The first signs of premature birth. Premature birth, threat of premature birth. Risk of premature birth

03.07.2024

Timely, or urgent (on time) childbirth is the physiological completed process of pregnancy. Complications of premature birth are directly related to the term of the latter and largely determine the necessary measures for this complex medical and social problem.

It consists of caring for premature newborns, measures to improve their future life, as well as additional socio-economic costs. Therefore, the most difficult and most important question is “how to prevent premature birth.”

Definition and features of flow

The terms of birth accepted abroad and in Russia, which are considered premature, differ, which explains the difference in statistics. According to the recommendations of the World Health Organization, premature birth is considered to be one that occurs between 22 and 37 weeks of pregnancy, or on the 154th to 259th day, with a fetal weight of 500 to 2,500 g and a body length of at least 25 cm.

In the Russian Federation in 1992, the accepted time frame was 28-37 weeks, or on the 196-259th day, and spontaneous abortion at 22-27 weeks is a separate category that is not classified as childbirth.

This difference is due to the fact that nursing newborns from 22 weeks with a body weight from 500 to 1,000 g requires highly qualified and experienced neonatologists, as well as special highly sensitive devices for artificial ventilation of the lungs and other advanced equipment. All this is available in specialized specialized neonatal centers in Russia, but is not available in ordinary maternity hospitals.

In case of multiple pregnancy, birth is considered premature between 22 and 35 weeks of pregnancy. Since the body weight of each of them is lower than in a singleton pregnancy, early birth is more dangerous for them. However, most children born at 28 weeks of gestation or later can be successfully nursed.

Among all births, premature births account for from 6 to 10%, of which from 5 to 7% - at 22-28 weeks, from 33 to 42% - at 29-34 weeks and 50-60% - at 34-37 weeks . The incidence of morbidity and mortality of premature infants in the perinatal period is 30-70%.

What are the features and dangers of premature birth?

They are characterized by:

the beginning (of a significant number - about 40%) of premature rupture of water;
development of abnormal labor;
increased duration or, conversely, rapid or rapid labor;
the occurrence of fetal asphyxia or hypoxia of varying degrees;
bleeding in the afterbirth and early postpartum periods;
frequent infectious complications.

Classification and consequences

There is no generally accepted single classification. According to the letter of the Ministry of Health of the Russian Federation, preterm birth, in accordance with gestational age, is recommended to be divided into:

Very early

Frequency 5%, occurs after 27 weeks + 6 days. Newborns are characterized by extreme prematurity, body weight below 1,000 g and severe immaturity of the lungs, although in some cases prevention of respiratory distress syndrome is effective.

The survival prognosis for such children is extremely poor, and mortality and morbidity rates are extremely high. Surviving premature babies born at 24 weeks of pregnancy and even later very often subsequently remain disabled due to persistent physical and mental disabilities.

Early

Frequency (15%) - 28-30 weeks + 6 days. The prematurity of such children is regarded as “severe”. They are characterized by a body weight of less than 1,500 g. and immature lung tissue, the accelerated development of which can be achieved through the use of glucocorticosteroid drugs (Dexamethasone) and agents that stimulate the formation of surfactant - a biologically active substance that covers the epithelium of the alveolar mucosa and does not allow their walls to collapse.

The severity of the condition of children born at 30 weeks of pregnancy is significantly less pronounced compared to those born earlier, and is close to average.

Premature

Frequency (20%) - 31-33 weeks + 6 days. The survival rate of children born at 32 weeks of gestation is very high and averages 95%. Their degree of prematurity is assessed as average. However, they are very prone to infectious diseases, since the formation and formation of the fetal immune system at these times is just beginning.

Late premature

Frequency (70%) - 34-36 weeks +6 days. By this time, the fetal lung tissue is practically formed and there is no need to stimulate its maturation. In addition, these children have a significantly lower susceptibility to infectious pathogens compared to newborns of the previous group, and drug prolongation of pregnancy does not have a significant effect on the causes of mortality.

Based on the totality of symptoms and the nature of occurrence, the following are distinguished:

Spontaneous premature birth (70-80%), of which from 40 to 50% occur with regular labor with preserved amniotic fluid and 25-40% with rupture of amniotic fluid in the absence of regular labor.
Induced or artificial premature birth (20-30%), carried out for certain medical reasons.

Indications for artificial premature birth and their stimulation

Indications for induction may be associated with pathology in the body of the mother and/or fetus. In the first case it is:

severe decompensated endogenous (organ or system) diseases that threaten a woman’s life;
severe in the form of severe preeclampsia and/or eclampsia;
pathology of liver function, accompanied by impaired bile flow (intrahepatic cholestasis of pregnancy);
complication of pregnancy in the form of HELLP syndrome (hemolysis of red blood cells in combination with a low platelet count in the blood and increased activity of liver enzymes) and some others.

Indications from the fetus are:

progression of deterioration of the condition, despite the measures taken;
developmental defects incompatible with life;
intrauterine death.

For these purposes, drugs are used that stimulate the “ripening” of the cervix, increasing the tone and contractile activity of the uterus. These drugs include Mifepristone in combination with Misoprostol, Oxytocin, Dinoprostone and Dinoprost. They are administered into the vagina, into the cervix, intraamniotically, intravenously in large doses and according to developed schemes.

An attempt to self-induce at home can lead to extremely severe complications, often resulting in death even with emergency medical care.

Possible complications

Prematurity of labor on the part of women in labor is often the cause of certain complications, which develop in them much more often than in urgent cases. Such complications include:

massive bleeding caused by its presentation or dense increment;
ruptures of the cervix and perineal tissue due to their unpreparedness for the passage of the fetus during rapid labor;
infection of the birth canal with the development of septic conditions; development of coagulopathic conditions during prolonged labor, etc.

Hypogalactia is associated with the unpreparedness of the woman’s body at this stage, complications during pregnancy and childbirth, a weak sucking reflex in an immature newborn and forced late attachment to the mother’s breast.

But the greatest threat premature birth poses is to the health and life of the child. The survival rate in perinatal centers among children born before 23 weeks of pregnancy is only 20%, at the 26th week - already 60% and at 27-28 weeks - up to 80%.

Based on survival rate and depending on body weight, children are divided into categories:

I - low body weight (1,500-2,5000 g). Children in this category more often survive, by about 3 years they reach the level of development of their peers and then continue to develop in accordance with accepted age indicators.
II - very low body weight (1,000-1,500 g). Approximately 50% of such children cannot be nursed, and the rest often develop persistent organ or systemic disorders.
III - extremely low body weight (500-1,000 g). In specialized neonatal centers, it is possible to deliver some of these children, but almost always they are left with persistent disorders of the function of the central nervous system, respiratory system, digestion, and genitourinary system.

However, criteria such as gestational age, weight and height do not always correspond to fetal maturity. For example, among children weighing 2,500 g. from 18 to 30% are full-term, and with a weight of 3,000 g. - from 4 to 8% premature.

Therefore, when determining maturity, the proportionality of the physique, the condition of the skull bones, the nature of the distribution and density of growth of vellus hair, the color and thickness of the skin, the severity of the subcutaneous fat layer, the location of the umbilical ring, the degree of development of the child’s external genitalia, etc. are also taken into account.

Causes of preterm birth and risk factors

Among specialists there is no single and clear idea about the mechanisms of development of this disorder. Most of them consider hormonal disorders, chronic infectious processes and neoplasms of the internal genital organs, as well as disorders in the blood coagulation system, to be the main causes.

The main mechanisms of pathology are associated with:

An increase in the release of specific information protein molecules into the blood during infectious processes in a woman’s body.
The development of coagulopathic processes (blood clotting disorders), which cause microthrombosis in the placenta with its subsequent premature detachment.
An increase in the content and activation of the oxytocin receptor system in the muscle layer of the uterus. This helps to increase its contractile activity due to the opening of calcium channels in muscle cells and the entry of calcium ions into them.
Premature rupture of the membranes due to infection of the lower parts of the membranes, which usually occurs with isthmic-cervical insufficiency.

Risk factors

Multiple contributing factors are usually considered as causes of pregnancy failure. What can trigger premature birth? All risk factors can be conditionally grouped into 4 groups.

Complications that arose during this pregnancy:

infection of the vagina and cervix;
bleeding from the uterus;
severe gestosis, occurring with edema, high blood pressure and proteinuria (protein in the urine);
sensitization by Rh factor;
antiphospholipid syndrome;
polyhydramnios and multiple births;
breech presentation of the fetus;
placenta previa or premature abruption;
pathology, including asymptomatic ones, of the urinary tract;
the cervix of the uterus is prematurely “ripe” for childbirth;
premature violation of the integrity of the membranes and rupture of water;
abnormalities of fetal development.

