Premature labor. The threat of preterm birth: causes, signs, timing, management of childbirth

Despite the current medical equipment that can save the life of a premature baby weighing only 500 g, the diagnosis of threatened preterm birth instills fear in every pregnant woman. What threatens such a condition to a future woman in labor, is there a chance to prevent this scenario and what you need to know about premature birth is the main topic of this article.

According to the international classification, premature delivery is called between 22 and 38 gestational weeks. A few years ago, such a diagnosis was announced only after 28 weeks, because before that time a woman had a miscarriage and the baby died, because it was impossible to save him.

The outdated classification recognized premature birth from 28 to 37 weeks (the weight of the crumbs was more than 1 kg). If the child was born sooner, his weight was equal to 0.5-1.5 kg and he lived or lived for more than 7 days, such a case was also counted as premature delivery. In all other cases, a late miscarriage occurred.

Now modern equipment allows you to nurse tiny babies weighing 500 g or more. For this, special boxes are used, which play the role of the mother's body. But not all medical institutions have the necessary equipment and medicines. Yes, and nursing a premature baby is not cheap, so it is not always possible to save a newborn weighing less than 1 kg.

Depending on the gestational age, the threat of preterm birth (code 060 according to ICD 10) is:

• early birth process - starts at 22-27 gestational weeks; the fetus weighs from 0.5 to 1 kg;
• early premature birth - 28-33 weeks, the baby's weight approached 2 kg;
• full-fledged premature birth - gestational age 34-37 weeks; the child is already sufficiently formed for a full life, his weight is about 2.5 kg.

Threat of preterm labor and weeks of pregnancy

In order to at least dispel the fears of women about premature birth, we can give optimistic statistics on childbirth at different gestational ages. Less than 9% of all births are preterm. And the fact that 8 women in labor out of 100 could not bring the baby to the end of pregnancy cannot but inspire hope.

Of this number of preterm births, 7% occur between 22 and 28 weeks. Of course, it is very difficult to nurse such babies and not all of them nurse them. But the operational work of neonatologists and the presence of specialized equipment gives a chance to save the newborn.

About 30% of babies are born between 27 and 33 weeks. They have a high survival rate and quickly catch up with their peers who were born at term. But they are still unable to fully breathe, so they need expensive treatment.

More than 60% of early births occur after 34 weeks of gestation. Newborn crumbs are quite a bit behind in weight, but their body fully works outside the womb. The survival rate of such children is close to 100%.

The threat of preterm birth - causes

Creates unfavourable conditions for the further bearing of the fetus, and then the threat of premature birth, many factors. Sometimes this happens for unknown reasons, and sometimes it is possible to accurately identify and eliminate the provoking factor.

Consider the causes of the pathological course of pregnancy known to medicine:

1. Endocrine diseases. There are several chronic disorders that can provoke premature delivery. This is an imbalance of female hormones, diabetes, hypo- or hyperthyroidism.
2. Untreated genital infections in a woman (for example, chlamydia, gonorrhea, ureaplasmosis, herpes) often become the culprits of unplanned childbirth. And even if the woman's condition was stabilized, there remains a risk of infection of the fetus and the formation of defects in it.
3. Gynecological diseases during gestation. Cervical erosion, vulvovaginitis, endometriosis, adenomatosis, salpingitis and other pathologies create conditions for premature birth with an unfavorable outcome for a woman.
4. Infections (for example, acute SARS, viral hepatosis, carious teeth) are a source of a dangerous infection that disrupts the normal course of pregnancy.
5. progesterone deficiency. Lack of progesterone (female hormone) causes miscarriage. The situation can be corrected by regular intake of Utrozhestan with the threat of premature birth.
6. Abnormal structure of the uterus. Congenital malformations, neoplasms, adhesions and physical deformation of the uterus caused by surgery most often provoke uterine contraction, as well as insufficiency of the cervical canal. A woman rarely manages to carry a baby even up to 17 weeks, because under the weight of the fetus, the cervix opens and a miscarriage occurs.
7. Non-communicable somatic diseases (for example, heart disease, vitamin and amino acid deficiency, kidney, liver failure, etc.). They cause exhaustion of the body and disrupt the course of pregnancy.
8. Abnormal fetal development. Breakdowns at the genetic level and all kinds of defects often end in miscarriage in the first trimester. In some cases, the body decides to get rid of the defective fetus at a later date, and the woman starts giving birth. Most often, there is a threat of premature birth between 22 and 28 weeks.
9. Complicated gestation. Multiple pregnancies, polyhydramnios, preeclampsia, abnormal position of the fetus and other conditions that aggravate pregnancy can pose a threat of premature birth.
10. Misbehavior of a pregnant woman. Drinking alcohol, smoking, lifting weights, stress, inadequate sleep are frequent provocateurs of the threat of early childbirth.

Important! Any trauma in the abdomen can cause a threat of premature birth. Therefore, a woman should be especially careful to avoid falls, bumps and other physical influences on the stomach.

The first signs of threatened preterm birth

The clinical manifestations of the threat of premature birth at first are somewhat similar to the symptoms of a miscarriage. If you turn to an obstetrician-gynecologist in time, the outcome is favorable. Most often, a woman is sent to a hospital for preservation. It is difficult to predict how much you will have to lie with the threat of premature birth. There are times when the condition stabilizes and the woman is discharged, and it also happens that she remains in the hospital until the birth.

If the first signs are ignored, amniotic fluid flows out and the woman begins childbirth. In this situation, it remains only to wait for the birth of the baby and provide him with the necessary help to save him.

