Preterm, late-term,

and postterm
pregnancies
Triono Adisuroso
MD, SpOG, MMed, MPhil

Preterm birth
Birth occurs < 37 weeks (20+0/7 36+6/7 weeks)
Multifactorial
Incidence: 12.5% in the US
70% of perinatal mortality and 30-50% of long-term
neurologic impairment

Preterm birth: spontaneous and indicated

Epidemiology

Uterine components of
parturition pathway

Preterm parturition
syndrome

Preterm causes
Maternal risk factors

Race/ethnic: blacks 16-18%, whites 5-9%,

developed countries < developing countries

Interpregnancy interval <6 months is 2-fold

increased risk for PTB

Maternal nutrition status

Pregnancy history

Recurrent risk: 15-50% - mechanism is not clear

Previous PTB led 2.5 increased risk for next
pregnancy

Spontaneous PTB is more likely to subsequent

spontaneous PTB

Persistent intrauterine infection increases repetitive

spontaneous PTB

Underlying disorders causes indicated PTB:

hypertension, diabetes, or obesity

Pregnancy characteristics

Multiple pregnancy: 15-20% of all PTBs

Nearly 60% of twins are delivered preterm
40% of twins have spontaneous PTB or PPROM
Uterine overdistension resulting in contractions and
PPROM causes spontaneous PTB

Vaginal bleeding due to placenta previa or placental

abruption

Polyhydramnios or oligohydramnios
Maternal surgery in 2nd and 3rd trimester leads to
contractions

Maternal medical disorders

 Maternal psychosocial stress had <2-fold increased risk

of PTB

Clinical depression
Smoking, alcohol, and elicit drugs
Intrauterine infections related to innate immune system
activation and result in 25-40% of PTB

Microorganism access to amniotic cavity:

1. ascending infection (common pathway)
2. hematogenous
3. accidental introduction
4. retrograde

 Bacterial vaginosis (BV): 1.5-3-fold increases PTB

Other genital infections: chlamydia, syphilis,
gonorrhea

Non-genital tract infections

Cervical insufficiency;
- Cervical length abnormality: <25 mm
- Cervical incompetence
- Uterine abnormalities: didelphys. bicornu, septum
- Cervical surgery: LEEP, LLETZ, conization

Short cervix

Biological and genetic

markers
Biological fluid: amniotic fluid, cervical mucus,

vaginal secretions, urine, serum, plasma, saliva)

Cytokines, chemokines, estriol, and other analytes

related to inflammation associated with PTB

Fetal fibronectine (fFN)

- A glycoprotein in cervicovaginal fluid
- Absent >24 weeks
- The most predictor for PTB

Roles of genetic components

PTL and PPROM related to genetics

80% higher risk of having PTB in women with
sisters having PTB

SNP associated with PTL and PPROM

TNF gene and BV
IL6 allele and BV
Proteome (protein encoded genome) related to PTB

Clinical manifestations of
PTB

Clinical presentations
- Preterm labour
- PPROM
- Cervical insufficiency
- Amnionitis
- Vaginal bleeding

Causative mechanisms
- Infections
- Hemorrhage
- Uterine distention
- Trauma
- Fetal compromise

Risk factors
- Multiple pregnancy
- Placental abruption
- Preeclampsia
- Diabetes
- Hypertension
- Pyelonephritis

Diagnosis and management

Diagnosis

Diagnosis of PTB is challenging such as gestational age

and clinical manifestations

Accurate diagnosis is difficult because signs and

symptoms similar to normal pregnancy

Cervical dilatation
Cervical length: Transvaginal US > transabdominal US,
Elastography

Fetal fibronectin (fFN) of cervicovaginal fluid

Management

Treatment to reduce mortality and morbidity

- Antenatal corticosteroids
- Antibiotics
- Neuroprotectants
- Progesterone
- Cervical cerclage
Tocolytic therapy
- To reduce uterine contractions
- Tocolytic agents: Ca-channel blockers, NSAIDs,

Cyclooxygenase inhibitors (COXs), Betamimetic tocolytics,

oxytocin antagonists, MgSO4

Cervical cerclage and

elastography

Prevention of PTB
Routine prenatal care
Access to prenatal care
Nutrition
Smoking cessation
Periodontal care
Screening to reduce risks: asymptomatic

bacteriuria, genital infections, fFN, CL assessment,

combined test

Late-term and Post-term

Definition and incidence

Based on LMP
- Late-term: 41 weeks + 0 day 41 weeks+6 days
- Post-term: 42 weeks + 0 day
4-14% of post-term
2-4% reach 43 weeks
5% giving birth at 40 weeks

 Accurate determination of gestational age for

accurate diagnosis and appropriate management to

Antenatal fetal surveillance and induction to

decrease perinatal mortality and morbidity

Pathogenesis
Integration and synchrony of multiple factors:
- Fetal hypothalamic-pituitary-adrenal axis
- Placenta and membranes
- Myometrium and cervix
Fetal pituitary defects
Fetal adrenal hypoplasia
Placental sulfatase deficiency leads to low estrogen
resulting in delayed onset of labour and cervical
ripening

Etiology factors
Unclear
Primipara > multipara
Previous post-term
Carrying a male fetus
Maternal obesity
23-30% of genetic factors
Fetal abnormalities: anencephaly and placental
sulfatase deficiency

Perinatal risks
Perinatal morbidity and mortality
Abnormal fetal growth
- Macrosomia birth injuries
Meconium and pulmonary aspiration syndrome
Neonatal convulsions
A 5-minute low Apgar score (<4)
Increase NICU admission

 10-20% of post-maturity syndrome: lacks of

subcutaneous fat, fernix, lanugo, meconium

staining in amniotic fluid, skin, membrane, and
umbilical cord

Olygohydramnios
Stillbirth

Perinatal morbidity and

mortality

Maternal risks
In association between maternal and obstetric
complications:

- Severe perineal laceration

- Infection
- Postpartum hemorrhage
- Caesarean delivery

Management
Antenatal fetal surveillance
- Biophysical profile (BPP)
- Non-stress test (NST)
- Contraction stress test (CST)
- AF evaluation
Induction of labour

BPP

Thank you