Preterm Pregnancy

What is Preterm Pregnancy?

Preterm Pregnancy or Preterm Birth refers to the birth of a child at least three weeks before the estimated delivery date. Complete pregnancy is usually about 40 weeks. Some babies are born as early as 28 to 37 weeks. They are called premature babies.

Is Preterm Pregnancy a Medical Emergency?

Preterm Pregnancy occurs spontaneously; in some cases, babies are at higher risk of complications, requiring immediate medical attention.

Types

Depending on the gestational age, it can be classified as the following:

• Extremely preterm: If a baby is born less than 28 weeks of pregnancy, it is termed as extremely preterm
• Very preterm: If a baby is born less than 32 weeks of pregnancy, it is termed as very preterm
• Later preterm: If a baby is born less than 37 weeks of pregnancy, it is termed as late preterm

Causes

The exact causes are not known, but preterm birth can happen due to the following reasons:

• Early induction of labour
• History of multiple previous pregnancies
• Presence of vaginal infections
• History of chronic conditions such as diabetes and high blood pressure
• Genetic mutations
• Being obese or overweight
• Psychological stress
• Tobacco smoking
• Medical conditions such as preeclampsia

Risk Factors

Factors that increase the probability of developing preterm birth include:

• History of chronic conditions such as diabetes and high blood pressure
• Medical conditions such as preeclampsia
• History of multiple previous pregnancies
• History of Previous Preterm Pregnancy
• History of previous abortions
• Carrying twin pregnancies, triplets, or more
• Presence of vaginal infections
• Presence of periodontal infections
• Conceiving through in vitro fertilization
• Being obese or overweight
• Psychological stress
• Tobacco smoking
• Using illicit substance abuse
• Physical injury or trauma

Symptoms & Signs

Some signs that indicate Preterm Pregnancy include:

• Frequent abdominal contractions or tightening
• Constant dull back pain
• Mild abdominal pain and cramps
• Vagina spotting or presence of light bleeding
• Leaking of watery fluid from the vagina
• A sensation of pelvic pain and pressure

Investigations

Investigations that are performed to predict preterm birth in women include the following:

• Placental alpha microglobulin-1: This test is performed to predict spontaneous Preterm Birth in a woman who exhibits any signs and symptoms of Preterm Pregnancy
• Fetal fibronectin: Fetal Fibronectin (fFN) is a protein found between the amniotic membrane and uterine lining. A cervical or vaginal swab is taken and tested for fFN. A positive fetal fibronectin test indicates the risk of Preterm Pregnancy
• Obstetric ultrasound: Through the ultrasound, the length of the cervix is measured, which could determine the possibility of Preterm Pregnancy

Diagnosis

The diagnosis is made by reviewing the signs and symptoms and considering the investigation tests' results.

Treatment options

Medical treatment

Medical treatments for women with suspected preterm pregnancy include the following. These medications are prescribed based on gestational age:

• Steroid injections are given to the mother who is at risk of Preterm Birth to strengthen the baby's lungs and other organs
• Antibiotics are prescribed to newborns to prevent any infections
• Magnesium sulfate is prescribed to reduce the risk of cerebral palsy in newborns
• Tocolytic medications are given to help prolong pregnancy for a few hours or days
• Complete bed rest is recommended for the mother to prolong the gestational age
• Preterm Pregnancy babies are kept under ventilators to provide adequate warmth
• After the Preterm Birth, kangaroo mother care is provided. This therapy refers to keeping the mother in skin-to-skin contact with the baby and giving frequent breastfeeding to improve the baby's development.

Premature babies are kept in an incubator and kept warm to maintain normal body temperature. Sensors are taped on the baby’s body to monitor blood pressure, heart rate, breathing, and temperature continuously. A ventilator is also used to make breathing easy for the baby. A feeding tube is inserted to send fluids and nutrients. Breast milk is also collected from the mother and given to the baby through the feeding tube. The feeding tube is kept until the baby is strong enough to suck.
As infants are prone to developing infant jaundice, preterm babies are kept under a set of bilirubin lights for a short period. These light rays break down extra bilirubin because the liver is still developing and cannot perform this function effectively. In very rare cases, preterm babies even require a blood transfusion to increase the blood volume.

Interventional Treatment Including Surgery And Indications For Surgery/ Surgical Treatment

Surgical intervention includes cervical cerclage. This is a procedure in which the cervix is stitched closed. This is done when the cervix is weak and cannot be closed. If the cervix is weak, it can break open easily, leading to preterm birth.
In very few cases, Preterm Pregnancy can cause serious complications that may require a surgical procedure for the baby's survival.