To prevent an unplanned delivery, you should pay attention to the following symptoms of threatened preterm birth:

• Threatened preterm birth can be recognized by barely perceptible pains below the navel, a feeling of heaviness or contraction in the uterus, a change in the motor activity of the fetus, strange secretions (mucus with blood). Appeal to the doctor and compliance with his recommendations allows you to stop the pathological process. When opening the cervix or diagnosing isthmic-cervical inferiority, a woman is given a ring if there is a threat of premature birth.
• Beginning premature birth. The symptomatic picture is much brighter. A woman notices severe pain in the lower back, cramping painful sensations appear from the bottom of the abdomen. Perhaps the discharge of the mucous plug, the outflow of water, the development of bleeding. The uterus, as a rule, softens and is already open. If, with the threat of premature birth, timely treatment is prescribed, there is a chance to delay childbirth for a while.
• Started premature birth process. Once the process of childbirth has begun, it can no longer be slowed down. And no injections with the threat of premature birth can prevent the early birth of a baby. A woman experiences all the symptoms of childbirth: severe pain, contractions, attempts.

The threat of premature birth: what to do?

If the slightest symptoms of the threat of premature birth appear, a woman needs to consult a doctor. Early intervention can save a child's life. After all, even a few extra days spent in the womb can be decisive.

It is very dangerous to go to the hospital on your own. Any shaking on the road can aggravate the situation, so it is better to wait for the ambulance to arrive. It is also important that the woman is brought to a department that specializes in premature babies. If the threat cannot be eliminated, the child will have every chance of surviving.

After calling an ambulance, you can take a sedative - a valerian tablet or motherwort tincture. Two tablets of Nosh-pa will not hurt either. Before the doctors arrive, it is better to lie down and try not to worry.

After contacting an obstetrician-gynecologist, it is important to follow all the recommendations and take the prescribed drugs if there is a threat of premature birth. Any frivolity on the part of a woman can result in the loss of a child.

The support of relatives and the atmosphere in the family is especially important. It has long been proven that stress, moral violence at home, unreasonable experiences play an important role in the development of the threat of preterm birth. Therefore, you need to take a responsible attitude to your psychological state and, if there is a need, ask for help from a specialist.

Treatment of threatened preterm birth

Therapy of the threat of early delivery is aimed at stopping and delaying the onset of labor. A woman is always hospitalized, and if there is still time to carry out conservation measures, they are prescribed drug treatment. As a rule, it consists of a dropper at the threat of preterm labor to reduce uterine tone, sedatives and restorative drugs.

• Drug treatment involves tocolysis in women. This treatment consists in suppressing the contractile activity of the uterus, which allows you to temporarily suspend labor activity. First of all, magnesia is administered intravenously to a woman with the threat of premature birth. It quickly relaxes the smooth muscles of the body of the uterus, relieves pain, stops pathological contractions. This treatment has only been shown for early stages threat development.
• Also use beta-agonists, which also prevent premature birth. Ginipral, Fenoterol, Salbutamol are used with great success to stop the threat of premature birth.
• To enhance the effect of the latter, calcium channel blockers are prescribed. They are taken 30-40 minutes before the intravenous administration of adrenomimetics. Nifedipine is considered the most effective blocker for the threat of preterm birth. It is used only in the most critical period of maintaining pregnancy and after stabilization of the condition is canceled. And Ginipral is transferred from intravenous administration to oral administration and is taken until 36-38 gestational weeks.

Important! The formation of a threat of preterm labor between 25 and 34 weeks involves the introduction of glucocorticoids, which help respiratory system fetus to form sooner. In order for the full opening of the alveoli of the lungs in a premature baby, Dexamethasone is used with the threat of premature birth.

• Additionally, sedative therapy is carried out to stabilize the psycho-emotional background of a pregnant woman. Drugs allowed during pregnancy are Oxazepam and Diazepam.
• If a rapid increase in prostaglandins that cause fetal rejection is diagnosed, a course of Indomethacin is carried out in the form of rectal suppositories from 14 to 32 gestation weeks.
• Special attention is paid to the cause of such a pathology. So, if the threat of premature birth was provoked by an infection, antibiotic therapy is carried out. The use of antibiotics is also relevant when the waters break before the 33rd gestational week. This helps protect the baby from infection. After 34 weeks, when the waters break, childbirth does not stop.
• If a woman has isthmic-cervical inferiority of the cervical canal of the uterus, for up to 28 weeks, suturing is performed under local light anesthesia. This prevents the opening of the cervix and prolapse of the fetus. At a later gestational age, the Golgi ring is attached to the cervix.

Important! Even if a woman has a successful pregnancy, the threat of premature birth, although scanty, still exists. Therefore, it is important to know the first signs of such a pathology.

How to prevent preterm labor

Not a single woman is insured against unplanned childbirth, so no one has canceled prophylaxis. Significantly reduce the risk of such an outcome of pregnancy helps good preparation of your body before conception and correct behavior after pregnancy.

What do we have to do:

1. Pass a comprehensive examination. At this stage, it is necessary to identify and cure chronic diseases, eliminate abnormal features of the uterus, and treat sexual infections.
2. Timely visit the antenatal clinic and register. It is important to immediately discuss with the gynecologist the existing health problems, to provide the results of the past examination at the planning stage.
3. Avoid contact with sick people during pregnancy.
4. Reduce or eliminate excessive physical exercise and isolate yourself from stressful situations.
5. Pass absolutely all tests according to the pregnancy schedule.
6. Monitor your well-being, and if you suspect, immediately consult a doctor.

Compliance with these simple rules can reduce the chance of a threat of premature birth at any time.

