Start premature. What can cause preterm labor

Preterm birth is the birth of a child from the 22nd to the 37th obstetric week. Before this interval, it is generally accepted that a spontaneous abortion occurred. With the development of pediatric resuscitation, the terms of preterm birth were increased - until 2012 they were counted from the 28th week of pregnancy, and the weight of a viable newborn should be at least 0.5 kilograms. According to statistics, about 7% of births in the country occur before the standard time and are considered premature.

Classification

• deep prematurity (up to 1 kg) - if the birth occurred on the 22-28th week (about 5% of the total number of births);
• heavy (up to 1.5 kg) - it accounts for 15%, 28-30 weeks;
• the average degree of prematurity (up to 2 kg) - covers about 20%, 31-33 weeks;
• mild degree (up to 2.5 kg) - children are born at 34-36 weeks.

In some maternity hospitals, the terms are still counted from 28 weeks, due to the lack of equipment for nursing this group of babies.

Possible causes of preterm labor

The refusal of pregnant women to undergo the necessary tests and tests leads to the development of diseases that are asymptomatic.

Early detection of infectious processes will help save the baby. Unplanned pregnancies, referral to IVF specialists increase the unfavorable prognosis of a possible interruption of gestation.

The following factors contribute to the development of preterm birth:

• constant stressful environment;
• infectious and inflammatory processes
• pregnancy as a result of IVF
• low, compared with the average, social level;
• bad living conditions a pregnant woman (private houses with poor heating, lack of running water and sewerage, densely populated apartment);
• the inability to switch to lightweight, recommended by gynecologists, physical labor;
• early pregnancy before adulthood;
• pregnancy after 35 years of age;
• chronic diseases in the anamnesis of a pregnant woman (diabetes mellitus, hypertension, disorders in the thyroid gland, etc.);
• acute stage or intensification of chronic genital infections (primary infection due to unprotected sex);
• low levels of hemoglobin in the mother's blood;
• the use of various drugs, alcoholic beverages or nicotine addiction by a pregnant woman;
• employment in hazardous industries;
• long trips and acclimatization (rest before childbirth in hot countries);
• severe course of respiratory diseases with complications (dry cough can provoke uterine contractions);
• various malformations of the uterus;
• overstretching of the uterus with multiple pregnancies, in large numbers amniotic fluid and large fruit;
• surgical operations performed during pregnancy;
• injury at work or at home;
• placental abruption;
• intrauterine infection of the embryo;
• various bleeding;
• abnormal development of the fetus;
• incompatibility of the blood type of mother and child (Rhesus conflict);
• rupture of the amniotic membranes, which occurred prematurely;
• spontaneous dilatation of the cervix.

All of these conditions are not the direct cause of possible premature birth, but only influencing factors.

Potential causes of preterm labor include:

Obstetric and gynecological

• the fetus is not retained in the uterus due to isthmic-cervical insufficiency (weakness of the muscle layer of the cervix);
• infectious diseases of the genital organs - an inflammatory process that occurs in the uterus itself, provokes muscle weakening and, as a result, loss of elasticity;
• excessive stretching of the uterus during multiple pregnancy, a large amount of amniotic fluid and a large fetus;
• various malformations of the uterus (bicornuate, saddle, etc.);
• placental abruption that occurred prematurely;
• antiphospholipid syndrome;
• premature birth, miscarriages, missed pregnancies in the history of the woman in labor;
• previous abortions;
• a short period of time elapsed between two pregnancies (up to 2 years);
• depreciation of the body against the background of constant childbirth (three to five in a row);
• abnormal development and infection of the fetus in the womb;
• bleeding or the threat of miscarriage in the early stages;
• pregnancy that occurred with the help of assistive technologies (IVF, etc.);
• severe toxicosis, with a threat to life, as a result of which childbirth is induced.

Extragenital

• endocrinopathies - violations of functionality in the body of a pregnant endocrine glands (thyroid gland, adrenal glands, pituitary gland, ovaries, etc.);
• infectious and inflammatory diseases in the acute phase (flu, tonsillitis, SARS, pyelonephritis, etc.);
• diseases of the cardiovascular system (heart defects, arrhythmias, rheumatoid arthritis, hypertension, rheumatism, etc.);
• diabetes mellitus of all types;
• surgical interventions during pregnancy performed on the pelvic organs and abdominal surface (including surgery to remove appendicitis);
• self-medication with medical preparations- in addition to the threat of the formation of possible deformities of the child, the likelihood of a miscarriage is formed. Some medications cause bleeding, uterine contractions, and dehydration;
• violation of the ban on sex life causes the release of hormones into the mother's body, provoking uterine contractions;
• the physical age of the mother is pregnant before the age of 18 and after 35. Women who have crossed the age of 35 suffer from acquired chronic diseases, which leads to premature birth. The body of a young girl who becomes pregnant before full adulthood is not physically mature and provokes spontaneous abortions.

According to WHO, up to 40% of miscarriages are due to premature rupture of the amniotic membranes. In case of activation of one of the mechanisms, premature birth occurs due to:

• inflammatory process that caused increased production of biologically active substances;
• in the vessels of the placenta, microthrombi are formed (increased blood clotting), leading to its death and subsequent exfoliation;
• an increased concentration of calcium ions in the cells of the myometrium, causing labor activity.

Symptoms of preterm labor

Signs of preterm labor are similar to the symptoms spontaneous abortion or the onset of normal labor. A few days before the start of the process, there are warning signs that most women do not pay attention to:

• pulling pains in the lower abdomen, reminiscent of primary contractions;
• feeling of pressure in the genitals of a pregnant woman;
• high fetal activity;
• discharge from the genitals, sometimes with an admixture of blood;
• frequent urge to urinate and defecate.

The main stages of preterm birth:

Threatened preterm labor - at this stage, the symptoms proceed unnoticed for most pregnant women. Unexpressed weak pains, pulling sensations in the lower abdomen are attributed to mild ailments. A slight tension, contraction of the uterus is attributed to an increase in the activity of the baby, who begins to move his legs and arms vigorously. In some cases, vaginal discharge occurs, in rare cases - with an admixture of blood. When contacting gynecology, the doctor notes a closed and dense uterus. Do not delay with an unscheduled visit to the doctor - timely detection of a threat will save the child's life.

