• Preterm birth complications are the leading cause of death among children<5 years
• 1 million deaths Incidence 5-18% in 2015
• Inequality in survival rates across world
• >90% of extremely preterm babies (<28 weeks) born in low-income countries
[WHO, November, 2017]
The risk for spontaneous early PTD increases with maternal age and decreases with height; it is higher in women of African and South Asian origin than in the white population. The risk is also higher in cigarette smokers and in those conceiving after the use of ovulation induction drugs.
Also there has been a significant rise in preterm births due to use of assisted reproductive technology and multiple births.
Medical intervention and iatrogenic preterm delivery are also constituting a significant contribution in rise of preterm deliveries.
Older age of pregnant women presence of other medical conditions also have a role.
Screening on the basis of previous obstetric history and therapeutic intervention in the high-risk group is likely to have a small impact on the overall rate of prematurity because only about 10% of spontaneous early preterm births occur in women with this history.
Screening has a high sensitivity and positive predictive value (both >60%) in women with a prior preterm birth and a singleton pregnancy; therefore, intervention will be most effective in this population. Its sensitivity is lower (approximately 30–40%) in both low-risk singleton or multiple pregnancies as these women may have preterm births that are not as related to an abnormal cervical length.
• Screening by history alone will identify only 10% of women who go on to have a preterm birth.
• The risk of preterm birth increases with each subsequent preterm birth, and is higher in women with preterm birth at earlier gestation.
• The risk of preterm birth is increased in WOMEN UNDERGOING SURGERIES IN THE CERVIX for precancerous lesions so they should be screened regularly
• It is unclear if monitoring of uterine activity like watching for contractions helps reduces the incidence of preterm birth or improves perinatal outcome.
• There is no evidence to support digital assessment of cervical length that is doing repeated internal examination in order to reduce the prevalence of preterm birth.
• The cervical parameter found in most populations to have the best predictive accuracy of preterm birth is a cervical length of less than 25 mm.
• Woman who are high risk for preterm birth should be offered serial transvaginal measurement of cervical length between 16 and 24 weeks of gestation and offered treatment if cervical length is <25 mm.
• Woman with suspected threatened preterm labour after 30 weeks of gestation should be having a transvaginal assessment of cervical length and should be offered treatment like medicines to prevent contractions and steroids for lung maturity if cervical length is <15 mm.
• Nowadays we have a test which can be done in OUTPATIENT in the vaginal secretion to check for pretem labour.
• Also women should be screened for both symptomatic and asymptomatic urinary tract infections and for vaginal infections specially in the high risk group.
• They also should be offered treatment for the same.
• Also dental infections need to be treated as they do have a role in preterm labour
• Also a careful selection should be done for choosing women for cerclage procedures that is closing the neck of the womb with suture.
• ONE THING THAT LEAVES EVERYONE IN A TIZZY AND IS VERY DIFFICULT TO PREDICT IS LEAKAGE OF AMNIOTIC FLUID.
It is very important to follow up atleast the high risk women in dedicated clinics with a good fetal medicine department and keeping the baby as long as possible in its best incubator the mother’s womb.
Also it is not only important for parents to take babies back home but also the long term health both physical and mental needs to be paramount in decision to deliver early.
SO A GOOD PERINATAL TEAM SHOULD BE INVOLVED WITH SHARED CARE AND SHOULD INCLUDE FETAL MEDICINE NEONATLOGIST OBSTETRICIAN AND THE EXPECTING PARENTS
Director – Obstetrics & Gynecology
Madhukar Rainbow Children’s Hospital, Malviya Nagar, Delhi