No matter how much you want to delay the moment of hospitalization, remember that you are risking not only your own health, but also the life of your unborn baby. Do not ignore dangerous symptoms and do not be afraid to seek help. Doctors will do everything in their power to keep you pregnant. And you just have to unquestioningly follow their appointments.

Video "What is the reason for the development of the threat of premature birth"

Preterm birth is one of the most important aspects of maternal and child health. Premature babies account for 65-70% of early neonatal and infant mortality. Stillbirth in preterm births is observed many times more often than in timely ones. Perinatal mortality in premature newborns is 30-35 times higher than in full-term ones.
In Russia, it is customary to consider preterm birth that occurs between 28 and 37 weeks of gestation with a fetal weight of 900 g or more. However, in the coming years in Russia, the statistics of preterm birth, as well as perinatal morbidity and mortality, will be carried out according to WHO recommendations, according to which perinatal mortality is recorded from the 22nd week of pregnancy with a fetus weighing more than 500 g. According to these criteria, in the United States, the frequency of preterm birth in 2005 was 9.7%, in the UK - 7.7%, in France - 7.5%, in Germany - 7.4%. In connection with the terms of pregnancy adopted in our country, the frequency of premature births ranges from 5.4-7.7%.
The causes of preterm labor are multifactorial. Risk factors for preterm birth are both socio-demographic (disorder family life, low social level, young age), and clinical causes. Every third woman who has a premature birth is a primigravida, in which risk factors include previous abortions or spontaneous miscarriages, urinary tract infections, and inflammatory diseases of the genitals. An important role in the occurrence of preterm labor is also played by the complicated course of this pregnancy, the development mechanism of which allows us to identify the main causes.
Based on many years of experience in research and clinical work on the problems of habitual pregnancy loss and premature birth, V.M. Sidelnikova identifies the following main reasons for the latter.
. Infection - acute and/or chronic, bacterial and/or viral - is one of the main causes.
. Maternal and/or fetal stress due to the presence of extragenital pathology, pregnancy complications and placental insufficiency, which leads to an increase in the level of fetal and/or placental corticotropin-releasing hormone and, as a result, to the development of premature birth.
. Thrombophilic disorders that lead to placental abruption, thrombosis in the placenta. High level thrombin can provoke an increase in prostaglandin production, protease activation and placental abruption, which is the most common cause early delivery.
. Overdistension of the uterus in case of multiple pregnancy, polyhydramnios, malformations of the uterus, infantilism leads to the activation of oxytocin receptors, etc. - and to the development of premature birth.
Often there is a combination of these factors in the development of preterm birth. The appearance of symptoms of activation of the contractile activity of the uterus, that is, symptoms of threatening premature birth, is the final link in a complex chain of activation of the contractile activity of the uterus. Without knowledge of the causes of preterm labor, there can be no successful treatment. Currently, all treatment of the threat of interruption is reduced to symptomatic treatment - the use of funds to reduce the contractile activity of the uterus. This explains why, with a huge number of different tocolytic drugs in our arsenal, the frequency of preterm birth in the world does not decrease, and the decrease in perinatal mortality is mainly due to the success of neonatologists in nursing premature babies.
In connection with the foregoing, the tactics of managing and treating the threat of preterm labor should take into account the possible causes of their development, and not consist only in the appointment of symptomatic agents aimed at reducing the contractile activity of the uterus.
Treatment tactics are determined by many factors, such as gestational age, the condition of the mother and fetus, the integrity of the fetal bladder, the nature of the contractile activity of the uterus, the degree of changes in the cervix, the presence of bleeding and its severity.
The duration of pregnancy is closely related to the causes of preterm birth. According to WHO recommendations, preterm birth is divided according to gestational age into very early preterm birth - 22-27 weeks of gestation, early preterm birth - 28-33 weeks and preterm birth - gestational age of 34-37 weeks. This division is due to different management tactics and different pregnancy outcomes for the fetus.
It depends on the state of health of the mother whether it is possible to prolong the pregnancy or whether it is advisable to deliver it ahead of schedule. The condition of the fetus is assessed special methods: ultrasound scanning, doppler examination of blood flow in the mother-placenta-fetus system, cardiotocography. If the condition of the fetus allows, it is necessary to prolong the pregnancy at least for the time necessary for the prevention of fetal respiratory distress syndrome.
The integrity of the fetal bladder has great importance when choosing tactics. With a whole fetal bladder, expectant tactics and therapy aimed at prolonging pregnancy are possible. With premature outflow of amniotic fluid or a high lateral rupture of the fetal bladder, tactics are determined by the presence or absence of infection, the nature of the presentation of the fetus, etc.
Depending on the nature and activity of the contractile activity of the uterus and the degree of changes in the cervix, expectant management can be chosen, aimed at prolonging pregnancy. Conservative tactics are possible in the state of health of the mother and fetus, which allows prolongation of pregnancy, with a whole fetal bladder, with cervical dilatation no more than 2 cm, in the absence of signs of infection.
When choosing expectant management tactics in case of a threat of preterm birth, it is necessary to:
. decide on a case-by-case basis which type of tocolytic therapy should be used;
. accelerate the "maturation" of the lungs of the fetus by preventing fetal respiratory distress syndrome, as well as improve its condition;
. determine the alleged cause of the threat of preterm labor (infection, placental insufficiency, thrombophilic disorders, pregnancy complications, extragenital pathology, etc.) and treat pathological conditions in parallel with the treatment of the threat of interruption.
Distinguish threatening, beginning and begun premature birth. Threatening preterm birth is characterized by intermittent pain in the lower back and lower abdomen against the background of increased uterine tone. In this case, the cervix remains closed. When starting premature birth, there are usually cramping pains in the lower abdomen, accompanied by a regular increase in the tone of the uterus (contractions). The cervix is ​​shortened and opened. At the same time, premature rupture of amniotic fluid often occurs.
Preterm birth is characterized by: untimely discharge of amniotic fluid; weakness of labor activity, discoordination or excessively strong labor activity; fast or rapid childbirth or, conversely, an increase in the duration of labor; bleeding due to placental abruption; bleeding in the afterbirth and early postpartum periods due to retention of parts of the placenta; inflammatory complications both during childbirth and in the postpartum period; fetal hypoxia.