Beginning preterm labor - the symptoms become more pronounced compared to the first stage, there is a sharp pain in the lumbar region and cramping muscle contractions. The discharge of the mucous plug, spotting and discharge of amniotic fluid are the main characteristics of the second stage. There is an incomplete opening of the cervix (1-2 fingers) and its softening, observed when examined by a gynecologist. During this period, it is possible to stop labor and extend the duration of pregnancy.

Premature birth is in progress - it is impossible to stop the process during this period, contractions become more frequent, become regular, the cervix is ​​​​completely dilated and the fetus begins to move towards the exit into the small pelvis.

Diagnosis of preterm birth

Blurring of specific symptoms, combined with many factors, makes it impossible to accurately determine the fact of preterm birth. In practice, a preliminary diagnosis is made according to the following criteria:

• collection of anamnesis by the gynecologist leading the pregnancy - complete information about all the factors that influenced the condition of the pregnant woman. Subjective assessment of sensations by the expectant mother (pain, activity of the child, pulling sensations);
• examination by a gynecologist in order to detect uterine tone and cervical dilatation. A vaginal examination in the mirrors will determine whether the cervix is ​​shortened, the degree of its smoothness and opening of the pharynx;
• appointment ultrasound to determine the level of cervical dilatation and possible separation of the placenta, the estimated weight of the fetus, its presentation and position, the integrity of the amniotic sac, the general condition of the placenta, the exclusion of its presentation;
• clinical blood and urine tests;
• cervical maturity test (correct prognosis up to 95% of cases);
• fibronectin test (to determine substances in secretions present during childbirth);
• registration of the fetal heartbeat;
• tests for STDs.

Treatment Methods

If preterm birth is suspected, mandatory hospitalization is carried out in a hospital, where a number of manipulations are performed:

• prolongation of pregnancy - an attempt to artificially continue pregnancy using medicines. Patients need a strict regimen with a state of rest, the appointment of sedatives, antispasmodics, electrorelaxation of the uterus, acupuncture and electroanalgesia. If insufficiency (softening and opening of the cervix) is detected, sutures or an obstetric ring (pessary) are applied to the cervix to prevent further disclosure;
• in case of detection of infectious diseases or the threat of infection due to amniotic fluid, antimicrobial therapy is prescribed;
• additionally, the maturation of the fetal lungs is accelerated with the help of glucocorticoids (prevention of respiratory distress syndrome).

If all of the above manipulations did not work, then the process of obstetrics begins.

Preterm birth in most cases proceeds rapidly, as a result of which the risk of complications in the woman in labor and the fetus increases.

During such childbirth, the fetus suffers from hypoxia - uterine contraction occurs with a high frequency and advancement through the birth canal is accelerated. Weak vessels, soft bones of the skull and small size of the fetal head cause birth injuries, intracranial hemorrhages and injuries of the cervical spine. A premature baby is traumatized due to rapid delivery, a caesarean section also does not exclude injuries.

If it is impossible to maintain pregnancy, obstetric care is carried out with the utmost care. Preventive measures against possible ruptures of the cervix and perineum are not used to avoid damage to the fetus. The risk of complications in childbirth in the mother increases - the paradox is that the size of the fetus is small, but the wrong passage through the birth canal causes a high degree of traumatism. Artificial prolongation of pregnancy after the outflow of amniotic fluid increases the risk of postpartum hemorrhage and endometritis.

Childbirth carried out after 35 weeks of pregnancy proceeds in the usual manner. At this time, the fetus is viable and no additional measures are required to save it.

• with signs of internal infection;
• in case of deep prematurity of the fetus;
• with a frozen pregnancy.

Preventive measures to prevent early birth

Medical:

• Cervical suturing - used for women from high group risk, does not apply to multiple pregnancies.
• The appointment of progesterone - effectively reduces the possibility of premature birth.
• Antibacterial prophylaxis - timely treatment of STDs.
• Removing the tone of the uterus.

Independent:

• drinking at least 8-10 glasses of water (excluding carbonated drinks and strong coffee) daily to prevent dehydration (when there is a lack of fluid in the body, labor pains will begin);
• emptying the bladder every 2-3 hours (additional pressure on the walls of the uterus will cause it to contract);
• it is forbidden to lift weights and overstrain, do sharp bends and squats;
• it is advisable to take small breaks for additional rest during the day, if possible - in a prone position, on the left side;
• stimulation of the breast and nipples, intimate activity should be avoided.

In case of any ailments, an urgent appeal to the antenatal clinic to the doctor leading the pregnancy is necessary. Timely detection of the threat of preterm birth increases the chances of birth healthy child by 30 percent.

Childbirth is the natural end of pregnancy. The baby is born full term at 38-42 weeks. The fetus is already ripe for this period, and its internal organs are ready to function outside the womb.

The process of childbirth begins when the body of the pregnant woman feels the readiness of the child for birth. But there are times when childbirth begins prematurely.

This indicates the presence of any problems in the mother or child. A premature baby is not yet ready for independent living Therefore, such situations are prevented by doctors in order to prolong the pregnancy as much as possible until the normal period.

What is the risk of preterm birth?

If labor activity occurred on time from to pregnancy is a premature birth.

But careful care, attention and love for the baby will help overcome this condition. A weak baby now more than ever needs contact with his mother.

More severe consequences of preterm birth for child. It is often required to connect a premature baby to a camera that performs the functions of the respiratory system. After all children born before unable to breathe normally.

These babies have underdeveloped lungs They are low in surfactants. Their deficiency is replenished by medication, which allows saving the majority of premature babies.

But still, in some cases, one cannot do without artificial ventilation of the lungs for a month. Sometimes in such children, due to the immaturity of the lung tissue, chronic lung diseases appear. Therefore, the doctor prescribes drugs to stimulate the growth of this tissue.

