ESSENTIALS OF DIAGNOSIS
Preterm regular uterine contractions approximately 5 minutes apart.
Cervical dilatation, effacement, or both.
Preterm birth is defined as delivery prior to 37 weeks’ gestation, and spontaneous preterm labor with or without premature rupture of the fetal membranes is responsible for at least two-thirds of all preterm births. Prematurity is the largest single contributor to infant mortality, and survivors are at risk for a myriad of short- and long-term complications. Rates of infant death and long-term neurologic impairment are inversely related to gestational age at birth. The cusp of viability in contemporary practice is 23–25 weeks’ gestation, and infants born prior to 23 weeks rarely survive. About two-thirds of the preterm births occur between 34 weeks and 36 weeks and 6 days (termed “late preterm birth”), and good outcomes are expected at these gestational ages. Importantly, however, even these late preterm infants are at significantly increased risk for both morbidity and mortality when compared to those infants born at term.
Major risk factors for spontaneous preterm labor include a past history of preterm birth and a short cervical length as measured by transvaginal ultrasound. Patients with one or both of these risk factors have largely been the focus of recent intervention trials aiming to prevent preterm birth. Other known risk factors are many but include black race, multifetal pregnancies, intrauterine infection, substance abuse, smoking, periodontal disease, and socioeconomic deprivation.
In women with regular uterine contractions and cervical change, the diagnosis of preterm labor is straightforward. However, symptoms such as pelvic pressure, cramping, or vaginal discharge may be the first complaints in high-risk patients who later develop preterm labor. Because these complaints may be vague and irregular uterine contractions are common, distinguishing which patients merit further evaluation can be problematic. In some cases, this distinction can be facilitated by the use of fetal fibronectin measurement in cervicovaginal specimens. This test is most useful when it is negative (less than 50 ng/mL), since the negative predictive value for delivery within 7–14 days is 93–97%. A negative test, therefore, usually means the patient can be reassured and discharged home. Because of its low sensitivity, however, fetal fibronectin is not recommended as a screening test in asymptomatic women.
Patients must be educated to identify symptoms associated with preterm labor to avoid unnecessary delay in their evaluation. In patients who are believed to be at increased risk for preterm delivery, conventional recommendations are for limited activity and bed rest. Randomized trials, however, have failed to demonstrate improved outcomes in women placed on activity restriction. Paradoxically, such recommendations may place a woman at an increased risk to deliver preterm. Women with preterm labor at the threshold of viability present unique ethical and obstetric challenges and are best managed in consultation with maternal-fetal medicine and neonatology ...