If symptoms occur that indicate the possibility of preterm labor, treatment should be differentiated, since in the beginning of childbirth, treatment can be carried out aimed at maintaining the pregnancy. Bed rest, sedatives, antispasmodics, etc. are prescribed. The main drugs that can successfully resist untimely termination of pregnancy include tocolytic drugs, or tocolytics. These include all medications that relax the muscles of the uterus. There are many of these drugs now, and on the basis of studies of the contractile activity of the myometrium, more and more new drugs are being offered, some of which are at the stage of clinical trials. It should be noted that the search for new drugs is due to the fact that the frequency of preterm birth does not decrease, the effectiveness of many tocolytics is low, and there are many side effects on the mother and fetus.
Nevertheless, the use of tocolytic agents is extremely important and relevant, since, although they do not reduce the frequency of preterm labor, they inhibit the contractile activity of the uterus, help prolong pregnancy, prevent fetal respiratory distress syndrome, etc.
One of the most effective tocolytic drugs are?-mimetics - drugs used to treat threatened miscarriage after 24-25 weeks of pregnancy or preterm birth for more than 30 weeks. Preparations of this series (ritodrin, Ginipral, salbutamol, etc.) are derivatives of epinephrine and norepinephrine, released during stimulation of sympathetic nerve endings, and they are sometimes called sympathomimetics or adrenergists in the literature. The action of?-mimetics is carried out through?-receptors. Stimulation of?-receptors leads to contractions of smooth muscles, and?-receptors - to the opposite effect: to relax the muscles of the uterus, blood vessels, and intestines. The presence of ?-receptors in other tissues (in particular, in the muscles of the heart) determines the frequency of severity of side effects of ?-mimetics. α-receptors are divided into α1- and β2-receptors. The tocolytic effect is provided by acting through? 2 receptors on the uterus, bronchi, intestines, as well as on the formation of glycogen in the liver and insulin in the pancreas. On?-receptors of cardio-vascular system their influence is less pronounced.
The mechanism of action of ?-mimetics is manifested through adrenergic stimulation, which leads to an increase in the formation of cyclic adenosine monophosphate (cAMP) from ATP by activating the enzyme adenylate cyclase. Due to the action of cAMP, Ca2+ is released from the cells back into the depot and smooth muscles are relaxed. α-mimetics cause an increase in blood flow through tissues and organs, an increase in perfusion pressure, and a decrease in vascular resistance. The effect on the cardiovascular system is manifested by an increase in heart rate, a decrease in systolic and diastolic pressure. Such a cardiotropic effect of ?-mimetics must be taken into account during therapy with these drugs, especially when they interact with other drugs. medicines. Before the introduction of?-mimetics, it is necessary to control the level blood pressure and pulse rate. To reduce side cardiovascular effects, calcium channel blockers are prescribed - finoptin, isoptin, verapamil. As a rule, compliance with the rules for the use of ?-mimetics, the dosing regimen, and strict control over the state of the cardiovascular system make it possible to avoid serious side effects.
Additional effects from the use of?-mimetics include: an increase in circulating blood volume and heart rate, as well as a decrease in peripheral vascular resistance, blood viscosity and plasma colloid-oncotic pressure.
IN last years data have been obtained that with long-term use of α-mimetics, a decrease in their effectiveness is observed. In addition, ?-adrenergic receptors are sensitive from 24-25 weeks of gestation; in earlier periods of pregnancy, the effect of their use is not so pronounced. If the threat of preterm labor is accompanied by an increase in the tone of the uterus, and not by contractions, then the effect of the use of?-mimetics is low, since they reduce the contractile activity of the uterus, and the tone decreases very slowly.
In Russia, the most common and frequently used drug from the group of?-mimetics is Ginipral - hexoprenaline. It is a selective?2-sympathomimetic that relaxes the muscles of the uterus. Under its influence, the frequency and intensity of uterine contractions decreases. The drug inhibits spontaneous, as well as labor pains caused by oxytocin; normalizes excessively strong or irregular contractions during childbirth. Under the influence of Ginipral, in most cases, premature contractions stop, which, as a rule, allows you to prolong the pregnancy to full term. Due to its? 2-selectivity, Ginipral has little effect on the cardiac activity and blood flow of the pregnant woman and fetus.
Ginipral consists of two catecholamine groups, which in the human body are methylated by catecholamine-O-methyl-transferase. While the action of isoprenaline is almost completely stopped by the introduction of one methyl group, hexoprenaline becomes biologically inactive only if both of its catecholamine groups are methylated. This property, as well as the high ability of the drug to adhere to the surface, are considered the reasons for its long-term effect.
Indications for the use of Ginipral are:
. Acute tocolysis - inhibition of labor pains during childbirth with acute intrauterine asphyxia, immobilization of the uterus before caesarean section, before turning the fetus from a transverse position, with umbilical cord prolapse, with complicated labor activity. As an emergency measure in preterm labor before taking the pregnant woman to the hospital.
. Massive tocolysis - inhibition of premature labor pains in the presence of a smoothed cervix and / or opening of the cervix of the uterus.
. Prolonged tocolysis - prevention of preterm labor with increased or frequent contractions without smoothing the cervix or opening the cervix. Immobilization of the uterus before, during and after surgical correction of isthmic-cervical insufficiency.
Contraindications to the appointment of this drug: hypersensitivity to one of the components of the drug (especially patients suffering from bronchial asthma and hypersensitivity to sulfites); thyrotoxicosis; cardiovascular diseases, especially cardiac arrhythmias occurring with tachycardia, myocarditis, malformation mitral valve and aortic stenosis; cardiac ischemia; severe liver and kidney disease; arterial hypertension; intrauterine infections; lactation.
Dosage. In acute tocolysis, 10 μg of Ginipral, diluted in 10 ml of sodium chloride or glucose solution, is used (introduced slowly intravenously over 5-10 minutes). If necessary, continue administration by intravenous infusion at a rate of 0.3 µg/min. (as in massive tocolysis).
With massive tocolysis - at the beginning, 10 μg of Ginipral slowly intravenously, then - intravenous infusion of the drug at a rate of 0.3 μg / min. You can enter the drug at a rate of 0.3 mcg / min. and without prior intravenous injection. Introduce intravenously (20 drops = 1 ml).
As the first line of aid in case of threatened abortion after 24-25 weeks of pregnancy or the threat of preterm labor, Ginipral is prescribed at the rate of 0.5 mg (50 μg) in 250-400 ml of saline intravenously, gradually increasing the dose and rate of administration (maximum 40 drops / min.), combining infusion with the intake of calcium channel blockers (finoptin, isoptin, verapamil) under the control of pulse rate and blood pressure parameters. 20 minutes before the end of the intravenous infusion, 1 tablet of Ginipral (5 mg) per os every 4 hours.
Reducing the dose of Ginipral should be carried out after the complete elimination of the threat of interruption, but not less than 5-7 days later (reduce the dose, and not lengthen the time interval between taking the drug dose). Based on the long-term use of Ginipral, it has been established that the effectiveness of its use is about 90%.
Thus, accumulated over decades of domestic and Foreign experience indicate that despite the ever-increasing arsenal of tocolytic agents, today there are no more effective means to suppress the contractile activity of the uterus, i.e. threats of preterm birth than?-mimetics, and, in particular, Ginipral.