Also the newborn is connected to the device vital organ controls to monitor respiration, heart rate, blood oxygen saturation, blood pressure. This device prevents cardiac and respiratory arrhythmia and respiratory arrest.

When caring prematurely born child a power supply device is also used. Initially, it can be administered intravenously. Thus, proteins, fats and carbohydrates, which are necessary for normal development, enter the baby's body.

For this purpose, a special technique is used using certain blood vessels and a pump for the sterile delivery of nutritional ingredients.

The incubator practically replaces the uterus of a premature baby. The right conditions for it are created there, the optimum temperature and humidity are maintained.

In the future, premature babies often become patients with special needs. Due to chronic lung disease, there may be an increased tendency to spastic, an increased risk of developing, during infection.

Besides, premature babies do not have very mature brains. There is too high sensitivity of the nervous tissue as a result of mechanical damage. The brain also lacks oxygen. All of this has a negative impact on performance. nervous system child.

Such children are often prone to neuroses, are more emotional, active, whiny and need special approach. They are not easy to deal with, they sleep little and eat poorly. As you get older, these side effects go away.

Tactics for the treatment of preterm birth

Delivery is carried out with monitoring of vital signs:

• control over the state of the pregnant woman: blood pressure, heart rate, indicators of the coagulation system and the study of diuresis through a urinary catheter;
• analysis of the condition of the fetus through and ultrasound;
• treatment of DIC syndrome;
• antishock therapy;
• oxygen inhalation.

Depending on the specific situation, choose active or conservative expectant management of preterm birth.

The last view is shown at satisfactory condition of the mother and fetus, whole fetal bladder, cervical dilatation by 2-4 cm, gestational age up to, no signs of infection.

A active tactics are appropriate when regular labor activity, the opened fetal bladder, the presence of signs of infection, severe extragenital diseases of the woman, impaired fetal life, complications of pregnancy and if fetal malformations are suspected.

In this case, childbirth most often takes place through the natural birth canal, but emergency cases also occur.

With threatening and beginning premature birth, it is carried out complex treatment to reduce excitability and suppress uterine contractions, increase the vital activity of the fetus and its "ripening", as well as to eliminate pathological conditions, which provoked premature birth.

Pregnant women with the threat of premature delivery bed rest shown. Appropriate electrorelaxation of the uterus, electroanalgesia, acupuncture.

With threatening and beginning childbirth, appoint sedatives, drugs to reduce uterine contractions, medicines for the prevention of respiratory distress syndrome in a newborn.

If childbirth has begun, use stimulants of the birth process (drugs that cause premature birth). With rapid delivery means for inhibition of labor activity are recommended.

Knowing the signs of preterm labor and how to prevent them, calmness, confidence in the successful outcome of the pregnancy and constant contact with the doctor will allow you to minimize the risk of giving birth premature baby.

Childbirth that occurs before 28 weeks of gestation is called a miscarriage.
The highest percentage of spontaneous termination of pregnancy falls on the terms of 34-37 weeks of pregnancy (55.3%), for an earlier period - 10 times less often.

1. Isthmic-cervical insufficiency (ICN) - failure of the cervix, in connection with which there is an inability to keep the ovum in the uterus. The most common causes of CI are:

Injuries of the cervix during previous pregnancies - childbirth with a large (more than 4 kg) fetus, fast and rapid labor, use of obstetric forceps or vacuum, cervical ruptures during childbirth;

Previous operations on the cervix - conization, amputation;

Intrauterine interventions - abortion, curettage, hysteroresection;

Gene defects leading to impaired synthesis of the connective tissue of the cervix (collagenopathy) - Ehlers-Danlos, Marfan, Rendu-Osler syndrome and others;

Infectious diseases, female genital organs, causing inferiority of the cervix - candidiasis, bacterial vaginosis, ureaplasmosis, chlamydia, mycoplasmosis, herpes and megalovirus infection;

Endocrine disorders (decrease in ovarian function, or hyperandrogenism - an increased content of male sex hormones), leading to changes in the structure of the cervix, its shortening and expansion of the cervical canal;

Malformations - hypoplasia of the cervix, genital infantilism;

Increased load on the cervix during pregnancy with multiple pregnancy, polyhydramnios, large fetus;

Placenta previa or its low location.

2. Uterine fibroids large sizes or submucous uterine fibroids.

3. Malformations of the uterus, leading to a violation of the implantation of the fetal egg - intrauterine septum, bicornuate uterus.

4. Common infectious diseases of the mother - influenza, viral hepatitis, rubella, chronic tonsillitis.

5. General diseases in the stage of decompensation - heart defects, hypertension, diseases of the blood, liver, kidneys, diabetes mellitus.

6. Neuro-endocrine diseases - adrenal insufficiency (Addison's disease), excessive production of hormones of the adrenal cortex (Cushing's syndrome), hypothyroidism.

7. Late preeclampsia (dropsy, nephropathy, preeclampsia, eclampsia). If on later dates puffiness begins to be observed - this is alarm symptom. If not only the legs begin to swell, but also the stomach, face, you should immediately consult a doctor. In general, with gestosis, a triad of symptoms is distinguished: initially, swelling occurs, to which arterial hypertension first joins, and then proteinuria (increased protein in the urine). However, the triad is not always clearly diagnosed.

8. Rhesus conflict - develops if a woman has Rh-negative blood, and the fetus has Rh-positive blood. The consequences can be tragic - there is a risk of developing a hemolytic disease in a child, pregnancy often ends in premature birth, more often operative (caesarean section), in severe cases, the child may die.

At risk for a possible onset are pregnant women:

Under 18 and over 40 years old,

With Rh negative blood

Practicing unprotected sex

Those who have undergone in vitro fertilization (risk of multiple pregnancies),

Suffering from decompensated chronic general somatic diseases,

Having excessive height and other markers of collagenopathy (mitral valve prolapse, tracheobronchial dysfunction, varicose veins, myopia),

Having a history of miscarriages, premature and rapid births,

Previously undergone intrauterine interventions (abortion, curettage, hysteroresection) or ruptures of the cervix during previous births,

Previously undergone surgery on the cervix (amputation, partial removal),

Surgical treatment for isthmic-cervical insufficiency (ICI) in previous pregnancies.

