seen in the third trimester. Women who delivered term gained, on average, 30 g more per week than women who delivered preterm. The weight gain curves for term vs. the types of preterm deliveries, preterm labor and preterm PROM are shown in Figure 1. Regression lines fitted to the data illustrate the similarities in the rate of weight gain among all three groups.

10. Singleton pregnancies after IVF-ET/GIFT
According to the study of "Increased risk of preterm birth in singleton pregnancies resulting from in vitro fertilization-embryo transfer or gamete intrafallopian transfer: a meta-analysis" by McGovern PG, Llorens AJ, Skurnick JH, Weiss G, Goldsmith LT., researchers found that The risk of preterm birth in singleton pregnancies resulting from IVF-ET/GIFT is twice that of natural conceived pregnancies.

11. Short time between pregnancies
Women who are pregnant again less than 6-9 months after giving birth are at higher risk of the preterm pregnancy. In a study of "Effect of the Interval between Pregnancies on Perinatal Outcomes" by Bao-Ping Zhu, M.D., Robert T. Rolfs, M.D., M.P.H., Barry E. Nangle, Ph.D., and John M. Horan, M.D., M.P.H. researchers suggested that the optimal interpregnancy interval for preventing adverse perinatal outcomes is 18 to 23 months.

12. Alcohol
Alcohol abuse increases the risk of preterm labor. According to the article of "Alcohol Use and Premature Birth" in 2006 Teresa Kellerman, the author wrote that Increased awareness about the risk of alcohol use during pregnancy can prevent many cases of premature birth, as well as the serious effects associated with Fetal Alcohol Spectrum Disorders.

13. Lack of prenatal care
Lack of prenatal care increases the rate of recurrent preterm delivery and health care costs when compared to university hospital-based prenatal care by Serdar Ural MD, Cary Cox, Karin Blakemore MD, Eva Pressman MD and Jessica Bienstock MD, researchers concluded that Inner-city patients with a history of PTD who received even minimal prenatal care in a university HS clinic had a significantly lower incidence of recurrent PTD than those who had no prenatal care. Prenatal care also lowers total health care costs in women with a history of PTD. The coordinated multidisciplinary aspect of care provided at academic centers may have a positive impact on the problem of PTD.

14. Other causes, include
a. Poor nutrients
b. Physical and drug abuse
c. Etc.

Diagnosis
If you are experience certain symptoms of preterm pregnancy, after recording the family history and physical exam, your may perform
1. Speculum examination of the cervix
Speculum Exam of the cervix is an examination of the cervix and vaginal walls to find out how much the cervix has opened and thinned, and any leaking fluid with the use of a sterile speculum.

2. Endovaginal cervical sonography
Endovaginal cervical sonography is a type of ultrasound used to examine the pelvic organs with an aim is to determine the length of the cervix in a preterm pregnancy if she is experience certain symptoms of preterm labor. According to the study of Mid-trimester endovaginal sonography in women at high risk for spontaneous preterm birth. by Owen J, Yost N, Berghella V, Thom E, Swain M, Dildy GA 3rd, Miodovnik M, Langer O, Sibai B, McNellis D; National Institute of Child Health and Human Development, Maternal-Fetal Medicine Units Network., researchers found that cervical length assessed by endovaginal sonography between 16 weeks' and 18 weeks 6 days' gestation, augmented by serial evaluations, predicts spontaneous preterm birth before 35 weeks' gestation in high-risk women.

3. Fibronectin test
Fibronectin test is performed by a specimen collected from the patient using a vaginal swab, it is a protein produced by the fetus is an excellent biological marker to determine the risk of preterm labor. The positive test is an indication of preterm pregnancy.

4. Transabdominal sonography
The test is to examine the length of the cervix to determine the risk of preterm labor.
In a study of "Comparison of transvaginal and transabdominal sonography in the detection of early pregnancy and its complications.", by Jain KA, Hamper UM, Sanders RC. researchers found that all six missed abortions were detected by endovaginal sonography, but only three were diagnosed on transabdominal sonograms. Our findings show that endovaginal sonography is more sensitive than transabdominal sonography in the detection of early pregnancy and its complications.

5. Etc.

Prevention
A. How to do
1. Healthy diet
Unhealthy diet can cause nutrients deficiency of which can increase the risk of preterm labor.
2. Quit smoking
Women who smoke during pregnancy are at higher risk of preterm pregnancy than non smoke women.
3. No excessive drinking
Excessive drinking not only increases the risk of preterm labor but also promotes Fetal Alcohol Spectrum Disorders.
4. Prenatal care
Increased risk of preterm labor for women who are pregnant without adequate prenatal care.
5. Avoid over or underweight Pregnant
Women who are under or overweight before pregnancy are associated with higher risk of preterm pregnancy.
6. Avoid infection
Avoid infection caused by bacteria, virus and sexual transmitting diseases by practice safe sex and eating healthy to enhance immune function.
7. Reduce stress
By meditation, yoga to keep you relax.
8. Etc.

B. Diet
Healthy diet and life style with moderate exercise should be beneficiary to provide an optimal health and reduce the risk of preterm labor
C.1. The American Pregnancy Association recommends alterations to your diet, including
1. Protein
Protein in your foods positively affects the growth of fetal tissue, including the brain. It also helps your breast and uterine tissue to grow during pregnancy,
a. 75 to 100 grams of protein per day as it can be divided into 2-3 servings of meat (1 serving = approximately 3 ounces/ size of a deck of cards) from chicken lean beef, lamb, pork, nut and tofu (1 serving = approximately ⅓ cup), etc.
b. 2-3 servings of legumes (1 serving = approximately ½ cup) such as red and white kidney beans,black beans, navy beans etc..