Premature births are those that occur between 22 and 37 weeks of gestation, inclusive, with a fetal weight of 500 to 2500 grams. Preterm births account for 5-10% of all births.

Classification of preterm birth

By deadline all preterm births are divided into:

Very early (term 22-27 weeks of pregnancy inclusive with a fetal weight of 500 to 1000 gr.);

Early (for a period of 28-33 weeks with a fetal weight from 1000 to 2000 gr.);

Premature birth (in the period of 34-37 weeks with a fetal weight of 2000 to 2500 gr.).

Most often, preterm births (more than 50% of all cases) occur at 34-37 weeks of gestation with the most favorable outcome and a high percentage of fetal survival.

Childbirth at a period of 22-27 weeks with the viability of the child for 7 days is considered premature, otherwise it is considered a late miscarriage.

With the flow distinguish:

Spontaneous preterm birth (make up about 80% of all preterm births);

Artificially induced (indications - severe diseases and conditions that threaten the life of a woman, intrauterine death of the fetus, fetal malformations incompatible with life).

By stages of development distinguish between premature births:

Threatening (accompanied by pulling pains in the lower back and lower abdomen, tone or contractions of the uterus, the cervix is ​​​​closed);

Beginning (characterized by clearly expressed cramping pains, sanious discharge, discharge of the mucous plug, cervical dilatation 1-2 cm, possible outflow of water);

Started (with the presence of regular contractions with intervals between them less than 10 minutes, rupture of the membranes, discharge of amniotic fluid, dilatation of the cervix more than 2 cm, bloody discharge from the genital tract, the presenting part of the fetus is located at the entrance to the small pelvis).

Causes of preterm birth

1.Related to women's health problems

Gynecological (malformations of the uterus, the consequences of abortion - scars and adhesions, isthmic-cervical insufficiency - weakness of the muscles of the cervix, which cannot withstand the growing pressure from the fetus);

Infectious (acute and chronic diseases of the genital and other organs of an infectious nature);

Endocrine (diseases of the endocrine glands, accompanied by a violation of their function).

2.Related to fetal health problems ( various deviations from the norm and malformations of the fetus, hereditary diseases).

3. Complications of the current pregnancy (severe forms of preeclampsia, Rhesus conflict, incorrect position of the fetus, polyhydramnios and multiple pregnancies, placenta previa or abruption, outflow of water).

4. Socio-economic factors (physical labor, unfavorable living conditions, bad habits, poor nutrition, stress, the woman's age is less than 18 and more than 35 years).

Management of preterm birth

If there is a threat of premature birth, it is urgent to call an ambulance, lie down, take a sedative and 2-4 no-shpa tablets. The sooner you seek help, the more likely you are to maintain your pregnancy and prevent unwanted preterm labor. Remember that every week spent in the mother's belly significantly increases the chances of your child to survive and have a successful pregnancy!

In the hospital, the cause of premature birth is clarified, the condition of the woman, the baby and the fetal bladder is assessed, the gestational age and the estimated weight of the fetus, as well as the stage of development of premature birth, are determined.

Complete physical rest and bed rest are prescribed. Measures are being taken to eliminate the causes of premature birth and pregnancy-preserving therapy (drugs are introduced that suppress uterine contractions and reduce its excitability). In parallel with this, therapy is prescribed to increase the viability and maturation of the fetus. Prevention of the so-called distress syndrome of the newborn (a number of respiratory dysfunctions due to lung immaturity) is being carried out. The condition of the woman and the child is constantly monitored.