Preterm labor can be threatening and begun. Important: if there is a threat, abortion can be prevented, but labor that has already begun cannot be stopped.

Threatening preterm birth is characterized by recurrent mild pain in the lower back and lower abdomen against the background of increased tone uterus. But the cervix remains closed.

With the onset of preterm labor, which cannot be stopped, the cervix shortens and opens, often there is an outpouring of amniotic fluid.

If your pregnancy has not reached 37 weeks, pay attention to the following complaints:
- Pain in the lower abdomen or lower back
- fights,
- premature discharge of water,
- blood secretions.

Why are premature births dangerous?

A serious test for the baby is his birth ahead of time. The organs and systems of a premature baby are not ready for extrauterine existence. Enormous efforts are required to create conditions in which the child will be able to compensate Negative consequences such an early birth.

As a result of preterm birth:

1. there is a rupture of the membranes surrounding the fetus, an outpouring of amniotic fluid that protects the baby from exposure external environment, then the infection joins;

2. premature babies are born with "immature" lungs, who cannot fully breathe, because they do not have surfactant - a special substance that is produced in the pulmonary alveoli (lung cells) and prevents them from "falling off";

3. in the process of expulsion of the fetus from the uterus and during contractions, hemorrhages may occur in the brain of the baby;

4. during passage through the birth canal, the still unhardened bones of the child's skull are injured;

5. ruptures and injuries of the cervix in the mother.

If your pregnancy is less than 37 weeks, you have characteristic complaints, then be sure to consult a doctor, but rather call an ambulance.
Before the arrival of the team of doctors, the expectant mother should lie down, take sedative tinctures (valerian, motherwort) and drink 2-3 No-shpy tablets.

The doctor chooses the tactics of managing a pregnant woman depending on the duration of pregnancy, the fact of amniotic fluid discharge, the condition of the mother and fetus. In obstetric hospitals for women with:

1. Assign bed rest.

2. Monitor the health of the mother and fetus.

3. Carry out therapy to reduce the excitability of the uterus and suppress its contractile activity - sedatives, beta-agonists and tocolytics - substances that specifically affect receptors and cause relaxation of the uterus.

4. Antibacterial therapy in case of a threat of infectious complications, while expectant tactics are chosen with control over the possible development of infection.

5. Prevention of pulmonary complications in a child, developing as a result of immaturity of the lung tissue - during childbirth up to 34 weeks of pregnancy.

- delivery at a gestational age of 28 to 37 weeks, accompanied by the birth of a premature and physically immature fetus weighing 1000-2500 g and 35-45 cm long. Premature birth can be threatening, incipient and incipient. Depending on this, the clinical manifestations and obstetric tactics in preterm labor will be different. With threatening and beginning childbirth, they tend to prolong the pregnancy. Preterm labor that has begun with the development of regular labor activity is carried out under the control of the state of the mother and fetus.

ICD-10

O60

General information

Premature birth ends in 5-12% of pregnancies. According to WHO definition, termination of pregnancy at terms of 22-28 weeks, which ended with the birth of a fetus weighing 500-1000 g and lived for at least 7 days, is considered as early premature birth with an extremely low fetal weight. If a child born from premature birth dies before the 7-day period, such an outcome of pregnancy is regarded by obstetrics and gynecology as a late miscarriage.

Premature births are always associated with a high risk of complications for the newborn. Premature birth that develops at 22-27 weeks is prognostically less favorable in terms of fetal viability, since by this time the lungs of the newborn have not yet reached the required degree of maturity to ensure respiratory function. The outcome of preterm birth at 28-34 or more weeks of gestation is potentially more favorable for the newborn.

Causes

Causes related to the health of the pregnant woman, the condition of the fetus, the course of pregnancy, socio-biological conditions can lead to premature birth. Among the "maternal" factors, STDs (mycoplasmosis, chlamydia, ureaplasmosis, herpes, cytomegalovirus infection, etc.), acute viral infections (rubella, influenza, viral hepatitis, etc.), chronic pathology of a pregnant woman (tonsillitis, pyelonephritis, heart defects, diabetes mellitus, hypertension), endocrinopathies (Addison's disease, Cushing's syndrome, hypothyroidism, obesity).

The term of pregnancy largely depends on the state of the reproductive organs. Premature birth is often found in women with diseases and abnormalities of the uterus - endometriosis, fibroma, uterine hypoplasia, bicornuate uterus, intrauterine septum, intrauterine synechia. The development of cervical insufficiency, leading to premature birth, is facilitated by damage to the uterus during diagnostic curettage, artificial abortions and childbirth, operations (conization, amputation of the cervix), etc.

The causes of preterm birth due to the condition of the fetus include, first of all, genetic disorders, severe congenital anomalies, malformations, intrauterine diseases (hemolytic disease) and fetal infections. In some cases, invasive prenatal diagnostics - cordocentesis, amniocentesis - can lead to premature birth.

The so-called combined factors of preterm birth associated with the course of pregnancy include immunological conflicts (Rhesus conflict), gestosis, placenta previa or its premature detachment, transverse position of the fetus, breech presentation, multiple pregnancy, multiple pregnancies and childbirth, etc.

The frequency of development of preterm birth directly depends on the socio-biological conditions in which the pregnancy proceeds. Premature birth can be provoked by heavy physical labor, excessive mental stress, stress, poor nutrition, and bad habits.

Symptoms of preterm labor

According to the clinical course, preterm labor can be threatening, beginning and beginning. When determining the stage of preterm labor, they are guided by an assessment of the contractile activity of the uterus, the state of the fetal bladder and the birth canal. In the case of a threatening nature of premature birth, a pregnant woman develops aching, nagging pains in the lower back and abdomen, tension of the uterus and its contractions, an increase in the motor activity of the fetus, and sometimes sanious discharge from the genital tract. Such symptoms require an urgent appeal to an obstetrician-gynecologist.