Associated general diseases:

acute infectious diseases during pregnancy, including intestinal ones, especially those occurring with high fever;
the presence of chronic foci of infection in the body (chronic tonsillitis, rhinosinusitis, periodontitis, etc.);
heavy physical activity, injuries and surgical interventions during pregnancy;
arterial hypertension and cardiovascular failure;
severe forms of diabetes mellitus;
renal pathology.

Compounded obstetric and gynecological history:

menstrual irregularities;
developmental anomalies of the internal genital organs and the presence of benign tumors of the uterus;
conization or amputation of the cervix, isthmic-cervical insufficiency;
pregnancy after premature birth;
four or more births;
two or more medical or one or more late spontaneous abortions;
pregnancy as a result of the use of assisted reproductive technologies.

Socio-biological:

age - less than 18 years (due to insufficient maturity of the reproductive system) and more than 34 years (due to acquired chronic diseases);
poor socio-economic living conditions;
frequent stressful conditions and negative emotional and mental stress;
nicotine, alcohol, drug intoxication.

Can sex trigger premature labor?

In the last stages of pregnancy, overly active sexual relations can provoke contraction of the smooth muscle fibers of the cervix and its dilation, leading to an increase in uterine tone. This can cause damage and premature rupture of the membranes in the area of the lower pole of the membranes, infection, leakage or discharge of amniotic fluid and stimulation of labor.

Do Bucospan suppositories cause premature birth?

Bucospan is an antispasmodic drug, that is, it relieves spasm of smooth muscles. During pregnancy, it, like other antispasmodics, is sometimes prescribed to reduce myometrial tone when there is a threat of miscarriage and in some other cases. In the normal course of pregnancy, theoretically, it can promote dilation of the cervix and provoke the onset of labor, especially in the presence of isthmic-cervical insufficiency. However, there are no reliable descriptions of this effect of the drug.

Premature birth is considered a multifactorial disorder. The more combinations of causative factors a woman has, the higher the likelihood of pregnancy failure, and such a patient should be included in the risk group.

Clinical signs

Due to the unpreparedness (immaturity) of the cervix, there is a risk of abnormal development of labor, as a result of which the whole process becomes protracted. In addition, 40% of such births occur without any precursors and begin with prenatal rupture of amniotic fluid. However, in most cases, the symptoms of premature birth are practically no different from those at term.

Depending on the clinical course, such births are divided into:

Threatening.
Beginning (for up to 34 weeks).
Started.

Due to the lack of specific symptoms, the threat of premature birth often presents certain difficulties in terms of diagnosis. It mainly manifests itself:

increased tone and excitability of the uterus during palpation;
complaints from a pregnant woman of increased discomfort or the appearance of moderate pain in the lower abdomen of a pulling or cramping nature, of “menstrual-like” pain in the lumbar region; in some cases there may be no complaints;
subjective and objective increase in fetal movement activity or, conversely, cessation of its activity;
a feeling of fullness or pressure in the vagina, frequent urge to urinate, and sometimes to defecate, which is associated with the low location and pressure on the internal tissues of the presenting part of the fetus.

In addition, in the case of premature rupture of the membranes, the woman in labor complains of liquid discharge from the vagina. The consequence of abundant discharge of amniotic fluid is a decrease in the volume of the abdomen and a decrease in intrauterine pressure. In this case, the body temperature often rises, which is accompanied by chills, sometimes severe. This indicates the rapid development of inflammation of the membranes (chorioamnionitis).

Diagnosis of the threat is carried out on the basis of the above signs and is clarified through a vaginal examination, tonuometry, external multichannel hysterography and ultrasound examination in dynamics.

During a vaginal examination, there are no changes in the cervix, it is formed, has a length of about 1.5-2 cm, its external os is closed or, if the birth is repeated, the tip of the finger is missing (up to 1 cm). The presenting part of the fetus can also be determined, pressed against the entrance to the pelvis. Data from instrumental studies indicate an increase in myometrial tone.

How to understand that premature labor has begun?

Their onset is characterized by severe cramping pain in the lower abdomen or regular contractions, confirmed by hysterography. A vaginal examination reveals a shortened and softened or (often) smoothed cervix and the opening of its external os in dynamics up to 3 cm. Palpation and ultrasound indicate the unfolding of the lower uterine segment.

Signs of labor having begun:

Regular labor (regular contractions) with an interval between them of about 10-15 minutes.
Discharge of amniotic fluid.
Slight, spotting, bloody discharge.
During vaginal examination, the fetal presenting part is determined at the entrance to the pelvis.
The dynamic opening of the external cervical pharynx is more than 3-4 cm.

Management of preterm labor

Management tactics can be conservative-wait-and-see or active. Its choice is determined by the following main factors:

The condition of a woman.
Timing of pregnancy.
The presence and severity of bleeding.
The clinical course of labor (threatening, incipient or begun) and its severity.
The condition of the fetus.
The degree of cervical dilatation.
Condition of the amniotic sac.
Presence of symptoms of infection.

Waiting tactics

If pain occurs in the lower abdomen and lumbar region, it is necessary to call an ambulance to hospitalize the pregnant woman. Pre-medical care for her consists of providing physical and psycho-emotional rest - bed rest, psychologically calming effects, taking infusion or tincture of motherwort and hawthorn, decoction or extract of valerian root, antispasmodic drugs (No-shpa, Drotaverine, Papaverine) in tablets, intramuscularly or in the form candles.

Conservative treatment of threatened preterm birth in a hospital setting

The goal of therapeutic intervention is to prolong pregnancy. Management consists of:

treatment of threat;
prevention of fetal asphyxia;
prevention of infectious complications based on body temperature measurements, blood tests and studies of smears and microflora of the cervical canal.

If there is a threat, the woman is prescribed bed rest, conditions are created for physical and emotional rest, light sedatives and antispasmodics are administered orally, intramuscularly, in the form of rectal suppositories, magnesium iontophoresis, acupuncture, and electrorelaxation therapy.

Use of tocolytics

If necessary, tocolytic agents are used. There are tocolytics with different mechanisms for suppressing uterine contractility. These include:

beta-adrenomimetic drugs that help reduce the content of calcium ions in cells (Ritodrine, Terbutaline, Ginipral); they are used orally or intravenously;
magnesium sulfate (intravenous drip), which reduces the contractility and excitability of the myometrium also by reducing the concentration of calcium ions in the cell cytoplasm;
non-steroidal anti-inflammatory drugs (Indomethacin rectally), which are inhibitors of prostaglandin synthesis; their use is recommended after the 32nd week of pregnancy (to avoid complications).

Tocolytic drugs that block the entry of calcium into the cell include Nifedipine. During studies of the effect of Nifedipine in the threat of premature birth, good results were obtained in terms of suppression of uterine contractility, in which it is comparable or even superior to beta-adrenergic agonists (Ritodrine, etc.), and the absence of an adverse effect on the fetus. The drug makes it possible to increase the gestational age up to 1 week. However, caution must be exercised when using it, since the drug can lead to hypotension, especially orthostatic.

As a rule, treatment begins with the appointment of beta-agonists or magnesium sulfate. If they are ineffective, non-steroidal anti-inflammatory drugs and calcium antagonists are prescribed. The combination of tocolytic agents with each other is used only for periods up to 28 weeks and when the external cervical os is dilated more than 2 cm. Further use of tocolytics according to a certain scheme as maintenance therapy is possible.

The use of gestagens, glucocorticosteroids

Progestogens (progesterone), which include Utrozhestan, are highly effective in stopping or preventing premature birth. Its combination with beta-agonists allows you to reduce the dosage of the latter. Utrozhestan is recommended to be used with caution due to its property of increasing the sensitivity of the pregnant woman's uterus to bacterial flora.

In addition, antibacterial therapy and therapeutic suturing of the cervix are often indicated. To prevent the development of RDS (respiratory distress syndrome) in the fetus, glucocorticosteroids are used. A consensus conference held in August 2000 recognized the most effective and recommended intramuscular administration of Dexamethasone for periods from 24 to 34 weeks twice (12 mg twice within 1 day) or four times (6 mg four times also during 1 day).

In exceptional cases, after careful observation, treatment is carried out on an outpatient basis (at home).