If it is impossible to save the pregnancy (the stage of the onset of preterm labor, discharge of water, etc.), the question of the method of delivery is considered. Premature births are necessarily anesthetized.

A caesarean section is performed if the estimated fetal weight is less than 2000 grams, and the gestational age is less than 34 weeks, with breech presentation of the fetus, the presence of diseases of the cardiovascular system in the mother, and uterine bleeding.

Complications of preterm birth

Premature births are more traumatic for the mother and baby than full-term births, and complications after them occur much more often.

Preterm labor in most cases is rapid, since the birth of a premature baby does not require full disclosure of the cervix. Due to the rapid passage through the birth canal, birth injuries in the fetus and soft tissue ruptures in the mother are possible.

Less common is weak labor activity, in which the duration of labor increases and fetal hypoxia develops.

Even less often, discoordinated labor activity is observed, in which the order of contractions is disturbed, the contractions are more painful, and in the intervals between them there is no complete relaxation of the muscles of the uterus.

The percentage of infectious complications after preterm birth, such as endometritis (inflammation of the uterus) and suppuration of the sutures, is much higher than after delivery at term. Very rarely, sepsis (generalized infection) and peritonitis (inflammation of the peritoneum) can occur.

Prevention of preterm birth

First of all, the prevention of preterm birth includes the elimination possible causes(most often, infections) even at the stage of pregnancy planning;

Early registration in the antenatal clinic, regular monitoring of pregnancy, especially if there is a history of premature birth, abortion or spontaneous miscarriage;

Timely delivery of tests, detection and treatment of infections during pregnancy;

Prevention, detection and treatment of complications arising during pregnancy;

Regular ultrasound monitoring of fetal development;

Mandatory hospitalization and treatment in the event of threatening preterm birth.

Termination of pregnancy in the period of 28-37 weeks is called premature birth. Termination of pregnancy in the period from the 22nd week to the 28th week, according to the rules World Organization health care, refer to very early preterm birth. In our country, termination at this stage of pregnancy is not considered a premature birth, but at the same time, they provide assistance in a maternity hospital, and not in a gynecological hospital, and take measures to care for a very premature newborn. A child born as a result of such childbirth is considered a fetus for 7 days, only after a week such a baby is considered not a fetus, but a child. This feature of the terminology is due to the fact that children born before the 28th week of pregnancy are often unable to adapt to the conditions environment outside the womb, even with the help of doctors.

Causes of preterm birth

Factors leading to preterm birth can be divided into socio-biological and medical.

It should be noted that in autumn and spring months the frequency of this complication is increasing. This is due to changing weather conditions, in particular the frequent change atmospheric pressure, which may affect the incidence of premature rupture of amniotic fluid. Severe colds with a high rise in body temperature and a strong cough can increase and cause labor prematurely. An adverse effect on the course of pregnancy of a number of production factors was noted: chemical substances, vibration, radiation, etc. Premature births are more common in young, unmarried, studying women, with a lack of protein and vitamins in food, as well as in women with bad habits.

Medical factors include severe infectious diseases, including those suffered in childhood, abortions, inflammatory diseases of the genital organs. Chromosomal disorders of the fetus - damage to the hereditary apparatus of the fetus under the influence of adverse external and internal factors (ionizing radiation, occupational hazards, taking certain drugs, smoking, drinking alcohol, drugs, unfavorable environmental situation, etc.) - can lead to premature birth, but more often in In such cases, early termination of pregnancy occurs. In most cases, the cause of premature births are diseases of the endocrine system, such as dysfunction of the thyroid gland, adrenal glands and ovaries, obesity, in which the work of all endocrine glands changes. Anatomical changes in the genital organs include genital infantilism (underdevelopment of the female genital organs), malformations of the uterus, traumatic damage to the uterus during abortions and curettage, tumors of the uterus. In almost one third of cases, the cause of preterm birth is isthmic-cervical insufficiency, in which, as a result of mechanical influences (trauma of the cervix after abortion, previous childbirth, other gynecological manipulations) or a lack of certain hormones, the cervix does not perform its obturator function.

Often the cause of premature birth is cervico-vaginal infections (trichomoniasis, mycoplasma, chlamydia, etc.) and viral infections (cytomegalovirus, herpes, influenza, adenovirus infection, mumps), especially those that are hidden. The presence of a chronic genital infection contributes to the disruption of the local protective barrier and fetal injury. Severe forms of extragenital diseases (not associated with the female genital organs) and pregnancy complications can also lead to preterm pregnancy. Such diseases include, for example, hypertension, cardiovascular diseases, anemia, chronic diseases of the lungs, kidneys, liver, etc.

Symptoms of the onset of labor

With the onset of preterm labor, regular labor activity and smoothing or opening of the cervix appear. The onset of labor is accompanied by the appearance of regular cramping pains in the lower abdomen, which increase in intensity over time, the intervals between contractions decrease. Quite often, premature birth begins with the outflow of amniotic fluid, and their amount can be from a few drops to several liters. In addition, the appearance of a woman's mucous discharge with streaks of blood or bloody discharge during a premature pregnancy indicates structural changes in the cervix, i.e. e. its smoothing. The appearance of any of the above symptoms requires urgent hospitalization in an obstetric hospital.

At the slightest suspicion of a deviation from the normal course of pregnancy, it is necessary to seek qualified help.