For beginning preterm labor, severe pain in the lower abdomen, regular contractions, a symptom of cervical plug discharge, the appearance of sanious discharge, and often leakage or outpouring of amniotic fluid are typical. With the onset of preterm labor, regular labor activity develops with an interval between contractions of less than 10 minutes, sanious discharge is noted, the presenting part of the fetus descends to the entrance to the pelvis and the rupture of the fetal bladder occurs.

In general, preterm labor is characterized by an untimely discharge of the waters; weak, sometimes strong or discoordinated labor activity; rapid or protracted course; placental abruption and bleeding; postpartum complications; fetal hypoxia.

Diagnostics

To establish the fact of preterm birth and its stage important criterion serves to assess the condition of the cervix and fetal bladder. Vaginal examination and examination of the cervix in the mirrors are carried out to determine the degree of opening of the uterine os, the length and consistency of the cervix. With threatening childbirth, the examination reveals an unchanged neck, a closed external uterine os; at the beginning of childbirth, the cervix is ​​shortened, the uterine os is ajar by 1-2 cm; at the beginning - smoothing of the cervix and opening of the uterine os by 2-4 cm is determined. The gynecological examination must be repeated in dynamics after 30-60 minutes.

To exclude urogenital infections and latent bacteriuria, cervical discharge is cultured for pathogens (staphylococcus, chlamydia, ureaplasma, gonococcus) and bacteriological examination of urine. With the help of ultrasound, the gestational age, the estimated weight of the fetus, its position and presentation, the integrity of the fetal bladder, the condition and localization of the placenta are specified, placenta previa is excluded. Auscultation and instrumental registration of the fetal heartbeat (fetal phonocardiography, cardiotocography) during preterm birth are necessary to detect signs of hypoxia.

Additionally, in order to determine the obstetric status, the Baumgarten tocolysis index is used, calculated by the sum of the points obtained by evaluating a number of objective parameters (presence of contractions, rupture of membranes, bleeding, opening of the cervix). At the same time, the lower the score, the more effective tocolytic therapy can be.

In some cases, with a slow opening of the cervix, premature birth must be differentiated from pathology. urinary tract and abdominal organs: pyelonephritis, cystitis, urolithiasis, gastroenteritis, spastic colitis, acute appendicitis.

Treatment for preterm birth

If preterm birth is suspected, immediate hospitalization of the pregnant woman in an obstetric hospital is necessary. If, with the threatening or incipient nature of preterm labor, the tactics of prolonging pregnancy is acceptable, then in the case of early labor, leakage of amniotic fluid, signs of infection or severe extragenital diseases, active labor management is resorted to.

Therapy for threatened and incipient preterm labor requires an appointment bed rest, sedatives (motherwort, valerian, diazepam) and antispasmodics (drotaverine, metacin, papaverine); physiotherapeutic effects - electrorelaxation of the uterus (amplipulse therapy), electroanalgesia, acupuncture.

In order to accelerate the maturation of the lung tissue of the fetus and prevent respiratory failure of the newborn with the threat of premature birth for up to 34 weeks of pregnancy, glucocorticoid drugs (dexamethasone, prednisolone, betamethasone) are prescribed. Therapy with glucocorticoids is contraindicated in the presence of a pregnant gastric ulcer or duodenal ulcer, endocarditis, circulatory failure III stage, nephritis, active tuberculosis, osteoporosis, severe forms of diabetes mellitus, preeclampsia.

Carrying out tocolytic therapy allows to achieve the removal of contractile activity and tone of the uterus. In preterm birth, the introduction of magnesium sulfate, beta-mimetics (ipratropium bromide, terbutaline, fenoterol, etc.), prostaglandin inhibitors (naproxen, indomethacin) is indicated. Prevention of fetal hypoxia and placental insufficiency is carried out by the appointment of dipyridamole, pentoxifylline, vitamin E.

If streptococcal, gonococcal, chlamydial infections, bacterial vaginosis, trichomonas vulvovaginitis are detected, antimicrobial therapy is prescribed. If isthmic-cervical insufficiency is detected, a special ring is applied to the cervix - the introduction of an obstetric pessary, according to indications (in case of insufficiency of the adrenal glands and thyroid gland) - hormonal correction.

Management of preterm birth

Taking into account the obstetric situation, the management of the onset of preterm labor can be expectant-conservative or active. In the first case, the progress of labor activity is monitored without the provision of special obstetric benefits. More often in preterm birth, there is a need for active intervention in the course of natural childbirth or a caesarean section.

The tactics of preterm labor are influenced by the gestational age, the stage of labor, the condition of the fetal bladder, the degree of cervical dilatation, the presence of infection, the severity of labor, the presence and nature of bleeding. The management of preterm labor is accompanied by constant cardiomonitoring.

30% of preterm births are abnormal - with excessive, weak or discoordinated labor activity. Therefore, in the management of preterm labor, antispasmodic drugs and epidural anesthesia during childbirth are widely used. With excessive labor activity, drugs are administered that inhibit the contractile activity of the uterus; with the weakness of the patrimonial forces, rhodostimulation is performed. In order to protect the fetus during passage through the birth canal, they resort to dissection of the perineum - perineotomy.

Indications for caesarean section in preterm birth are severe pathology of the mother and fetus, breech presentation of the fetus. After the birth of a premature fetus, if necessary, they immediately begin to carry out the entire volume of resuscitation.

Complications

In children born from premature birth, due to the immaturity of all anatomical structures, the presence of birth injuries (intracranial hemorrhages, injuries of the cervical spine) is often noted; hypoxia; functional unavailability of the lungs. For a woman, premature birth can be complicated by ruptures and injuries of the cervix, postpartum hemorrhage, infections (suppuration of sutures, postpartum metroendometritis, peritonitis, sepsis).

Prevention

When planning a pregnancy, all women are recommended to undergo a full examination by a gynecologist and narrow specialists to exclude potential risk factors. Prevention of preterm birth is facilitated by early registration and management of pregnancy under the supervision of an obstetrician-gynecologist. Special medical control is required by pregnant risk groups for the development of preterm birth - women with sexual infantilism, menstrual irregularities, endocrinopathies, recurrent miscarriage, chronic infections, who have undergone IVF, with Rh-negative blood, etc.