Contraindications to watchful waiting

Absolute contraindications to conservative tactics for managing the threat of premature birth are:

Pregnancy 36 weeks or more.
Oblique, transverse position of the fetus.
Foot presentation in combination with central rupture of the membranes and an open cervical canal.
Signs of intrauterine infection.

Relative contraindications:

pregnancy 34-35 weeks;
foot presentation of the fetus in combination with a high rupture of the membranes and a closed cervical canal;
criminal (outside a medical institution) intervention in the uterine cavity for the purpose of termination of pregnancy, but in the absence of obvious infection;
multiple pregnancy, nephropathy, severe extragenital (concomitant) pathology in a woman;
the presence of pathogenic microorganisms in the vagina or third degree of purity;
the presence of leukocytosis in the blood with a shift to the left under normal body temperature.

If there are relative contraindications and there is a threat of premature birth, preventive measures for fetal hypoxia, antibacterial therapy (as indicated), therapy for the underlying pathology and preparation for childbirth are carried out. If they do not start within 5 days, they are stimulated by administering prostaglandins intravenously or drip administration of Oxytocin under the control of cardiotocography. Active management is necessary in the following cases:

Suspicions of the presence of abnormalities of fetal development.
Complications of pregnancy in the form of severe gestosis that cannot be corrected.
Severe somatic pathology in a woman in labor.
Discharge of water and absence of amniotic sac.
The presence of regular contractions.
Threats of intrauterine fetal asphyxia.
Presence of symptoms of infection.

Active tactics for managing preterm birth

The first stage of labor is characterized by a high degree of mobilization of the adaptive mechanisms of the pregnant body and the placental-fetal system. Their gradual depletion sometimes leads to a rapid change in the obstetric situation, disruption of the life support systems of the fetus and the development of its hypoxia. In this regard, it is necessary to carry out constant cardiac monitoring and carry out individual decisions on the implementation of appropriate preventive (every 2 hours) and therapeutic measures.

After dilation of the cervix to 3 cm, the use of epidural analgesia is recommended. It helps to reduce or eliminate pain, expand the cervical canal, relax the pelvic floor muscles in the second period (expulsion period), improve blood microcirculation in the tissues of the mother and fetus, and also reduce the likelihood of developing discoordination uterine contractions and increased blood pressure. In addition, epidural analgesia, unlike pain relief with Promedol, does not cause respiratory depression in the newborn.

In the event of a threat of rapid or precipitate labor, correction of the contractile function of the uterus is carried out through the intravenous drip of Partusisten. It is administered at a certain speed over 10 minutes with a gradual reduction in the dose until the required frequency and regularity of contractions are established, the external pharynx opens to 8 cm and the fetal head moves into the narrow part of the pelvic cavity.

The second period is characterized by a high degree of risk of injury (mainly craniocerebral) to the fetus. Therefore, during the period of expulsion, protection of the mother’s perineum to prevent ruptures is not carried out. In order to stretch the soft tissues of the pelvic floor and facilitate the passage of the fetus, the obstetrician-gynecologist uses his fingers to stretch the skin and muscles from the side of the vagina in the direction of the ischial tuberosities. If necessary, the perineum is dissected.

In case of premature birth, indications for resolution by cesarean section are:

Severe form of gestosis (preeclampsia and eclampsia).
Placental presentation.
Premature detachment with a normal location of the placenta.
A transversely located fetus or complications that arise in the case of its breech presentation.
A woman has a burdened obstetric history due to miscarriage, stillbirth.

Prevention of premature birth

There are no clinically acceptable preventive diagnostic methods that can predict preterm birth in the long term (over 3 weeks).

Tests

Today, the generally accepted and most informative test for preterm birth is based on the determination of the glycoprotein fibronectin in cervical mucus after 20 weeks. The latter is contained in significant quantities in the cells of the fetal membranes and amniotic fluid.

The detection of fibronectin in the cervical mucus indicates the appearance of amniotic fluid in it and is considered as a precursor. The sensitivity of testing is highest (up to 71%) two weeks before preterm birth. Three weeks before, the information content of the test is about 59%, and during pregnancy up to 37 weeks - no more than 52%. This test can only be performed in a medical facility.

There is also a fairly informative test for determining premature disruption of the fetal membranes in a antenatal clinic. For independent determination of amniotic fluid in vaginal secretions, we offer a test pad - “FRAUTEST amnio”. However, diagnosis using this test is unreliable.

Transvaginal ultrasound

Another relatively informative study is an echographic dynamic determination of the length of the cervix using a transvaginal sensor of an ultrasound device. If the length of the cervix exceeds 3 cm, then the probability of birth within the next few weeks does not exceed 1%.

Other preventive measures

Preventive measures even before pregnancy include informing women about risk factors, minimizing any manipulation of the internal genital organs, quitting smoking and unmotivated intake of pharmaceutical vitamin preparations before and within 2 months after conception. During pregnancy, women at risk take progesterone derivatives, antibiotics and other antibacterial drugs as prescribed by a gynecologist, carry out antibacterial therapy as indicated, etc.

The technique of suturing a shortened neck has an ambiguous preventive effect. In some cases, an obstetric pessary is used separately or in addition to cervical sutures. It is installed in the vagina and is a ring. If there is a threat of premature birth, this ring should provide additional support, which reduces pressure on the lower uterine segment and creates an obstacle to the opening of the external pharynx and rupture of the fetal membranes. However, most experts are skeptical about the effectiveness of this medical product.

The main role in addressing issues of preventing pathology and its complications belongs to the antenatal clinic. Its staff identifies women with risk factors, carries out dynamic monitoring of them, develops an individual plan of preventive measures, and carries out hospitalization in the department of pathology of pregnant women for examination and individual adequate treatment.

Women's awareness of pathology allows them, even at the stage of preparation for conception, to take advantage of the recommendations of a specialist, and during pregnancy, to seek medical help in a timely manner. The deep knowledge of doctors and their ability to correctly analyze possible causes and risks make it possible to avoid the unreasonable prescription of medications, which often lead to side effects and complications, as well as to reduce the frequency and severe consequences of this pathology.

Introduction.

Etiology of premature birth.

Clinic and diagnosis of premature birth.

Tactics for managing premature birth.

Management of premature birth.

Prevention of premature birth.

Characteristics of a premature baby.

Prevention of SDR in premature infants.

Premature birth (miscarriage) – This is a birth that occurs during pregnancy from 28 to 37 completed weeks. The incidence of preterm birth ranges from 5 to 12%. Among those who died in the perinatal period, the proportion of premature babies ranges from 40 to 60%.

Etiology of premature birth. Premature birth is characterized by multifactorial causes causing termination of pregnancy. Among the factors causing abortion, three groups of reasons can be distinguished:

premature termination of pregnancy caused by maternal factors:

isthmic-cervical insufficiency, which leads to disruption of the obturator function of the isthmus and cervix. Develops against the background of hormonal disorders (functional) or damage to the isthmic region due to traumatic birth, induced abortion, deep ruptures of the cervix (organic).

Malformations of the uterus (intrauterine septum, unicornuate, double uterus, etc.).

Extragenital diseases of the mother (heart defects in the stage of decompensation, hypertension, nephritis, blood diseases, diabetes, etc.).

Infectious diseases of the mother (influenza, viral hepatitis, rubella, etc.).

premature termination of pregnancy caused by a fetal factor:

fetal malformations.

premature termination of pregnancy caused by a combination of factors:

late gestosis;

Rhesus conflict;

abnormalities of placenta attachment;

premature detachment of a normal or low-lying placenta;

incorrect position of the fetus;

hyperextension of the uterus with polyhydramnios, multiple pregnancies;

age (under 18 and over 30 years old).

Women with premature birth are characterized by manifestations of general and local infantilism, late development of menstrual function, and a high index of infectious diseases.

Clinic and diagnosis of premature birth. There are threatening, beginning and beginning premature births. For threatening Premature birth is characterized by pain in the lower back and lower abdomen. The excitability and tone of the uterus are increased, which can be confirmed by instrumental studies. During vaginal examination, the cervix was preserved, the external os of the uterus was closed. Leakage of water and increased motor activity of the fetus are often observed.

At starting Premature birth usually involves severe cramping pain in the lower abdomen or regular contractions. During a vaginal examination, changes are noted in the cervix - shortening, often smoothness, premature rupture of amniotic fluid.

Started Premature birth is characterized by the presence of regular labor and the dynamics of cervical dilatation (up to 2–4 cm), which indicates the irreversibility of the process that has begun.