2. Calcium Daily requirement of calcium is around 1000 milligrams during pregnancy. Calcium helps your body regulate fluids, and it helps build your baby’s bones and tooth buds, such as milk (1 serving = 1 cup), eggs (1 serving = 1 large egg), yogurt (1 serving = 1cup),pasteurized cheese (1 serving = approximately 1.5 ounces/ or 4 playing dice stacked together), tofu (1 serving = ½ cup), etc.

3. Iron
In combination with sodium, potassium, and water, iron helps increase your blood volume and prevent anemia. A daily intake of 27 milligrams is ideal during pregnancy.
a. 2-3 servings of green leafy vegetables (1 serving = approximately 1 cup)such as collard turnip, spinach, lettuce, etc.
b. 3 servings of whole grains (1 serving = approximately. ½ cup or one slice), such as bread, cornmeal, cereal, oatmeal, etc.

4. Folate/Folic Acid
Folic acid plays a key role in reducing the risk of neural tube defects, including spina bifida. Experts recommend 600 to 800 micrograms (.6 to .8 milligrams) daily.
a. 2 servings of dark green leafy vegetables (1 serving = approximately 1 cup), such as collard, turnip, spinach, lettuce. etc.
b. 2-3 servings of fruit (1 serving = approximately ½ cup), such as orange, strawberry, lemon, mango, tomato, etc.

5. Vitamin C
Fruits and vegetables rich in Vitamin C will help with wound healing, tooth and bone development, and promotes metabolic processes. Experts recommend at least 85 milligrams per day. 3 servings of fruit or vegetables (1 serving = approximately ½ cup), such as orange, strawberry, lemon, mango, tomato, etc. (Source)

6. Etc. for more healthy foods please visit 100+ Healthy Foods Classification

C. Antioxidants
Intake of antioxidants should be beneficial for anyone to prevent the disease at the beginning, including pregnant women. For more information of the effects of antioxidants to cancers and diseases.

D. Etc.

Treatments
The aim of most treatments have been directed toward the inhibition of myometrial contractions by delay delivery long enough to allow certain treatments and to transfer the mother and fetus to an appropriate hospital.
A. In general approaches
Treatment of preterm labor are depended totally in the types of symptoms of which a woman is experiencing. In many case, closely managing such as below are beneficial, depending to the diagnosis.
1. Empty your bladder
2. Lie down tilted towards your left side may slow down or stop signs and symptoms
3. Avoid lying flat on your back to prevent the increased uterine contractions to increase
4. Drink several glasses of water to reduce the risk of dehydration cause of contractions
5. Monitor the time of between contractions for one hour every day
6. Etc.

Remember that premature labor does not always result in premature delivery. Some women experience the symptoms of premature labor, sometimes put on bed rest until the pregnancy progresses further.

B. Medication
B.1. Tocolytics
Tocolytics also known as anti-contraction medications are the types of medication used to suppress premature labor for women who are experience the symptoms of preterm labor with an aims to buy time for the administration of certain medication to accelerate fetal lung maturity, including beta-mimetics (terbutaline), magnesium sulfate,
calcium channel blockers (for example, nifedipine), non-steroidal anti-inflammatory drugs, NSAIDs (indomethacin), etc..

B.2. Progesterone

Progesterone 17-hydroxyprogesterone caproate, can help to reduce the risk of preterm birth in women with recurrent preterm birth by 40–55%as it relaxes the uterine musculature, maintains cervical length, and has anti-inflammatory effect. In a study of " Polymorphisms in folate metabolizing genes and risk for spontaneous preterm and small-for-gestational age birth." by Engel SM, Olshan AF, Siega-Riz AM, Savitz DA, Chanock SJ., researchers concluded that our results suggest the possibility of a direct or indirect role for the SHMT1(1420)T variant in spontaneous preterm or SGA births.

B.3. Antibiotics and Preterm Labor, including Premature Rupture of Fetal Membranes

In case of preterm labor is a result of infection than antibiotic is given through IV injection. In a study of "Can antibiotics prevent preterm birth--the pro and con debate." by Lamont RF., researcher found that Antibiotics used prophylactically for the prevention of preterm birth are more likely to be successful if: they are used in women with abnormal genital tract flora (rather than other risk factors for preterm birth, e.g. low BMI, twins, generic previous preterm birth); they are used early in pregnancy prior to infection (tissue penetration/inflammation and tissue damage); they are used in women with the greatest degree of abnormal genital tract flora; and if they are used in women with a predisposition to mount a damaging inflammatory response to infection.

B.4. Cervical cerclage

In case of preterm labor is as a result of cervix shortens, cervical cerclage is benefial by placing a suture around the cervix that can prevent further shortening and widening. But cccording to the study of "Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data." by Berghella V, Odibo AO, To MS, Rust OA, Althuisius SM., researchers found that Cerclage does not prevent preterm birth in all women with short cervical length on transvaginal ultrasonography. In the subgroup analysis of singleton gestations with short cervical length, especially those with a prior preterm birth, cerclage may reduce preterm birth, and a well-powered trial should be carried out in this group of patients. In contrast, in twins, cerclage was associated with a significantly higher incidence of preterm birth.

B.5. Antenatal Corticosteroids
In order to prevent the damage as a result of immature lungs which are not yet producing their own surfactant of preterm baby, medcation of Antenatal Corticosteroids such as Betamethasone, dexamethasone, etc., is beneficial to stimulate the production of surfactant in the lungs of the fetus.

B.6. Etc.

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