If these symptoms appear, you should immediately call an ambulance, which will deliver future mother to the hospital. In some cases, it is possible to prolong the pregnancy; if this is not possible, then conditions are created in the hospital for careful delivery - childbirth, during which a still very fragile baby experiences the least possible load.

Features of the course of childbirth

In preterm birth, premature rupture of amniotic fluid, weakness and dysfunction of labor, rapid or impaired regulatory mechanisms, and fetal hypoxia are more often observed.

Premature rupture of amniotic fluid is more often manifested in isthmic-cervical insufficiency or the presence of infection. The lower pole becomes infected, and as a result of inflammation, the membranes are easily torn. Normally, the fetal bladder ruptures closer to the full opening of the cervix, that is, already with the development of labor. A woman's sensations can be different: from a small wet spot on her underwear to a large number water flowing from the vagina and flowing down the legs. The water should be clear, but can be cloudy and dark brown (in the presence of infection). Births that occurred ahead of schedule, very often proceed quickly or even rapidly. A woman has rather painful contractions, their frequency increases, the intervals between contractions are less than 5 minutes and quickly decrease to 1 minute, the first stage of labor (until the cervix is ​​fully dilated) is reduced to 2-4 hours. Due to the fact that the head of a premature fetus is smaller, the expulsion of the fetus begins when the cervix is ​​not fully opened. A smaller baby passes through the birth canal faster.

Premature baby

A child born as a result of premature birth has signs of prematurity, which are determined immediately after birth. The body weight of such a newborn is less than 2500 g, the height is less than 45 cm, there is a lot of cheese-like lubricant on the skin, the subcutaneous tissue is not sufficiently developed, the ears and nasal cartilages are soft. The nails do not go beyond the tips of the fingers, the umbilical ring is located closer to the bosom. In boys, the testicles are not lowered into the scrotum (this is determined by touch), in girls, the clitoris and labia minora are not covered by the labia majora, the cry is squeaky. It should be noted that the presence of one sign is not an indisputable proof of the prematurity of the child, the prematurity of the fetus is determined by the combination of signs.

Unlike timely births, there are more complications in preterm births. Firstly, the baby's head does not have time to adapt to the mother's pelvic bones and reconfigure. The configuration of the head is the possibility of displacement of the bones of the fetal skull during childbirth to reduce its volume when passing through the birth canal. This mechanism allows you to reduce the pressure on the head and cervical region spine of a newborn baby. The bones of the skull of a premature baby are rather soft and cannot provide protection for the brain, the risk of trauma, hemorrhages under the membranes in the brain tissue of the fetus during childbirth increases. As a result, the child may experience hemorrhages, he does not have time to adapt to changes in the environment, his regulatory system is disturbed. Secondly, often a woman gets ruptures of the birth canal (cervix, vagina and external genitalia), as the tissues do not have time to adapt to stretching.

With threatening and beginning childbirth, a woman is urgently hospitalized.

Much less often in preterm birth, weakness of labor activity occurs. Weakness can be manifested by weak, infrequent or short contractions. The time of childbirth increases significantly, the woman gets tired, the child also begins to suffer. Other anomalies of labor activity are possible, for example, the strength and frequency of contractions is sufficient, and the cervix does not dilate. All this is associated with a violation of regulatory systems in preterm birth, there is no sufficient hormonal preparation for childbirth. Infectious complications in childbirth and the postpartum period are much more common in both the mother and the fetus. Among these complications are suppuration of the sutures (if any), postpartum metroendometritis (inflammation of the mucous membrane and muscular layer of the uterus), peritonitis (inflammation of the peritoneum) and the maximum spread of infection (sepsis). This is due to the presence of a latent or overt infection that was present before childbirth in a pregnant woman, which is often the cause of miscarriage. Infection can join during childbirth, due to their duration (with weakness), for example, chorioamnionitis (inflammation of the membranes of the embryo). Premature babies have reduced immunity and, accordingly, are more susceptible to infections.

Prognosis for a child

Due to the peculiarities of obstetric tactics and the different outcome of childbirth for the fetus, it is considered appropriate to divide preterm birth into three periods, taking into account the timing of gestation (pregnancy): preterm birth at 22-27 weeks, preterm birth at 28-33 weeks, preterm birth at 34- 37 weeks of gestation.

Premature birth at 22-27 weeks (fetal weight from 500 to 1000 g) is most often caused by isthmic-cervical insufficiency (due to trauma in previous births), infection of the lower pole of the fetal bladder and premature rupture of the fetal bladder. Therefore, in this group of women, as a rule, there are few primigravidas. The presence of infection in the genital tract excludes the possibility of prolonging pregnancy in most pregnant women. The lungs of the fetus are immature, and it is not possible to accelerate their maturation by prescribing medications to the mother in a short period of time. Such children belong to the high-risk group and are more often subject to urgent resuscitation. They are in incubators, under the strict supervision of a neonatologist and qualified nurses. Children almost always need a further stage of nursing and are registered for a long time in perinatal centers or clinics at the place of residence.

Premature birth at a gestational age of 28-33 weeks (fetal weight 1000-1800 g) is due to more diverse causes than earlier preterm birth. There are more than 30% of primigravidas in this category of childbirth.

More than half of women carry out expectant management and maintain pregnancy. In such children, the lungs do not have time to "ripen", the production of surfactant is disrupted. Surfactant is a mixture of fats and proteins that is synthesized in the large alveoli (the building block of the lungs), coating them, promoting their expansion and preventing them from collapsing when inhaled. In the absence or deficiency of this substance, the child's breathing is disturbed. A surfactant preparation can be administered to neonates as needed and greatly facilitates breathing, but this preparation is very expensive and not readily available. Therefore, in order to prevent respiratory failure, women are prescribed glucocorticoids. They stimulate the production of surfactant and the "maturation" of the lungs in the fetus for 2-3 days with the threat of preterm birth. With the onset of labor, glucocorticoids are administered intravenously at intervals of 3-4 hours.