In preterm birth, a premature baby weighing more than 1000 g is born, capable of existing outside the womb with appropriate care and treatment.

As recommended World Organization(WHO), preterm births include births from 22 to 37 weeks of gestation (fetal weight is 500 g or more). There are very early preterm birth (22-27 weeks), early (28-33 weeks) and preterm birth (34-37 weeks). In our country, childbirth at 22–27 weeks is not considered premature, but medical care provide in the conditions of a maternity hospital, and also take all necessary measures to nurse the born fetus. A child born in such early term(from 22 to 27 weeks), is considered a fetus during the first 7 days of life. Only after a week has passed, if the baby was able to adapt to extrauterine conditions of existence, he is considered a child.

In modern obstetrics, the frequency of preterm birth not only does not decrease, but tends to increase due to an increase in the number multiple pregnancies, widespread use of assisted reproductive technologies.

Causes of preterm birth

The causes of preterm birth can be divided into two groups - socio-biological (non-medical) and medical.

Socio-biological reasons include bad habits(alcohol, drugs, smoking during pregnancy), low socio-economic standard of living of the expectant mother, harmful working conditions (presence of radiation, vibration, noise, irregular schedule, night work), as well as malnutrition, chronic stress.

The main medical causes of preterm birth are:

• Infection (is one of the most significant causes leading to early termination of pregnancy). Both acute and chronic infections (bacterial and viral) can lead to premature birth. It could be a common infectious disease internal organs(pneumonia - inflammation of the lungs, pyelonephritis - inflammation of the kidneys, etc.), then the infection penetrates the fetus through the placenta; or infection of the genital organs (chlamydia, trichomoniasis, gonorrhea, herpes, etc.), then to fertilized egg ascending way can penetrate the infection from the vagina.
• Aggravated obstetric history (abortions, miscarriages - termination of pregnancy before 22 weeks and premature birth in the past) and / or gynecological history (inflammatory diseases of the female genital organs, uterine fibroids - a tumor of the muscular layer of the uterus, hormonal disorders, genital infantilism - underdevelopment of the genital organs, malformations uterus development).
• Isthmic-cervical insufficiency - the inferiority of the obturator function of the cervix due to trauma during abortion, ruptures in previous births, etc.
• Extragenital pathology (diseases of internal organs) - endocrine pathology (obesity, diabetes, thyroid disease), severe diseases of the cardiovascular system, kidneys and other organs. This group of causes also includes thrombophilic conditions (diseases associated with an increase in the activity of the blood coagulation system), in which the risk of premature placental abruption, thrombosis (blockage of placental vessels by blood clots), leading to premature birth, sharply increases.
• Complicated course of pregnancy (preeclampsia - toxicosis of the second half of pregnancy; pronounced forms of fetoplacental insufficiency; causes leading to overstretching of the uterus - polyhydramnios, multiple pregnancies).

Symptoms of preterm labor

A sign of the onset of labor will be the appearance of regular cramping pains in the lower abdomen, which over time become stronger, longer and more frequent. At the beginning, when the pains in the lower abdomen are rather weak and rare, mucous or mucous-bloody discharge may appear from the vagina, which indicate structural changes (shortening and smoothing) of the cervix.

A fairly common scenario may be premature rupture of amniotic fluid, while a clear or yellowish liquid is released from the vagina, the amount of which can vary from a teaspoon to a glass or more. The outflow of amniotic fluid may be accompanied by pain in the lower abdomen, and may occur in the complete absence of an increase in the tone of the uterus. As a rule, the outflow of amniotic fluid is caused by infection of the lower pole of the fetal bladder in an ascending way (the infection enters from the vagina).

The appearance of any of the above symptoms is the basis for calling an ambulance and urgent hospitalization in a maternity hospital, since the sooner the expectant mother is in a medical institution, the greater the chances of maintaining the pregnancy. If there is no opportunity to prolong the pregnancy, the maternity hospital will create all conditions for careful delivery, reducing the risk of complications for the mother and fetus, as well as for nursing a premature newborn.

How is preterm birth

The most common complications of the course premature birth are anomalies of labor (weakness, discoordination of labor, rapid or rapid labor), premature rupture of amniotic fluid, the development of intrauterine fetal hypoxia (lack of oxygen).

Quick delivery. For premature birth, a rapid and even rapid course is characteristic. This circumstance is due Firstly, the fact that for the birth of a premature fetus, a smaller opening of the cervix (6–8 cm) is sufficient than with timely delivery (10–12 cm).

Secondly, it was found that the contractile activity of the uterus during preterm birth is approximately 2 times higher than the activity during delivery at term.

Third, a small fetus moves faster through the birth canal. In this case, there are frequent, painful, prolonged contractions. If the average duration of timely delivery is 10–12 hours, then preterm labor lasts 7–8 hours or less.

The rapid course of labor is a serious anomaly, which, even with timely delivery, can lead to the development of hypoxia (oxygen starvation) of the fetus. Active contractile activity of the uterus leads to a decrease in uteroplacental blood flow, resulting in fetal hypoxia, and also has a pronounced mechanical effect on the fragile body of a premature baby. In addition, with a rapid passage through the birth canal, the fetal head does not have time to adequately adapt to them, resulting in trauma to the cervical spine, as well as hemorrhages under the membranes of the fetal brain during childbirth. As a result of injuries, a premature baby experiences difficulties in the process of adapting to new (extrauterine) conditions of existence, which is most often manifested by neurological disorders and requires careful monitoring and treatment.

Due to the rapid progress of the child, ruptures of the soft birth canal (ruptures of the cervix, vagina, labia) may occur due to the fact that the tissues do not have time to properly adapt to the size of the fetus being born.

Weakness of labor activity. A rarer complication of preterm labor is the weakness of labor activity, when the frequency and strength of contractions decreases, which significantly increases the duration of labor and also adversely affects the intrauterine state of the fetus (hypoxia develops).