When a pregnant woman is admitted for premature birth, she must:

find out the possible cause of the threat or occurrence of premature birth;

establish the gestational age, estimated fetal weight, position, presentation, the presence and nature of the fetal heartbeat, the nature of vaginal discharge, the condition of the cervix and amniotic sac, the presence of signs of infection, the presence of labor and its severity;

establish the stage of development of premature birth and determine the tactics of labor management in each specific case.

Diagnosis of premature birth often requires special research methods aimed at determining the excitability and contractility of the uterus; as well as some biochemical research methods. Hysterography and tonemetry make it possible to evaluate the contractile activity of the uterus.

Dynamic determination of the activity of a number of enzymes often makes it possible to judge the readiness of the uterus for the development of premature birth.

With a long-term threat of premature birth, the state of the fetoplacental system is determined:

determination of daily estriol secretion;

phono- and electrocardiography of the fetus;

Ultrasound examination in dynamics.

Tactics for managing premature birth. The course of premature birth is characterized by a number of features:

up to 40% of premature births begin with premature rupture of amniotic fluid;

anomalies of labor;

increased duration of labor;

the occurrence of fetal asphyxia;

bleeding in the afterbirth and early postpartum period;

Infectious complications during childbirth are common.

The management of preterm birth depends on:

stages of premature birth;

gestational age;

conditions of the amniotic sac;

mother's condition;

degree of cervical dilatation;

presence of signs of infection;

the presence of labor and its severity;

the presence of bleeding and its nature.

Depending on the situation, they adhere to expectant-conservative or active tactics of labor management.

Management of women with onset of preterm labor. You should try to stop labor: prescribe one of the drugs that inhibit the contractile activity of the uterus or a combination of them (25% solution of magnesium sulfate - 5 - 10 ml intramuscularly 2 - 3 times a day, 0.5% solution of novocaine 50 - 100 ml intravenously drip blood pressure control). The most effective use of beta-mimetic drugs is that they reduce the intensity of uterine contractions and lead to persistent relaxation of the uterine muscles. Partusisten is started to be administered intravenously, 10 ml in 250 ml of physiological solution at a rate of 10 - 15 drops per minute for 4 - 6 hours. The rate of drug administration depends on individual tolerance, which is manifested by side effects such as tachycardia, hand tremors, decreased blood pressure, and nausea. After completing the intravenous administration of partusisten, the same drug is prescribed in tablets. Contraindications to the prescription of beta mimetics: heart disease, thyrotoxicosis, diabetes mellitus, intrauterine infection, bleeding associated with placental pathology.

At the same time, to prevent SDR in newborns, dexamethasone is prescribed at a dose of 18–24 mg per course. This drug is used to accelerate the maturation of the lungs in the fetus.

Management of women with premature pregnancy complicated by premature rupture of amniotic fluid in the absence of labor. In 25–40% of pregnant women, preterm labor begins with premature rupture of amniotic fluid, while in 12–14% labor does not develop independently after rupture of the membranes. In such pregnant women, the method of choice is conservative expectant management. This is due to the fact that perinatal mortality is significantly lower than with active tactics (immediate induction of labor); often it is not possible to induce labor even with repeated use of labor stimulants; the frequency of chorioamnionitis and purulent-septic diseases in newborns depends on strict adherence to antiseptic measures and taking into account contraindications for choosing this tactic; Due to vasospasm in the uteroplacental circulatory system, after the administration of oxytotic drugs, the cardiac activity of the fetus often changes.

Indications for conservative expectant management: during pregnancy 28 - 34 weeks, in cases of longitudinal position of the fetus, no signs of infection, no severe obstetric and extragenital pathology.

Necessary conditions for conservative expectant tactics are strict adherence to aseptic and antiseptic measures and the creation of a protective treatment regimen. In case of premature rupture of amniotic fluid, pregnant women must be hospitalized in a special ward, processed according to the same schedule as the maternity ward. Linen is changed daily, and sterile linens are changed 3-4 times a day. A hygienic shower is performed every 3–4 days. Tests of blood, urine, vaginal smears, and cultures from the cervical canal for microflora are carried out once every 5 days. After taking smears, the vagina is treated with a tampon soaked in a disinfectant solution.

Therapy with conservative expectant management:

antispasmodics (isoverine 1 ml 2 times a day intramuscularly, platiphylline 1 ml of a 0.1% solution 2 times a day intramuscularly, etc.)

tocolytic drugs (magnesium sulfate 25% - 10.0 2 times a day intramuscularly, papaverine 1 - 2 ml of a 2% solution intramuscularly, etc.)

prevention of fetal hypoxia (Nikolaev’s triad, sigetin 2–4 ml intramuscularly, vitamin C 5 ml intravenously with 20% or 40% glucose solution, 10% solution of gutimin 10 ml intramuscularly once a day).

As the duration of the anhydrous interval increases, in case of increased contractile activity of the uterus or changes in the cardiac activity of the fetus, one of the listed drugs or their combination is again prescribed. If pregnancy continues for more than 10–14 days, therapy is repeated. Bed rest is indicated only in the first 3 to 5 days.

Indications for preparing a pregnant woman for delivery after prolonged leakage of amniotic fluid are: prolongation of pregnancy to 36–37 weeks with an estimated fetal weight of at least 2500 g; the appearance of signs of infection (leukocytosis with a shift of the formula to the left, microflora in the cervical canal); deterioration of the fetus' condition. In these cases, therapy is prescribed for three days aimed at preparing the body for childbirth: glucose - 40% solution with 5 ml of 5% vitamin C intravenously, ATP 1 ml intramuscularly, folliculin or sinestrol 20,000 - 30,000 IU intramuscularly 2 times a day , calcium chloride solution, 1 tablespoon 3 times a day orally, oxygen therapy, isoverine - 1 ml 2 times a day intramuscularly. If labor does not develop within 1–2 days, then labor induction begins.

If an intrauterine infection develops, estrogens and antispasmodics are prescribed, and after 4–6 hours labor is induced (2.5 units of oxytocin in combination with 2.5 mg of prostaglandin F 2α in 500 ml of saline). Delivery must be done through the natural birth canal. At the same time, intensive antibiotic therapy, the use of drugs that increase the body’s immunological reactivity, and correction of electrolyte disturbances are indicated.

During childbirth, all women in labor are required to prevent fetal hypoxia once every 3–4 hours.

Contraindications to conservative expectant management:

Absolute: 1. Transverse and oblique presentation of the fetus, foot presentation with a central rupture of the membranes and an open cervical canal;

2. signs of intrauterine infection appear;

3. pregnancy period is 36 weeks or more.

Relative: 1. Gestation period 34 – 35 weeks;

2. foot presentation with high rupture of membranes and a closed cervical canal;

3.indication of criminal intrauterine intervention, but without obvious signs of infection;

severe extragenital pathology in the mother, nephropathy, multiple pregnancy;

leukocytosis with a shift of the formula to the left at normal body temperature, pathogenic microflora in the vagina or degree of vaginal cleanliness of the third degree.

In this case, within 3 to 5 days, preparation for childbirth, prevention of fetal hypoxia and treatment of the underlying disease are carried out. In the absence of labor, labor induction is resorted to.

Indications for active management of preterm birth:

absence of amniotic sac;

presence of regular labor;

presence of signs of infection;

intrauterine fetal suffering;

severe somatic diseases of the mother;

complications associated with pregnancy that cannot be treated;

suspected deformity or abnormal development of the fetus.

Management of premature birth. Premature birth usually occurs with great tension in the adaptation mechanisms of the “mother – placenta – fetus” system. Their depletion is manifested by disturbances in uteroplacental blood flow and fetal hypoxia. Therefore, it is necessary to carry out a set of measures to prevent fetal hypoxia every 4 to 6 hours. In case of rapid labor, suppression of contractions is not advisable; it is necessary to prescribe antispasmodics to improve placental blood flow. The most unfavorable prognosis for a premature baby occurs during prolonged labor. Therefore, timely diagnosis and treatment of labor weakness are of great importance. If labor stimulation is necessary, preference should be given to administering minimal doses of oxytocin (5 units in 500 ml of 5% glucose solution at a rate of 10–12 drops per minute).