Premature births at a gestational age of 34-37 weeks (fetal weight 1900-2500 g or more) are due to even more diverse reasons, the percentage of infected women is much less than in the previous groups, and primigravidas - more than 50%. However, due to the fact that the lungs of the fetus are almost mature, it is not necessary to administer drugs that stimulate the maturation of the surfactant.

Children are less likely to be transferred to the intensive care unit, but round-the-clock care and supervision are necessary in all cases until the child's condition is completely stabilized.

Nursing features

Premature babies, after examination by a neonatologist, are most often immediately transferred to the intensive care unit, and if necessary, to the intensive care unit. They are monitored around the clock, cared for and treated, as well as preventive measures are taken. possible complications. Premature babies have imperfect thermoregulation, they can be in an incubator, where temperature regime, humidity, oxygen levels, etc. They have a tendency to respiratory disorders, reduced resistance to environmental factors, so it is necessary to have round-the-clock duty not only of nursing staff, but also of a neonatologist. In most cases, premature babies, after certain efforts of a group of neonatologists, are transferred to the second stage of nursing in a specialized hospital. If there is a perinatal center in the city, the second stage of nursing is carried out in the same hospital where the birth took place, and the children are not transported. It should be noted that often premature babies stabilize rather quickly, and there is no need for a second stage of nursing.

Management of preterm labor

With threatening and beginning childbirth - when there is no cervical dilatation or it is insignificant - tactics are aimed at prolonging pregnancy. The woman is urgently hospitalized, strict bed rest is created, sedatives are prescribed, and the causes that led to premature birth are eliminated (if possible). For example, suturing of the cervix is ​​performed for isthmic-cervical insufficiency, treatment of vaginal infections, restoration of the natural microflora of the vagina or antibiotics in the presence of an infectious process, treatment is carried out in conjunction with a therapist or endocrinologist (if necessary). An obligatory component is drugs that reduce the tone of the uterus (tocolytics), improve the functioning of the placenta, increase immunity, vitamin therapy, as well as drugs that improve intrauterine nutrition of the child and accelerate the "maturation" of the lungs of the fetus.

In each case, an individual approach is needed, but the efforts of doctors do not always lead to the desired results, and the process turns into the onset of premature birth.

Round-the-clock care and supervision are necessary in all cases until the child's condition is completely stabilized.

Premature birth requires a qualified obstetrician-gynecologist, nurse and neonatologist. It is necessary to constantly monitor the woman and the condition of the fetus. A woman is regularly examined, pressure, body temperature are measured, urine and blood tests are monitored. In addition to data from cardiac monitoring, they control the development of labor, listen to the fetal heartbeat, and determine the position of the fetus. Fetal heart rate monitoring is a study of the heart rhythm. It is carried out on a special apparatus at rest, in the position of the pregnant woman on her side for 30-60 minutes. On the anterior abdominal wall of a pregnant woman, with the help of an elastic band, there are recording sensors that record the heartbeats of the fetus, as well as the frequency and strength of contractions.

Most of the complications in childbirth, both on the part of the mother and the fetus, are due to a violation of the contractile activity of the uterus. To identify the features of the contractile activity of the uterus during preterm labor, it is recommended to maintain a partogram (a graphical representation of the frequency and strength of contractions) and record the contractile activity of the uterus. A partogram can be carried out without any technique, by touch, with a stopwatch, to fix the frequency, strength and duration of contractions, and then depict them on a graph. However, all specialized centers have cardiomonitor monitoring, which clearly displays the condition of the child during the birth process, as well as the tone of the uterus and the effectiveness of contractions in dynamics, which allows you to correct and provide qualified medical care for any deviations.

To determine the degree of cervical dilation, the doctor examines the woman on the gynecological chair. Due to the possible negative impact on the fetus, pacing or inhibition of labor is carefully considered, and often the issue needs to be resolved within a short time, with the decision being made by several doctors. Prevention of fetal hypoxia (lack of oxygen) is carried out; in most cases, narcotic painkillers are refused (since they adversely affect the fetal respiratory center). Childbirth is carried out in the supine position, because it is easier to control childbirth in this position, the head does not move quickly along the birth canal, the woman and fetus feel satisfactory, in contrast to the supine position, in which the pregnant uterus compresses large venous vessels, worsens maternal and fetal circulation. Pain and epidural anesthesia speed up the process of opening the cervix, which is often too fast. The fetal head does not have time to adapt to the birth canal, and often poorly extensible perineum exacerbates the situation, so they are approached individually.

It is in the power of the woman herself to reduce the likelihood of preterm birth. There is no need to hide previous abortions and inflammatory processes in the past from the doctor with whom the woman is registered. It is necessary to immediately inform the doctor about all changes in your body, go to special classes in preparation for childbirth. When a pathology is detected, one should not refuse the treatment prescribed by the doctor. It is necessary to limit physical activity, monitor the diet, which should be varied and well balanced. Excessive intake of spicy, salty or fatty foods leads to exacerbation of chronic diseases digestive system that can cause premature birth. If symptoms of pregnancy appear, sexual activity should be avoided during the last two months of pregnancy. If there is the slightest suspicion of a deviation from the normal course of pregnancy, it is necessary to seek qualified help.

Nadezhda Egorova,
obstetrician-gynecologist, assistant of the department of obstetrics and gynecology,
Astrakhan State medical Academy, Astrakhan