Discoordinated labor activity. In addition to excessively violent or weak labor activity, somewhat less frequently in preterm labor, discoordinated labor activity is observed - a type of anomaly of the birth act, in which the contraction of the muscles of the uterus is disturbed (normally, the contraction begins in the corner of the uterus and spreads from top to bottom). With discoordinated labor activity, sharply painful contractions are noted, in between which the uterus does not completely relax, which leads to the development of intrauterine fetal hypoxia.

Incorrect position of the fetus. In preterm birth, abnormal fetal positions (for example, breech presentation) are more common due to the small size of the fetus in relation to the size of the uterine cavity.

Premature discharge of amniotic fluid. This complication occurs in preterm birth quite often and is caused by isthmic-cervical insufficiency or infection. The part of the fetal bladder facing the vagina, under the influence of infection, undergoes inflammatory changes, becomes fragile, and the fetal membranes rupture. The outflow of amniotic fluid often occurs unexpectedly, while fluid is released from the vagina (from a wet spot on linen to large amounts of water flowing down the legs). The color of the amniotic fluid may be light and transparent (which is evidence of a relatively satisfactory condition of the fetus), in some cases the water may acquire green color, be cloudy, with bad smell(which is considered as a sign of intrauterine fetal hypoxia or infection).

Infections. Infectious complications during childbirth or postpartum period in premature births are observed much more often than in term births. This may be due to the protracted course of labor (with weakness of labor activity), the long duration of the anhydrous period - more than 12 hours (since often after the outflow of amniotic fluid before the onset of contractions, many hours can pass), as well as the initial presence of a pregnant infection in the body, which caused preterm birth. The most common infectious complications are postpartum endometritis (inflammation of the uterus), suppuration of the sutures after suturing the gaps. Extremely rare, but serious complications can be peritonitis (inflammation of the peritoneum) and sepsis (generalized spread of infection throughout the body).

Management of preterm birth

Since childbirth is a strong stress for the body of a premature baby, the management of preterm labor has a number of fundamental differences from the management of labor during full-term pregnancy.

The main "motto" that obstetricians are guided by is the most careful, expectant tactics in the management of preterm labor, the absence of any intervention without significant reasons.

Preservation of pregnancy. At the stage of threatened or beginning preterm labor, if there are no contraindications (such as amniotic fluid rupture, serious complications during pregnancy, cervical opening more than 4 cm, infection, etc.), treatment is carried out aimed at maintaining pregnancy. Currently, obstetricians are armed with effective drugs that suppress the contractile activity of the uterus - tocolytics (the most widely used drug in this group is GINIPRAL). To quickly reduce uterine tone, tocolytics begin to be administered intravenously, after a decrease in tone, they switch to taking these drugs in the form of tablets.

Prevention of complications. In the event of a pronounced threat of termination of pregnancy in a period of less than 34 weeks, the prevention of respiratory distress syndrome of the newborn (respiratory disorders caused by insufficient maturity of the lung tissue) is carried out by prescribing adrenal cortex hormones - glucocorticoids (PREDNISOLONE, DEXAMETHASONE, BETAMETASONE) to the pregnant woman.

The course of prevention of fetal respiratory distress syndrome takes an average of 24 hours (various schemes for prescribing glucocorticoids have been developed - from 8 hours to 2 days, the choice of which is made depending on the specific obstetric situation). These drugs help to accelerate the maturation of pulmonary surfactant in the fetus, since it is the lack of this surfactant, which is located in the alveoli - the pulmonary "vesicles" through which gas exchange between blood and air is carried out, and which prevents the lung from collapsing on inspiration, causes the development of respiratory disorders premature newborn.

It has been established that at a gestational age of more than 34 weeks, the lungs of the fetus already have enough surfactant, so there is no need to prevent respiratory distress syndrome. Obstetricians and neonatologists currently have surfactant preparations (CUROSURF, SURFACTANT BL) in service, with the introduction of which premature newborns can significantly reduce the frequency and severity of respiratory distress syndrome.

During childbirth, both the condition of the woman in labor is carefully monitored (temperature, blood pressure are measured, if necessary, a clinical blood test is performed), and the intrauterine condition of the fetus by cardiotocography (two sensors are applied to the abdomen to register CTG, recording the tone of the uterus and cardiac activity of the fetus , which allows for an effective assessment of the intrauterine "well-being" of the fetus), as well as by regularly listening to the fetal heart sounds through the anterior abdominal wall.

Prevention of intrauterine fetal hypoxia is carried out, for this purpose PIRACETAM, ASCORBIC ACID, COCARBOXYLASE, ACTOVEGIN are prescribed.

Anesthesia. A prerequisite for the proper management of preterm labor is adequate pain relief, since pain leads to the development of vascular spasm, which will certainly have a negative impact on the condition of the premature fetus, for which childbirth is a strong stressful situation. In order to anesthetize childbirth, antispasmodics and analgesics, epidural anesthesia (an anesthesia method in which the drug is injected into the epidural space) are used. The injection is performed in the lumbar region, a catheter is inserted into the space between the wall of the spine and the hard shell covering the spinal cord, and an anesthetic is supplied through it.

Given the fact that narcotic analgesics (for example, PROMEDOL) can have a depressing effect on the fetal respiratory center, the use of this group of drugs is not advisable. Epidural anesthesia has proven itself in the management of preterm labor, as it helps to improve uteroplacental blood flow, having a beneficial effect on the intrauterine state of the fetus and helping him to overcome birth stress in relatively "comfortable" conditions.

Rhodostimulation. The next feature of the tactics of conducting labor in premature pregnancy is a very cautious attitude to rhodostimulation with the development of weakness of labor activity.

If during timely childbirth, having started labor stimulation, it must be continued until the end of labor, then in case of premature birth, a sparing technique is used: when labor is normalized, stimulation is stopped, since stimulation for the fragile organism of a premature fetus can cause the development of intrauterine hypoxia.