In the second stage of labor, the prevention of birth injuries in the fetus becomes of great importance. For this purpose, the second stage of labor is carried out without perineal protection; take measures to reduce the resistance of the pelvic floor muscles. All manipulations to reduce muscle resistance are carried out with the head located in the pelvic cavity. In all women in labor, management of the second period must begin with the expansion of the vulvar ring. To do this, the midwife inserts her fingers into the vagina and, while pushing, stretches the muscles and skin of the perineum towards the ischial tuberosities. Next you need to do one of the following:

dissection of the perineum;

Pudendal anesthesia;

irrigation of the perineal skin with lidocaine aerosol;

administration of a centrally acting muscle relaxant - mefedol 10% solution 20 ml intravenously slowly.

Birth in a breech presentation with a fetal weight of less than 2000 g should proceed independently with the support of the fetal torso. If the fetus weighs more than 2000 g, it is possible to provide manual assistance according to Tsovyanov.

Surgical interventions are performed according to vital indications from the mother.

Management of the third period involves generally accepted measures to prevent bleeding.

When treating pain, you should avoid drugs that depress the fetal respiratory center.

To carry out a premature birth, it is necessary to have an incubator for premature babies in the birth unit, which is turned on 30 minutes before the birth of the child. The baby is received in warm underwear, the tray and changing table are heated. The temperature in the labor room should be at least 25 - 26 degrees Celsius, all manipulations are carried out with great care.

Prevention of premature birth. It should be carried out taking into account ideas about the etiology and pathogenesis of this pathology. In antenatal clinics, it is necessary to organize monitoring of pregnant women, identifying risk groups for premature birth. In non-pregnant women, the causes of miscarriage should be carefully studied and corrected. In case of prematurity, careful monitoring should be carried out at all stages of pregnancy, hospitalization during critical periods and pathogenetic therapy in specialized hospitals.

Characteristics of a premature baby. A child born prematurely has signs of immaturity: body weight less than 2500 g, length less than 45 cm, a lot of cheese-like lubricant, insufficient development of the subcutaneous fat layer, fluff on the body, soft cartilage of the nose and auricle, nails do not extend beyond the fingertips, the umbilical ring is located closer to the womb, in boys the testicles are not lowered into the scrotum, in girls the labia minora are not covered by the labia majora.

The degree of maturity is assessed using a special scale. In addition, the newborn is assessed using the Apgar scale, breathing is assessed using the Silverman scale, which evaluates the movement of the chest, retraction of the intercostal spaces, retraction of the sternum, participation of the wings of the nose and the position of the lower jaw, and the nature of breathing.

Prevention of SDR in premature infants. RDS develops due to a lack of surfactant in the immature lungs of a premature baby. The composition of the surfactant depends on the degree of maturity of the fetal lungs. To determine the latter, the lecithin/sphingomyelin ratio in the amniotic fluid is examined. If the ratio is more than 2, the lungs of the fetus can be considered mature.

When certain medications, in particular glucocorticoids, are administered to pregnant women, the maturation of the fetal lungs can be accelerated. For the course of treatment, 8–12 mg of dexamethasone is prescribed (4 mg 2 times a day intramuscularly or in tablets 2 mg 4 times a day for 2–3 days). Corticosteroids are prescribed to pregnant women who are prescribed tocolytic agents.

When preventing RDS in 28–32 weeks of pregnancy, if labor has not occurred, but the threat of its occurrence remains, it is advisable to carry out glucocorticoid therapy after 7 days in the same doses.

Contraindications to the administration of glucocorticoids: peptic ulcer of the stomach and duodenum, circulatory failure of the third degree, endocarditis, nephritis, active form of tuberculosis, severe forms of diabetes, osteoporosis, severe nephropathy.

Content

If a woman’s pregnancy ends before the doctor’s deadline and the baby is born, premature birth occurs. The degree of threat to the health of a new person depends entirely on the number of obstetric weeks and how long the mother carried the baby under her heart. It is important to be aware of the potential causes of preterm birth in order to avoid such premature births and their dangerous consequences for child health in the future.

What is premature birth

Labor activity completed by delivery before the 38th obstetric week characterizes pathological childbirth. For the health of babies, this is a pathological process, however, thanks to modern technologies, doctors have learned to care for children born from the 28th obstetric week onwards. However, health problems still cannot be avoided, since the fetus has not yet fully completed its intrauterine development. Therefore, if there is a threat of premature birth, the pregnant woman is urgently placed for preservation.

Signs

The longer a child stays in the mother’s womb, the greater the chances of him being born strong and healthy. However, situations are different, and we should not exclude cases when a woman does not complete her pregnancy until the period established by the gynecologist. The characteristic signs of premature birth are not much different from natural labor, and the first warning sign is leakage of amniotic fluid.

Since the baby is characterized by increased physical activity in the second half of pregnancy, diagnosis can be difficult. However, a vigilant expectant mother should pay attention to the following alarming symptoms:

increased tone of the uterus during palpation;
nagging or cramping pain in the lower abdomen;
constant fetal activity;
frequent urge to go to the toilet;
pulling sensation in the lumbar region;
a bursting feeling in the vaginal area.

How do they begin?

If a nagging pain in the lower abdomen occurs, and a woman detects leakage of amniotic fluid, she must immediately call an ambulance or immediately contact her local gynecologist with a complaint. Early labor can provoke a miscarriage, which should not be allowed under any circumstances. Early labor begins with sharp abdominal pain, which only intensifies in different positions of the body. Pregnancy is at risk, and it is better for the woman to consent to hospitalization.

Causes

The main question most expectant mothers ask is how to avoid premature birth. In fact, the first step is to find out in detail why this pathological process is progressing, and how to reduce the risk of untimely birth of the baby. The specialist informs about this even when planning a pregnancy in order to save the woman from subsequent problems during 40 obstetric weeks. In modern obstetric practice, the following causes of premature birth are distinguished:

previous abortions, instrumental cleaning of the uterine cavity;
abuse of bad habits;
infection of the cervix and vagina;
Rhesus conflict;
polyhydramnios and multiple births;
premature aging or placental abruption;
breech presentation of the fetus;
intrauterine infections;
fetal gene mutations;
antiphospholipid syndrome;
severe forms of gestosis;
rupture of membranes;
isthmic-cervical insufficiency;
excessive sexual activity;
the presence of hidden urinary tract infections;
diabetes mellitus during pregnancy;
pathologies of the thyroid gland in the expectant mother;
preeclampsia;
multiple pregnancy (twins);
inflammation in women during pregnancy;
uterine bleeding.

Classification

Premature birth is not considered a disease, but the general condition of the newborn depends entirely on the timing of early delivery. If it was not possible to carry the child to 40 obstetric weeks, a conditional classification is presented below, which gives at least a vague idea of the degree of the pathological process and potential diseases in the newborn person:

Very early birth. The premature appearance of the baby occurs at 22-27 weeks. The weight of the fetus varies between 500 - 1,000 g, the doctor diagnoses underdevelopment of internal organs and systems, problems with the opening of the lungs.
Early birth. Premature birth occurs between 28 and 33 weeks. The child weighs up to 2 kg, while the natural ventilation of the lungs is impaired and the circulatory system is imperfect.
Premature birth at 34-37 obstetric weeks, although considered pathological, is reassuring to parents, since all internal organs and systems are already formed. A newborn weighs about 2,500 g.

Indications for artificial premature birth

In practice, there are cases when doctors deliberately insist on premature, rapid stimulation of labor. The need for this arises when diagnosing extensive pathologies in the body of a mother or child. In addition, the lives of both may be at risk. Such critical moments are the detection of the following pathologies:

decompensated endogenous diseases of a complicated form, fraught with death for the patient;
preeclampsia and eclampsia, as a manifestation of severe gestosis, fraught with the inevitable death of the baby;
extensive liver pathologies in pregnant women, when the natural outflow of bile is pathologically disrupted;
diagnosis of HELLP syndrome in the body of a pregnant woman with increased activity of liver enzymes;
intrauterine malformations incompatible with the further viability of the fetus;
intrauterine fetal death, fraught with infection and contamination of the blood of a pregnant woman.

How to call

If pathology is suspected or the presence of one of the above pathological factors, the pregnant woman is taken to the maternity hospital. When determining the diagnosis and the need to induce labor prematurely, doctors use certain medications, which are usually administered intra-amniotically into the vagina. In this case we are talking about the following medications: the synthetic hormone Mifepristone in combination with Misoprostol, Oxytocin, Dinoprostone and Dinoprost. Superficial self-medication is contraindicated, since there is a high probability of death of the mother and child.