Role of Diet/ Exercise/ Lifestyle Changes/ Preventive Measures

The following are to be followed during pregnancy to prevent preterm pregnancy:

• Proper prenatal care
• A balanced diet is rich in nutrition
• Regular gentle exercises and breathing exercises
• Reducing stress level
• Avoiding tobacco smoking, consumption of alcohol, and usage of illicit drugs
• Taking folic acid as prescribed by the physician to reduce Preterm Birth and other birth defects
• Taking vitamin supplements, iron, and calcium as prescribed by the physician
• Avoiding exposure to toxic chemicals such as carbon monoxide
• Avoiding domestic abuse
• Appropriate prenatal care
• If working, avoiding night shifts to decrease the risk of Preterm Pregnancy

Specialized care is taken for preterm babies after pregnancy in the hospital and after discharge from the hospital. The breathing and feeding of the baby are monitored. Since premature babies are more prone to infections, precautions are taken to avoid crowded places, unnecessary travelling, or contact with sick people.
Regular follow-ups and checkups with a physician are mandatory. Immunizations or vaccinations are to be given at an appropriate age. The growth and development of the child are regularly monitored, and if any disabilities are observed, early interventions are warranted as they lead to better outcomes.

Complications

Preterm birth poses a risk of various complications for the baby. Some complications arise soon after birth, while some develop in later stages of life. The earlier the baby is born, the higher the complications. Some of the complications include:

• Preterm babies require special care in the neonatal intensive care unit (NICU).
• Babies are at higher risk of developing breathing difficulties due to immature lungs. Respiratory complications such as respiratory distress syndrome and chronic lung diseases may develop.
• After delivery, half of the babies die due to a lack of appropriate thermal care and breastfeeding.
• There is a higher risk of developing infections such as sepsis, pneumonia, and urinary tract infections.
• Babies having breathing problems in the initial days of life are at an increased risk of developing asthma.
• Preterm babies would have immature brain development, which may, in the long run, lead to cerebral palsy and mental retardation. They also develop behavioural problems, which later can lead to social-emotional problems.
• Immature brain development also leads to learning difficulties and visual and hearing impairments.
• Preterm babies would have poor health and delayed growth and development.
• There is an increased risk of developing conditions such as attention deficit hyperactivity disorder (ADHD) and sudden infant death syndrome (SIDS).
• There is an increased risk of developing chronic diseases such as heart disease, hypertension, and diabetes. Heart complications such as patent ductus arteriosus.
• There is also an increased risk of developing conditions like anaemia, rickets, and jaundice.

Prognosis

Preterm Pregnancy is the leading cause of death in infants and children under 5 years of age. The survival rate of babies born preterm is very low. The babies that survive face severe or often lifelong disabilities. The chance of survival without long-term difficulties is significantly less. In many cases, preterm survivors lead a normal quality of life as they reach adulthood. However, they have an increased risk of developing various health problems.

When To Contact The Doctor?/ How To Identify The Complications?

Medical consultation is recommended immediately after observing any regular uterine contractions or other signs and symptoms of preterm pregnancy.

Indications For Hospitalization

Preterm Pregnancy requires immediate hospital admission. Babies who are born prematurely need admission to NICU. NICU provides specialized care to the babies where their vital signs are monitored. Along with vital signs, body fluids and the progression of their growth are monitored. Stay in the NICU can be a few weeks to months, depending upon the type of preterm birth. Preterm pregnancy and preterm birth require hospitalization and care with maternal-fetal medicine (MFM) specialist, a neonatologist, and other pediatric subspecialists. Even after going home, these babies need specialized care.

Screening Methods

Some of the screening tests that are done to predict preterm birth include:

• Screening for asymptomatic bacteriuria in mother
• Ultrasound examination to determine the length of the cervix

Suggested Clinical Specialists/ Departments To Consult For This Condition

Obstetrics and Gynaecology

Additional Information

• WHO has recommended new guidelines to improve the outcomes of preterm birth. These guidelines include the following:
• Providing steroid injections to mothers during pregnancy
• Providing antibiotics at the time of early induction of labor
• Providing magnesium sulfate to prevent future neurological impairments in the child
• Providing thermal care to the prematurely born infant
• Providing kangaroo mother care therapy and breastfeeding to the newborn infant
• Providing oxygen and other interventions that could help the baby breathe better