Maintaining a period of attempts. In the period of expulsion of the fetus (the period of attempts), in order to extract the fetus as carefully as possible, childbirth is accepted without protection of the perineum from ruptures (the so-called obstetric benefit), and to minimize compression of the fetal head by the tissues of the birth canal, a perineal dissection is performed - episiotomy. At birth, a neonatologist is always present, ready to provide emergency care to the newborn and, if necessary, resuscitation.

Operation caesarean section. Enough difficult question is to determine the indications for caesarean section in preterm birth, especially if the gestational age is less than 34 weeks. In modern obstetrics, delivery by caesarean section for preterm pregnancy up to 34 weeks in the vast majority of cases is carried out according to absolute indications - that is, in situations that pose a threat to the life of the mother. Absolute indications include premature detachment of the placenta, placenta previa (the placenta overlaps the cervix, and childbirth through the natural birth canal is impossible), transverse position fetus, etc.

The decision on the need for operative delivery in the interests of the fetus during premature pregnancy is made collectively (with the participation of several specialists), taking into account the prognosis for the future life of the child and if it is possible to provide qualified neonatological care for nursing the newborn.

Premature birth: how to behave

The behavior of a woman in labor in the process of premature birth does not have significant differences from the behavior during timely delivery. If the doctor allows, you can walk around the ward, take comfortable body positions that relieve pain during contractions, using massage techniques (circular massage of the abdomen clockwise, rubbing the sacrum, etc.), breathe deeply at the time of the contraction. In some cases (for example, with a breech presentation of the fetus), it is recommended to lie down in bed.

In this case the best option will lie on its side, since this position eliminates the compression of large vessels (which may result in the development of intrauterine suffering of the fetus), and also prevents the fetus from moving too quickly through the birth canal.

Most importantly, stay calm and positive, listen carefully and follow the recommendations of midwives and doctors.

Premature baby

A child born as a result of premature birth has signs of prematurity, the severity of which is determined in the aggregate at birth - weight less than 2500 g, height less than 45 cm, an abundance of cheese-like lubricant on the skin, soft nasal and ear cartilages, in girls, the large labia do not cover the small , in boys, the testicles are not lowered into the scrotum, nail plates do not reach the fingertips. At birth, the child is examined by a neonatologist in the delivery room and is transferred to the neonatal intensive care unit or intensive care unit for further observation and treatment. As a rule, premature babies are placed in an incubator - a special incubator with transparent walls, in which temperature, humidity, and oxygen content are maintained within the optimal limits for the baby. Being in an incubator contributes to a smoother course of the period of adaptation of the newborn outside the mother's body.

The longer the gestational age and the weight of the baby at birth, the more favorable the prognosis. If necessary, the newborn is transferred from the maternity hospital to the children's hospital for the second stage of nursing. There are maternity hospitals specialized in the management of preterm labor and nursing of premature newborns, equipped with modern sophisticated equipment for babies, obstetricians and neonatologists in such medical institutions have accumulated extensive experience in the treatment, management of childbirth, which can significantly improve outcomes for both the mother and for a child. Women with a high risk of preterm birth should give birth in those obstetric institutions where there are all conditions for providing full-fledged resuscitation care to a premature newborn (incubators, ventilators, as well as specialists of the appropriate level).

Adaptation to new living conditions outside the mother's womb in a premature baby is more difficult and longer than in a full-term baby. This circumstance is due to the immaturity of organs and systems, reduced ability to self-regulation, insufficient development of the immune system. Significant progress has been made in the care of premature newborns: doctors have come up with surfactant preparations, which, when administered to a child, can significantly reduce the risk of respiratory distress syndrome, maternity hospitals are replenished with sophisticated equipment for providing high-tech care (incubators, ventilators, etc.). that allows to improve the outcomes and prognosis for the further growth and development of the child.

Prevention of preterm birth

The main measures aimed at the prevention of preterm birth are carried out at the level of the antenatal clinic, since it is high-quality monitoring of the course of pregnancy that makes it possible to predict and diagnose the threat of its interruption in time. Measures to prevent preterm birth include:

• Pregnancy planning with preliminary preparation, which consists in the treatment of existing somatic diseases, the treatment of chronic foci of infection, so that at the time of pregnancy the body future mother was in optimal condition for bearing a child.
• Early registration in the antenatal clinic and regular monitoring of the progression of pregnancy. This is especially true if a woman has had miscarriages, premature births, or abortions in the past.
• Treatment of foci of infection, especially colpitis ( inflammatory processes vagina) detected during pregnancy, since the most common pathway that provokes the development of preterm labor is ascending (infection from the vagina rises and infects the lower pole of the fetal bladder).
• Timely prevention and treatment of pregnancy complications (such as placental insufficiency, preeclampsia - toxicosis of the second half of pregnancy, pyelonephritis - inflammation of the kidneys, etc.).
• At ultrasonic monitoring of the intrauterine state of the fetus and the progression of pregnancy (with ultrasound, it is possible to measure the length and condition of the cervical canal in order to timely diagnose isthmic-cervical insufficiency).
• If there are signs of a threatened abortion, timely hospitalization and treatment with the prevention of respiratory distress syndrome in the fetus.

Premature birth: only without panic

With the appearance of cramping pains in the lower abdomen, the outflow of amniotic fluid (which may not be accompanied by a pain syndrome!) It is urgent to call an ambulance. In no case should you wait in the hope that "now everything will pass", because by doing so you miss the opportunity to save the pregnancy.

It is very important not to panic and not to get confused by the unexpected onset of preterm labor. Most importantly, calm down! After calling the ambulance, you can take a sedative (1-2 tablets of valerian, 30 drops of motherwort or 1 tablet, 1 teaspoon of NOVO-PASSIT) and lie on your left side until the doctor arrives.

You must take documents with you (exchange card, passport, birth certificate, medical insurance policy), you can take a bathrobe and slippers. Everything else that you may need will be brought by relatives later. Do not be nervous - remember that in a stressful situation, vasospasm occurs (including in the uterus, which disrupts uteroplacental blood flow), so for the sake of the child, keep emotions under control.