Diagnostics

If there is an internal deviation in the intrauterine development of the fetus, labor may begin earlier than the period specified by the doctor. Such thoughts are prompted by hypertonicity of the uterus, discharge of amniotic fluid, dilation of the cervix of the reproductive organ and acute pain syndrome that attacks the consciousness of the woman in labor with cyclical attacks. An additional examination method is ultrasound, which determines the condition and position of the fetus in the womb. Before relieving acute pain, the doctor may prescribe a special test to confirm the onset of labor.

Test

A special test system called Actim Partus reliably determines binding insulin-like growth factor 1 (IGFFR) in the mucus of the cervical canal. The enzyme is produced in high concentration by the membranes of the embryo several days before the onset of labor. Such laboratory research can only be carried out in a hospital setting, since it is not possible to organize collection of material at home without special equipment and tools.

How to prevent

Since in the early stages the child will be born premature, with low body weight and extensive damage to the internal organs, the doctor’s task is to stop premature births with the help of medications; alternative methods can also be used. Since labor can begin at any time, the woman first needs to be hospitalized, then examined, and then prescribed effective treatment, left under strict medical supervision. If you act correctly, the baby can be born exactly on time, without pathologies.

Dexamethasone for threatened preterm birth

To prevent the development of respiratory distress syndrome, doctors use synthetic glucocorticosteroids. If there is a threat of early labor, the drug Dexamethasone for intramuscular administration has proven itself well. It is allowed to use it strictly for medical reasons at an obstetric period of 24–34 weeks. There are two schemes for using this medicine:

12 mg twice for 24 hours;
6 mg in 4 doses throughout the day.

Conservative treatment in a hospital setting

The determination of a comprehensive treatment regimen is carried out individually - according to medical indications after identifying the main cause (pathogenic factor) of the progressive pathology. In conditions of mandatory hospitalization, doctors bring together representatives of different pharmacological groups to ensure positive dynamics and prolongation of pregnancy:

antispasmodic drugs intramuscularly or rectally: No-shpa, Drotaverine, Papaverine;
adrenomimetics for intravenous administration: Ritodrine, Terbutaline, Ginipral;
NSAIDs rectally: Indomethacin from 32 weeks of pregnancy;
glucocorticosteroids, gestagens orally or intramuscularly: Progesterone, Utrozhestan, Dexamethasone.

Management of preterm labor

To avoid potential complications with children's health, intensive therapy should be carried out in a hospital setting. There will definitely be a positive result if you strictly follow all medical instructions. There are several methods to combat such a global disorder, it all depends on the general condition of the patient and the fetus. Below are several effective tactics that are chosen by the doctor based on the complexity of the specific clinical picture:

Waiting tactics. The woman is provided with peace - physical and emotional, given soothing infusions, and mild sedatives and antispasmodics are used.
Active tactics. If the cervix dilates 3 cm or more, doctors use epidural analgesia or administer Partusisten intravenously.

Consequences for mother and child

For a woman, the consequences of premature birth are not so significant; they are more related to the physiological characteristics of the female body. For example, the perineum may tear, or the doctor performs a caesarean section with further stitches. But for a baby, the consequences of premature birth can seem fatal. It all depends on the due date. As an option:

severe birth injuries;
congenital diseases;
early mortality.

Pregnancy after premature birth

After a pathological birth, a woman’s body must recover properly, so rushing to conceive again is certainly not recommended. Doctors advise to be observed by a gynecologist for a year, undergo a full medical examination, promptly treat hidden diseases (if any), and only then think about the next addition to the family.

Premature births have become quite common these days. Despite modern medical equipment, which makes it possible to care for premature babies even in very severe cases, we all understand that it is better if the growth and development of a child to the physiological norm occurs in the mother’s womb, and not in an incubator, even an ultra-modern one. That is why the threat of premature birth is the number one fear among the “pregnant audience.”

The problem of premature birth is quite serious, it is clear that talking about this will not lift the mood of the expectant mother! But you shouldn’t worry or be afraid ahead of time either, because the likelihood of a successful delivery is much higher than the birth of a baby prematurely. In addition, if you know the signs of premature birth and take the necessary measures in time, then the baby can be prevented from being born ahead of schedule. We'll talk about this below.

What is premature birth?
Premature birth is always associated with a struggle for survival, with long, complex and expensive treatment aimed at the baby’s recovery. I note that such cases do not always have a successful ending. The earlier the pregnancy is terminated, the more often babies develop vision problems, severe neurological disorders, etc. The risk of an early birth for a baby is difficult to overestimate, since his body is simply not ready for independent functioning: his lungs, gastrointestinal tract are not ready, his body cannot maintain body temperature, etc.

There are cases when inducing premature birth is simply necessary (for medical reasons or at the request of the pregnant woman). According to Russian legislation, in our country it is possible to terminate a pregnancy up to 22 weeks; this is no longer considered an abortion, but a premature birth, despite the fact that it is classified as a late miscarriage. If a week after such an termination of pregnancy the child remains alive, then such birth is classified as early premature, and the surviving fetus is considered a child.

The method of carrying out premature birth is determined by the obstetrician-gynecologist, taking into account the reasons that caused it. If the birth canal is not ready, and if the reasons are late toxicosis, which is a threat to the mother’s life, eclampsia or convulsions, a cesarean section is performed, despite the almost complete absence of chances that the child will survive.

If time does not play a role or the termination of pregnancy is carried out for social reasons, doctors carry out the usual preparation of the birth canal using drugs that cause premature birth.

What births are considered premature?
Premature birth is considered to be a birth that occurs before 37 weeks of pregnancy. In obstetric practice, intervals are identified during which premature birth can occur:

at 22 weeks;
at a period of 22-27 weeks;
at a period of 28-33 weeks;
at 34-37 weeks.

Since January 1, 1993, in our country, according to the adopted new live birth criteria recommended by the World Health Organization, intensive and resuscitation care is provided to newborns weighing over 500 g, born from the 22nd week of pregnancy. Until 1993, premature births were considered those that occurred after the 28th week of pregnancy, and resuscitation was provided only to newborns weighing over 1000 g.

Babies born at 29, 30, 31 weeks of pregnancy almost always weigh more than a kilogram; their lungs are relatively well prepared for breathing, so they initially have a good chance of survival. But prematurity is not the only problem; it is often associated with hypoxia during labor and before birth, natal (birth) trauma (which often leads to the death of infants) and other diseases that caused premature birth.

Causes and symptoms of premature birth.

Endocrine diseases in a pregnant woman increase the risk of premature birth and problems during pregnancy. These include hormonal imbalance in the sexual sphere, thyroid diseases, and diabetes.
Sexual infections (chlamydia, ureaplasmosis, etc.) that a woman has during pregnancy doubles the risk of premature birth. In addition, they can cause illness and developmental defects in the child. Cervical erosion, chronic salpingitis, endometritis, and bacterial vaginosis also pose a threat.
Somatic infections (ARVI, tonsillitis, viral hepatitis, untreated teeth) are a source of infection for the fetus and can provoke premature birth.
The presence of malformations, anomalies and tumors of the uterus, changes in the cervix and adhesions due to childbirth and abortion in most cases are the factor that provokes the onset of premature birth. Damage to the circular muscles of the uterine isthmus (usually during childbirth or abortion), which prevent its opening during pregnancy, leads to isthmic-cervical insufficiency (ICI). With this phenomenon, the cervix, under the weight and pressure of the fetus, begins to open slightly already from 16-17 weeks of pregnancy, the amniotic sac “bulges” into it, which becomes infected and, as a result, ruptures, provoking premature birth.
Somatic diseases of a non-infectious nature in a pregnant woman (kidney, heart and liver diseases, exhaustion, nutritional deficiency) contribute to the weakening of the body and complicate the course of pregnancy. In this situation, premature birth occurs very often.
Fetal malformations and the presence of genetic diseases provoke premature birth. Usually the threat arises already at 32 weeks of gestation.
Various complications and features of pregnancy are also a risk factor. These include expecting twins (premature birth occurs due to uterine overdistension), polyhydramnios, complications such as gestosis in the later stages, feto-placental insufficiency, placental previa and placental abruption. All this can also cause premature birth.
Genetic features.
Abdominal injuries.
The presence of bad habits in the mother.
Female age under 18 and age over 30 are risk factors.
Hard physical work, lack of sleep, chronic stress, mental stress.
Poor nutrition and living conditions.
Single-parent family, unwanted pregnancy.

Premature birth and gestational age

Premature birth at 22-27 weeks.
Children born at this stage of pregnancy have the lowest survival rate, since their lungs are not yet mature, and their weight is in the range of 500-1000 g. The main factors that provoke premature birth at this stage of pregnancy are isthmic-cervical insufficiency, infection of the membranes and its breakup. A child born at 22-23 weeks has practically no chance of survival, and those few who were able to survive (and such cases have happened in obstetric practice) subsequently become disabled. Those born between 24 and 26 weeks are more likely to survive, and their health prognosis is much better. Premature births occur in only five percent of cases between 22 and 27 weeks of pregnancy.

Premature birth at 28-33 weeks.
The majority of children born at this stage survive safely, which is largely due to the high level of development of neonatological care, however, it is worth noting that not all children experience prematurity without consequences. Typically, children in this group weigh from 1000 to 1800 grams, their lungs are practically prepared for breathing. At this stage, premature birth can occur for a variety of reasons, ranging from pregnancy complications to Rhesus conflict.

Premature birth at 34-36 weeks.
Being born at this stage of pregnancy does not pose any danger to the baby. A healthy but premature baby born in a maternity hospital has every chance of rapid adaptation and excellent health in the future. The weight of babies born at this stage is usually more than two kilograms; the lungs are ready to work independently; a little support with medications is required to accelerate their maturation. The main culprits of premature birth at this stage are considered to be somatic diseases of the expectant mother, various complications of pregnancy and intrauterine hypoxia against the background of feto-placental insufficiency.

Symptoms and signs of premature birth.
Signs of premature birth can be compared to the threat of early termination of pregnancy. Most often, their onset is indicated by the rupture of amniotic fluid, but a few days before this, a woman usually experiences warning symptoms, to which she usually does not pay attention.

In obstetric practice, there are several stages of premature birth:

Threatened premature birth. During this period, symptoms of premature labor may not even be noticed. This may include nagging pain in the lower back and lower abdomen of a weak nature, tension or contraction of the uterus, which can be noticed by placing your hand on the stomach (usually it tenses), restless behavior of the baby (kicks more often), the appearance of mucous discharge from the genital tract, sometimes mixed with blood (on examination the uterus is dense and closed). Seeing a doctor at this stage will help avoid premature birth; minimal drug treatment is usually prescribed and absolute rest for the pregnant woman is recommended.
Beginning premature labor. Symptoms are more pronounced, in particular pain in the lower back and lower abdomen becomes more intense and cramp-like. At this time, the mucous plug often comes off, bloody discharge from the genital tract is observed, and water often pours out. During the examination, the specialist reveals shortening and softening of the cervix, its opening by 1-2 fingers.
Premature labor has begun. Usually, once the birth process has begun, it cannot be slowed down. Often, premature birth has a rapid course, for example, in first-time mothers it takes 6 hours; with repeated births, this time can be halved. The pain becomes very intense, acquiring a cramp-like character, and contractions become regular (every ten minutes or less), the cervix quickly opens, the waters break, the fetus is pushed towards the entrance to the pelvis.

So, if pain appears that resembles pain during menstruation, a feeling of heaviness in the lower abdomen and pressure on the lower part, fetal activity has increased significantly or, on the contrary, weakened, unusual discharge from the genital tract has appeared, you should know that these are the first signs of premature birth. In this situation, in order to “calm down” your “hurry”, you need to seek medical help immediately. Any delay can cost you dearly. In any case, it is better to play it safe in advance than to regret your short-sightedness and carelessness later.

Treatment of threatened preterm birth.
Usually, if a pregnant woman consults a doctor at the stage of threatening premature labor, she is recommended to be hospitalized in a maternity hospital, but this is not necessary in all cases. Of course, first a gynecological examination is carried out, tests are taken, the condition of the cervix and child is assessed, and the presence or absence of infection in the woman is determined.

It is worth dwelling in more detail on the leakage of amniotic fluid. Very often, because of fear, women do not go to the doctor if their waters have broken and contractions have not yet begun, but in vain. In this case, no one will immediately terminate the pregnancy (there is nothing to be afraid of), especially if it has not reached 34 weeks. If there are no signs of infection, the pregnant woman is simply admitted to the maternity hospital, where for several days (five to seven or more) specialists will prepare the fetus’s lungs for independent work (usually prescribing glucocorticoids), while the pregnant woman herself will be protected from infection by carrying out antibiotic therapy and creating sterile conditions . Delivery will occur only after the fetal lungs are ready so that the baby can breathe on his own. Prolongation of pregnancy in case of premature rupture of membranes is carried out based on the timeliness of treatment and the condition of the pregnant woman at the time of treatment.

If there is a threat of premature birth at 35 weeks or more with rupture of amniotic fluid, the pregnant woman is allowed to give birth, because the adaptation of such children to extrauterine life is usually successful. If the amniotic sac is preserved, treatment is aimed at stopping the onset of labor and eliminating the cause that caused it. If there is only a threat of preterm labor, outpatient treatment is sometimes possible, but in most cases hospitalization is recommended. Often, creating a calm environment for a pregnant woman is enough to stop labor and continue pregnancy.

Once the birth process has begun, it cannot be stopped. If the amniotic sac is intact, then medications are used as therapy, the effect of which is aimed at relaxing the uterus, and sedative therapy, physical therapy and bed rest are also introduced.

If the treatment is unsuccessful, the contractions do not stop, but increase each time, the question of delivery arises.

The danger of rapid premature birth.
As a rule, premature birth, which is rapid in nature, is always associated with hypoxia, which is caused by frequent contractions of the uterus and too rapid movement of the fetus along the birth canal. Soft bones and the small size of the fetal head, as well as weak blood vessels, in combination with the above, can provoke severe birth injuries to the fetus, intracranial hemorrhage and injury to the cervical spine. By the way, it is because of the way the birth process proceeded that in the case of premature birth, a premature baby may suffer, and not because of the fact of prematurity.

If specialists were unable to stop premature birth, then they do everything to ensure that the birth takes place as carefully as possible. No methods are used to protect the perineum from ruptures, as this may cause injury to the fetus. Even in the case of breech presentation of the fetus, childbirth is carried out naturally (in the absence of contraindications), and hospitals have all the conditions for caring for newborns. In case of extreme prematurity, a caesarean section is performed.

In the case of discoordinated labor or its weakness, gentle labor is carried out with careful pain relief, careful stimulation, while simultaneously monitoring the condition of the fetus.

If pregnancy is prolonged after the rupture of amniotic fluid, there is a high probability of developing endometritis and postpartum hemorrhage. Premature birth at 35 weeks has virtually no complications.

Caesarean section for premature birth is not used if the fetus is not fully term, and there are clear signs of chorioamnionitis and intrauterine infection, as well as in the case of intrauterine fetal death.

In these situations, a natural birth is necessary; a caesarean section poses a threat to the life and health of the woman.

Prevention of premature birth consists of eliminating the factors that cause it even at the stage of pregnancy planning. Therefore, it is very important to be healthy at the time of pregnancy, or if this happened by accident, it is necessary to register and undergo examination as early as possible.

Premature birth is one of the most important aspects of maternal and child health. Premature babies account for 65-70% of early neonatal and child mortality. Stillbirths with premature births are observed many times more often than with timely births. Perinatal mortality in premature newborns is 30-35 times higher than in full-term ones.
In Russia, it is customary to consider premature births that occur between 28 and 37 weeks of pregnancy with a fetal weight of 900 g or more. However, in the coming years in Russia, statistics of premature births, 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 fetal weight of more than 500 g. According to these criteria in the USA, the frequency of premature births in In 2005 it was 9.7%, in Great Britain - 7.7%, in France - 7.5%, in Germany - 7.4%. Due to the timing of pregnancy adopted in our country, the frequency of premature births ranges from 5.4-7.7%.
The causes of premature birth are multifactorial. Risk factors for premature birth are both socio-demographic (unsettled family life, low social level, young age) and clinical reasons. Every third woman who has a premature birth is a primigravida, whose risk factors include previous abortions or spontaneous miscarriages, urinary tract infections, and inflammatory diseases of the genitals. The complicated course of this pregnancy also plays an important role in the occurrence of premature birth, the development mechanism of which makes it possible 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.
. Stress of the mother and/or fetus 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 consequence, to the development of premature birth.
. Thrombophilic disorders that lead to placental abruption and thrombosis in the placenta. High thrombin levels can provoke an increase in prostaglandin production, activation of proteases and placental abruption, which is the most common cause of premature delivery.
. Overdistension of the uterus with multiple pregnancy, polyhydramnios, uterine malformations, infantilism leads to activation of oxytocin receptors, etc. - and to the development of premature birth.
Often there is a combination of these factors in the development of premature birth. The appearance of symptoms of activation of contractile activity of the uterus, that is, symptoms of threatening premature birth, is the final link in a complex chain of activation of contractile activity of the uterus. Without knowledge of the causes of premature birth, there can be no successful treatment. Currently, all treatment for the threat of miscarriage is reduced to symptomatic treatment - the use of drugs to reduce contractile activity of the uterus. This explains why, despite the huge number of different tocolytic agents in our arsenal, the frequency of premature births in the world does not decrease, and the decrease in perinatal mortality occurs mainly due to the success of neonatologists in nursing premature babies.
In connection with the above, the management tactics and treatment of the threat of premature birth should take into account the possible causes of their development, and not consist only of prescribing symptomatic drugs aimed at reducing the contractile activity of the uterus.
Treatment tactics are determined by many factors, such as gestational age, condition of the mother and fetus, the integrity of the amniotic sac, the nature of uterine contractility, 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 premature 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 - 34-37 weeks of gestation. This division is due to different management tactics and different pregnancy outcomes for the fetus.
The health status of the mother determines whether it is possible to prolong the pregnancy or whether it is advisable to give birth early. The condition of the fetus is assessed using 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 pregnancy at least for the time necessary to prevent fetal respiratory distress syndrome.
The integrity of the amniotic sac is of great importance when choosing management tactics. If the amniotic sac is intact, expectant management and therapy aimed at prolonging pregnancy are possible. In case of premature rupture of amniotic fluid or high lateral rupture of the membranes, the tactics are determined by the presence or absence of infection, the nature of the fetal presentation, etc.
Depending on the nature and activity of contractile activity of the uterus and the degree of changes in the cervix, expectant management tactics may be chosen, aimed at prolonging pregnancy. Conservative tactics are possible if the health of the mother and fetus allows for prolongation of pregnancy, if the amniotic sac is intact, if the cervix is dilated no more than 2 cm, and there are no signs of infection.
When choosing expectant management when there is a threat of premature birth, you must:
. decide on a case-by-case basis which type of tocolytic therapy should be used;
. accelerate the “maturation” of the fetal lungs by preventing fetal respiratory distress syndrome, as well as improve its condition;
. determine the suspected cause of the threat of premature birth (infection, placental insufficiency, thrombophilic disorders, complications of pregnancy, extragenital pathology, etc.) and treat pathological conditions in parallel with the treatment of the threat of miscarriage.
There are threatening, beginning and beginning premature births. Threatening premature 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 premature labor begins, cramping pain in the lower abdomen usually occurs, accompanied by a regular increase in the tone of the uterus (contractions). At the same time, the cervix shortens and opens. In this case, premature rupture of amniotic fluid often occurs.
Premature birth is characterized by: untimely rupture of amniotic fluid; weakness of labor, incoordination or excessively strong labor; rapid or rapid labor 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 premature birth, treatment should be differentiated, since when labor begins, treatment aimed at preserving pregnancy can be carried out. Bed rest, sedatives, antispasmodics, etc. are prescribed. The main medications 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 now many of these drugs, and based on studies of the contractile activity of the myometrium, more and more new drugs are being proposed, 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 premature births 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 drugs is extremely important and relevant, since, although they do not reduce the frequency of premature births, they inhibit the contractile activity of the uterus, help prolong pregnancy, allow the prevention of fetal respiratory distress syndrome, etc.
Some of the most effective tocolytic drugs include?-mimetics - drugs used to treat the threat of miscarriage after 24-25 weeks of pregnancy or preterm birth more than 30 weeks. Drugs of this series (ritodrine, Ginipral, salbutamol, etc.) are derivatives of epinephrine and norepinephrine, released upon stimulation of sympathetic nerve endings, and they are sometimes called sympathomimetics or adrenergics in the literature. The action of?-mi-metics is carried out through?-receptors. Stimulation of α-receptors leads to contractions of smooth muscles, and α-receptors lead to the opposite effect: relaxation of the muscles of the uterus, blood vessels, and intestines. The presence of β-receptors in other tissues (in particular, in the muscle of the heart) determines the frequency of severity of side effects of β-mimetics. ?-receptors are divided into ?1- and ?2-receptors. The tocolytic effect is achieved by acting through β2 receptors on the uterus, bronchi, intestines, as well as on the formation of glycogen in the liver and insulin in the pancreas. Their effect on β-receptors of the cardiovascular system is less pronounced.
The mechanism of action of β-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, the reverse release of Ca2+ from cells into the depot and relaxation of smooth muscles occurs. β-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. This cardiotropic effect of β-mimetics must be taken into account when carrying out therapy with these drugs, especially when they interact with other drugs. Before administering β-mimetics, it is necessary to monitor blood pressure and pulse rate. To reduce adverse cardiovascular effects, calcium channel blockers must be prescribed - finoptin, isoptin, verapamil. As a rule, compliance with the rules for the use of β-mimetics, the dosage regimen, and strict monitoring of the state of the cardiovascular system allow one to avoid serious side effects.
Additional effects from the use of β-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 recent years, evidence has been obtained that with long-term use of β-mimetics, a decrease in their effectiveness is observed. In addition, β-adrenergic receptors are sensitive from 24-25 weeks of pregnancy; in earlier stages of pregnancy, the effect of their use is not so pronounced. If the threat of premature birth is accompanied by an increase in uterine tone, and not contractions, then the effect of using β-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 β-mimetics is Ginipral - hexoprenaline. This 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 and oxytocin-induced labor contractions; During childbirth, it normalizes excessively strong or irregular contractions. Under the influence of Ginipral, in most cases, premature contractions stop, which, as a rule, allows you to prolong pregnancy to full term. Due to its β2-selectivity, Ginipral has a slight effect on cardiac activity and blood flow in the pregnant woman and fetus.
Ginipral consists of two catecholamine groups, which in the human body undergo methylation via catecholamine-O-methyl-transferase. While the effect of isoprenaline is almost completely abolished 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 drug’s high ability to adhere to surfaces, are considered the reasons for its long-lasting effect.
Indications for the use of Ginipral are:
. Acute tocolysis - inhibition of labor contractions during childbirth with acute intrauterine asphyxia, immobilization of the uterus before cesarean section, before turning the fetus from a transverse position, with umbilical cord prolapse, with complicated labor. As an emergency measure in case of premature birth before taking the pregnant woman to the hospital.
. Massive tocolysis is the inhibition of premature labor contractions in the presence of a smoothed cervix and/or dilatation of the uterine pharynx.
. Long-term tocolysis is the prevention of premature birth during intensified or frequent contractions without smoothing the cervix or dilating the uterus. Immobilization of the uterus before, during and after surgical correction of isthmic-cervical insufficiency.
Contraindications to the use of this drug: hypersensitivity to one of the components of the drug (especially for patients suffering from bronchial asthma and hypersensitivity to sulfites); thyrotoxicosis; cardiovascular diseases, especially cardiac arrhythmias occurring with tachycardia, myocarditis, mitral valve disease and aortic stenosis; cardiac ischemia; severe liver and kidney diseases; arterial hypertension; intrauterine infections; lactation.
Dosage. For acute tocolysis, use 10 mcg of Ginipral, diluted in 10 ml of sodium chloride or glucose solution (administered slowly intravenously over 5-10 minutes). If necessary, continue administration by intravenous infusion at a rate of 0.3 mcg/min. (as in massive tocolysis).
For massive tocolysis - at the beginning, 10 mcg of Gini-pral slowly intravenously, then - intravenous infusion of the drug at a rate of 0.3 mcg/min. The drug can be administered at a rate of 0.3 mcg/min. and without prior intravenous injection. Administer intravenously (20 drops = 1 ml).
As the first line of help in cases of threatened miscarriage after 24-25 weeks of pregnancy or the threat of premature birth, Ginipral is prescribed at the rate of 0.5 mg (50 mcg) in 250-400 ml of saline intravenously, gradually increasing the dose and rate of administration (maximum 40 drops/ min.), combining the 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 must be carried out after the threat of interruption has been completely eliminated, but not less than after 5-7 days (reduce the dose, and not lengthen the period of time between taking the drug dose). Based on many years of use of Ginipral, it has been established that the effectiveness of its use is about 90%.
Thus, the domestic and foreign experience accumulated over decades indicates that despite the ever-increasing arsenal of tocolytic agents, today there are no more effective means for suppressing the contractile activity of the uterus, i.e. threats of premature birth than?-mimetics, and, in particular, Ginipral.